JOINT PAIN

JOINT PAINDR.RISHIKESAN K.VSPECIALIST PHYSICIANVENNIYIL MEDICAL CENTRESHARJAH

ANATOMYLETS REVIEW THE ANATOMY OF THE SYNOVIAL JOINTS.SYNOVIAL MEMBRANE LINES THE JOINT CAVITY.IT SECRETES THE SYNOVIAL FLUID AND REDUCES THE FRICTION BETWEEN THE BONESSYNOVIAL FLUID IS AN ULTRAFILTRATE OF THE PLASMA.IT IS GOING TO BE REFLECTIVE OF WHAT IS HAPPENING INSIDE THE PLASMA.IF THERE IS ANY SYSTEMIC INFLAMMATORY DISEASE SYNOVITIS AND HENCE ARTHRITIS IS A POSSIBLE SYMPTOM

DEFINITION : arthritis Vs. ARTHRALGIAMAJOR CAUSE OF MORBIDITY AND MORTALITY PARTICULARLY IN OLDER POPULATION ARTHRALGIA MAY BE A REFERRED PAIN FROM MUSCLES ,TENDONS,BONESARTHRITIS IS A SPECIFIC PATHOLOGIC PROCESS OF INFLAMMATION OF JOINT STRUCTURE . MAY BE AUTO IMMUNE,INFECTIOUS OR TRAUMATIC AND WHAT ELSE.VIRTUALLY IMPOSSIBLE TO DIFFERENTIATE THE TWO WITHOUT AT LEAST A PHYSICAL EXAM

DIFFERENTIAL DIAGNOSISTRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF TENDON ,LIGAMENTS,MENISCUSINFECTIONS : GONOCOCCAL, NON GONOCOCCAL, LYME DISEASE, TB, VIRAL FUNGALCRYSTAL: GOUT,PSEUDOGOUTDEGENERATIVE: OAMALIGNANCY: SOLID TUMOR METASTASIS, LYMPHOMA, LEUKAEMIA, OSTEOSARCOMA, OSTEOCHONDROMARHEUMATIC: RA, SLE, REITERS, PSORIATIC, ANK SPONDYLITIS, AC.RHEUMATIC FEVER, SJOGRENSOTHERS : A HUGE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAIN

DIFFERENTIAL DIAGNOSISTRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF TENDON ,LIGAMENTS,MENISCUSINFECTIONS : GONOCOCCAL,NON GONOCOCCAL,LYME DISEASE,TB,VIRAL FUNGALCRYSTAL: GOUT,PSEUDOGOUTDEGENERATIVE: OAMALIGNANCY: SOLID TUMOR METASTASIS,LYMPHOMA,LEUKAEMIA,OSTEOSARCOMA,OSTEOCHONDROMARHEUMATIC: RA,SLE,REITERS,PSORIATIC,ANK SPONDYLITIS,ACUTE RHEUMATIC FEVER,SJOGRENSOTHERSWE HAVE GOT A HUGE WIDE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAINHERE MORE THAN EVER, IT IS ESSENTIAL TO HAVE A GOOD HISTORY AND PHYSICAL EXAM INORDER TO MAKE A PROPER DIAGNOSIS

TAKING A GOOD HISTORYSLICESYSTEMIC : ANY SYSTEMIC SYMPTOMS THAT ACCOMPANY THE JOINT PAIN LIKE FEVER,CHILLS ,RASH,FATIGUE,WEIGHT LOSSLOCATION: WHICH JOINT / JOINTS SORE? SINGLE, SOME ,MULTIPLE. IF MULTIPLE SYMMETRICAL OR ASYMMETRICAL IN DISTRIBUTIONINFLAMMATION: IS THE AFFECTED JOINT INFLAMMED?CHRONICITY: RECENT ONSET/ACUTE, INSIDIOUS ONSET/MORE CHRONIC.DOES THE PAIN COME AND GO OR PERSISTENT.WHAT TIME OF THE DAY PAIN WORSE?EVIDENCE OF TRAUMA

SLICE SYSTEMIC SYMPTOMS FEVER: GOUT,RA, INFECTIOUS ARTHRITIS (ESPECIALLY WITH CHILLS.) RASH: VASCULITIS LIKE CHURG STRAUSS, WEGENERS, PSORIATICFATIGUE : RA,SLE ,PMR ANY CHRONIC FORM OF ARTHRITIS.

DISTRIBUTION / LOCATION DIP JOINTS - PSORIATIC.MTP ,PROX.IP JOINTS -RA INFLAMMATION : SEPTIC, GOUT, Rheumatoid ArthritisCHRONICITY: ACUTE - INFECTIOUS, GOUT

HAND ARTHRITISLOCATION: ASK THESE QNsWHICH JOINT / JOINTS SORE?IS IT SINGLE ?SOME ?MULTIPLE? IF MULTIPLE , SYMMETRICAL OR ASYMMETRICAL IN DISTRIBUTION?

SLICE the OSTEOARTHRITISSystemic : Primary OA is not associated with any systemic symptomsLocation : Hands (wrists, MCPs, PIPs, DIPs) and weight bearing joints (hips, knees) primarily. Not necessarily symmetrical.Inflammation : Joints are not externally inflamed.Chronicity : Chronic and progressive. Insidious onset. Worsens with activity, pain improves with rest.Evidence of trauma : May occur secondary to trauma to a specific joint. But primary OA is not associated with trauma

SLICE- ing RHEUMATOID ARTHRITISSystemic: YES MOST OF THEM HAVING SYSTEMIC SYMPTOMS: FATIGUE , MALAISE,WEAKNESS,LOW GRADE FEVER,WEIGHT LOSSLocation :HAND ARTHRITIS, NOT IN DIPs. ALSO AFFECTS SHOULDERS,KNEES,HIP. BUT NO LBP. SYMMETRICInflammation. VERY PROMINENT,WARM ERYTHEMIC JOINTSChronicity: CHRONIC,INSIDIOUS, PROGRESSIVE,PAIN WORST IN THE MORNINGEvidence of trauma: NO TRAUMA INVOLVED

EXTRA ARTICULAR SYMPTOMSSEPTIC ATHRITIS : FEVER,CHILLS,NAUSEA,RASH (ERYTHEMA MIGRANS IN LYME DISEASE)MALIGNANCY : PALLOR,EASY BRUISING,INFECTION ELSEWHERE.RHEUMATOLOGIC OR AUTOIMMUNE : ALL MAY INCLUDE FEVER,WEIGHT LOSSREITERS SYNDROME : URETHRITIS, H/O CHLAMYDIAL INFECTIONS, ENTERITIS, CONJUNCTIVAL INFECTION, CONJUNCTIVITIS.PSORIATIC ARTHRITIS : PSORIASIS, SAUSAGE DIGITS,NAIL ABNORMALITIESSLE : MALAR RASHES,RENAL INSUFFICIENCYANKYLOSING SPONDYLITIS : ENTHESITIS,RASHESSJOGRENS SYNDROME : DRY EYES,DRY MOUTHWEGENERS : CHRONIC URI, LRTI, RENAL INSUFFICIENCY

WHAT NEVER HAS EXTRA ARTICULAR SYMPTOMS?

OSTEOARTHRITIS ! THE MOST COMMON FORM OF CHRONIC ARTHRITIS.IT IS STRICTLY LIMITED TO THE JOINTS.IT IS THE DEGENERATIVE DISEASE OF THE JOINTS

ACUTE MONOARTHRITISCRYSTAL INDUCED ACUTE MONOARTICULAR ARTHRITIS

SEVERE INFLAMMATIONCRYSTALS POSITIVE ACUTE MONOARTHROPATHY50000 CELLS IN SYNOVIAL FLUIDCULTURE POSITIVE

VIRAL ARTHROPATHY Vs. symmetrical arthropathyVIRAL ARTHROPATHYSYMMETRIC ARTHROPATHYNO SIGNIFICANT INFLAMMATIONNO RASH OR RENAL FAILURENO PULMONARY INVOLEMENTIgM TITRES HIGH FOR SPECIFIC VIRUSESLOOK FOR HEPATITIS PANELIgM PARVOVIRUS TITRESEPSTEIN BARR VIRUS TITRES CHRONIC SYMM.ARTHROPATHYCHRONIC.SYMMETRIC POLY ARTICULAR.SIGNICANT INFLAMMATION.EROSIONS ON XRAY.POSITIVE RF AND OR ANA.CONSTITUTIONAL Sx.EXTRA ARTICULAR MANIFESTATIONS.

LABORATORY WORK UP FOR JOINT PAININ ANY PATIENT WHO HAS SIGNS OF AN INFLAMMED JOINT,YOU MUST ORDER A JOINT ASPIRATEPATIENTS WITH SIGNS AND SYMPTOMS OF OSTEOARTHRITIS- NO EXTRAARTICULAR SYMPTOMS,OLDER AGE,ASYMMETRICAL- PLAIN RADIOGRAPHY IS THE BEST INITIAL TEST,WHILE CT IS MORE ACCURATEPATIENTS WITH SIGNS OF AUTO IMMUNE OR RHEUMATOLOGIC DISEASE ( EXTRA ARTICULAR SYMPTOMS) THERE ARE VARIOUS AUTO ANTIBODIES THAT MAY BE ORDERED CORRESPONDING WITH THE SUSPECTED SYNDROME.THESE Abs. HAVE VARIOUS LEVELS OF SENSITIVITY AND SPECIFICITY

Auto antibodies with various joint painAntinuclear Antibodies (ANA)Anti-Ro, Anti-La: Sjogrens SyndromeAnti-centromere: CREST SYNDROMEAnti-Histone: Drug Induced LupusAnti- ds DNA, Anti Sm: SLERh. factor(RF),Anti CCP: Seen in patients with Rheumatoid arthritis. However their absence doesnt rule out RAANCAc-ANCA: Wegeners granulomatosisP-ANCA: Churg-Strauss syndrome, poly arteritis nodosa

JOINT ASPIRATION OR ARTHROCENTESIS

JOINT ASPIRATION IS THE BEST INITIAL DIAGNOSTIC STEP FOR THE DIAGNOSIS OF : GOUT PSEUDOGOUT AND SEPTIC ARTHRITIS.

JOINT ASPIRATION OR ARTHROCENTESISA RED ,WARM, SWOLLEN,PAINFUL JOINT POINTS TO: GOUT PSEUDOGOUT SEPTIC ARTHRITIS (FROM VARIOUS AETIOLOGIES.)IN THE JOINT ASPIRATION WE LOOK FOR 4CsCOLORCELLSCRYSTALS , and we get a CULTURE

OSTEOARTHRITISCHRONIC PROGRESSIVE , NON INFLAMMATORY, IDIOPATHIC DEGENERATIVE JOINT DISEASE.CLOSELY RELATED TO AGING PROCESS: PRIMARY OAOF COURSE OTHER ARTHROPATHIES CAN PREDISPOSE TO OAWEIGHT IS A COMMON CAUSE MOST COMMONLY AFFECTS THE JOINTS OF THE HANDS,AS WELL AS WEIGHT BEARING JOINTS (KNEES,HIPS). JOINTS OFTEN APPEAR NORMAL, EXTERNALLY, DECREASED ROM, CREPITUS.

THE BEST FIRST STEP IN DIAGNOSTIC EXAMINATION IS XR OF THE AFFECTED JOINTS.TYPICAL FINDING IS A REDUCTION IN JOINT SPACE.

OSTEOARTHRITIS

JOINT PAIN IS THE MOST COMMON SYMPTOM.NO CONSTITUTIONAL SYMPTOMS.NODES ON DIPs AND PIPsANY LABS SHOULD BE NORMAL ABNORMALITIES IN LABS ARE NOT INDICATIVE OF OSTEOARTHRITIS

OSTEOARTHRITIS TREATMENT

ACETAMINOPHEN IS THE RX OF CHOICE IF THE PATIENT IS NSAID SENSITIVE. TOPICAL CAPSAICIN IS USEFUL BUT INFERIOR TO NSAIDs.

Rx. IS PALLIATIVE.NSAIDs ARE THE MAINSTAY OF TREATMENT.

DRY EYES AND DRY MOUTH

AUTO IMMUNE INFLAMMATORY AND DESTRUCTIVE DISEASE OF THE EXOCRINE GLAND.MAJOR SX: DRY EYES,DRYMOUTH AND PAROITDS ENLARGEMENTH/o NUMEROUS DENTAL CARIES1* AND 2* FORMS( SLE ,RA etc)BX.OF SALIVARY GLANDS SINGLE MOST ACCURATE TEST: LYMPHOCYTIC SIALOADENITISCOMPLICATIONS: NHL, NEONATAL LUPUSSCHIRMER TEST AND Anti- Ro /Anti- La TITRES

SCHIRMERs test