Common Diseases of The Joint

Lita Diah R
Internist Rheumatologist
Airlangga Medical Faculty/ Internal Medicine
Department/ Rheumatology Div/ Dr Soetomo Hospital
Surabaya
 What is Rheumatology?
Rheumatic diseases and conditions are characterized by
symptoms involving the musculoskeletal system.
Many of the rheumatic diseases and conditions feature
immune system abnormalities.
 What Are Rheumatic Diseases What is
Arthritis?
Inflammation and loss of function connecting or
supporting structure of the body
They especially affect joint, tendons, ligaments, bones
and muscles
The common symtoms are pain, swelling and stiffness
Some rheumatic diseases can also involve internal
organ
 Basic principles reumatic diseases

• Is the problem acute or chronic?

• Is it an articular or extra-articular problem?
• Is it a mono or oligo/poly arthritis?
• Are there features of joint inflammation?
• Are there extra-articular features?
What’s Inside?

5
 Inflammatory Non Inflammatory
Manifestation Non inflammatory Inflammatory
(e.g. OA) (e.g. RA,SLE)
Joint stiffness < 1 hour > 1 hour
Systemic (-) (+)

Symptoms Peak of pain After activity After take a rest

Instability Accompanied by Rare
weakness
Symmetric/ Rare Frequent
bilateral
Tenderness Rare Frequent
Inflammation Rare yes
Signs
Multisystem (-) Frequent
Laboratorium (-) Frequent
abnormality 6
 Articular Periarticular

Manifestation Articular Periarticular

Anatomical Synovium,synovial fluid, Tendon, ligament
structure cartilage,joint capsule bursa, muscle, bone,
fascia, nerve

Site of pain Diffuse, deep pressure Fokal, “point”

pain

Pain ( movement) Active/passive Active movement

movement (certain position)
( All directions)

Swelling Frequent Rare

(bone/soft tissue)
7
 Review of Organs System
Manifestation Disease

Rash SLE, vasculitis, PsA, dermatomyositis, JRA, lyme disease

Eye involvement Sjogren’s syndrome, RA, spondyloarthropathy, temporalis

arteritis, Behcet’s disease, Wargener granulomatous,SLE

Oral ulcer SLE, enteropathic arthritis, Behcet’s disease

Raynaud’s phen. Scleroderma, SLE, RA, MCTD

Pleuritis/pericarditis SLE, RA, MCTD,AS

CNS involvement SLE, vasculitis, lyme disease,antiphospolipid syndrome

GI involvement Enteropathic arthritis, polymyositis, scleroderma 8

ARTRITIS
Pattern joint
• Physical examination

Gait
Arms
Leg
Spine
 Musculoskeletal Disorders are common and a
major healthcare burden
• Prevalence of musculoskeletal pain was 14.9%.
• The most common musculoskeletal complaints
were knee pain 18.2%, low back pain 11.2%, and
soft tissue disorder 15.4%.
• Functional disability was reported in 6%.
• The prevalence of rheumatic diseases was OA
4.1%, rheumatoid arthritis 0.28%, osteoporosis
0.47%, connective tissue disease 0.09%, and gout
0.14%.
 Prevalence of Specific Conditions
Associated with Chronic Joint Pain

Mayo Clinic. Arthritis. Available at: https://healthletter.mayoclinic.com/secure/pdf/SRAR.pdf. Accessed: August 19, 2013;
Wong R et al. Prevalence of Arthritis and Rheumatic Diseases Around the World: A Growing Burden and Implications for Health Care Needs. Arthritis
Community Research and Evaluation Unit; Toronto, ON: 2010.
defective integrity of articular
cartilage, in addition to related
changes in underlying bone at
the joint margins
 Management of Osteoarthritis Flowchart
CORE TREATMENT
• Exercise • Weight reduction • Education

CONSIDER
• Acetaminophen ± topical NSAID gel • Heat and cold therapy • Intra-articular
• Assisted devices (splints, insoles) • TENS/acupuncture steroid injection

ASSESS GASTROINTESTINAL AND CARDIOVASCULAR RISK NSAID

• Suggested cardiovascular threshold <20% 10-year risk without absolute CONTRAINDICATION
contraindications • Opioids (weak opioids,
• Hepatic and renal profile • No ASA use such as tramadol, preferred to
strong opioids)

• Oral NSAIDs
• Coxib (coxib + PPI for those with higher gastrointestinal risk)
• nsNSAID + PPI
• Consider impact of ASA co-prescribed with nsNSAIDs/coxibs

• Opioids (weak opioids, such as tramadol, preferred to strong opioids)

• Surgery

ASA = acetylsalicylic acid; coxib = COX-2-specific inhibitor; NSAID = non-steroidal anti-inflammatory drug;
nsNSAID = non-specific non-steroidal anti-inflammatory drug; PPI = proton pump inhibitor; TENS = transcutaneous electrical
nerve stimulation
Adapted from: Adebajo A. BMC Fam Pract 2012; 13:23.
 Treatment should be tailored
according to :
• Knee risk factors ( obesity, adverse mechanical
factors, physical activity )
• General risk factors ( age, comorbidity, poly
pharmacy )
• Pain ( level of pain, intensity, disability )
• Sign of inflammation ( effusion )
• The location and degree of any structural
damage
 Rheumatoid Arthritis
The synovium red due to blood vessel diatations
and thickened due to inflammation and cellular Plus granulations form over the synovial
infiltration. membrane now called as pannus.
 Relative incidence of joint
involvement in RA
• MCP and PIP joints of hands & MTP of feet 90%
• Knees, ankles & wrists- 80%
• Shoulders- 60%
• Elbows- 50%
• TM, Acromio - clavicular & atlanto axial - 30%

• Don’t forget the cervical spine!!Instability at cervical spine

can lead to impingement of the spinal cord.
• Thoracolumbar, sacroiliac, and distal interphalangeal joints
(DIP)of the hand are NOT involved.
 Extra articular Involvement
• Constitutional symptoms ( most common)
• Rheumatoid nodules(30%)
• Hematological
• Respiratory- pleural effusion, pneumonitis , pleuro-pulmonary
nodules, ILD
• CVS-asymptomatic pericarditis , pericardial effusion,
cardiomyopathy
• Rheumatoid vasculitis- mononeuritis multiplex, cutaneous
ulceration, digital gangrene, visceral infarction
• CNS- peripheral neuropathy, cord-compression from
atlantoaxial/midcervical spine subluxation, entrapment
neuropathies
• EYE- kerato cunjunctivitis sicca, episcleritis, scleritis
Serological Markers in early Rheumatoid Arthritis

Marker of Persistence
Predictor radiographic Progression

Higher Specificity

Particular value in detecting RA

Who are RF-Negative
 MRI
Pre-contrast MRI Image
Scaphoid erosion not seen

Synovitis
Bone Marrow Edema
Soft Tissue
Involvement

Post-contrast MRI Image

<12 weeks RA Assessment  HR 1.87 DMARD free-remission and 1.3 lower rate joint
destruction over 6 year compared with ≥12 weeks

Meta-analysis : Average of 9 months early DMARD  33% reduction in long tern

progression rates compared treated later
Treatment modalities for RA
 NSAIDS
 Steroids
 DMARDs
 Immunosuppressive therapy
 Biological therapies
 Surgery
 Should DMARDs be used singly or in
combination?
• Since single DMARD therapy (in conjunction with
NSAIDS) is often only modestly effective , combination
therapy has an inherent appeal.

• DMARD combination is specially effective if they

include methotrexate as an anchor drug.

• Combination of methotrexate with leflunamide are

synergestic since there mode of action is different.
Agent Usual dose/route Side effects Contraindications

Infliximab 3 mg/kg i.v infusion at Infusion reactions, Active

(Anti-TNF) wks 0,2 and 6 followed increased risk of infections,uncontrolled
by maintainence infection, reactivation DM,surgery(with hold for 2
dosing every 8 wks of TB ,etc wks post op)
Has to be combined
with MTX.

Etanercept 25 mg s/c twice a wk Injection site Active

.
reaction,URTI ,
(Anti-TNF) May be given with MTX infections,uncontrolled
or as monotherapy. reactivation of DM,surgery(with hold for 2
TB,development of wks post op)
ANA,exacerbation
of demyelenating
disease.

Golimumab Once month, subcutan Same as that of Active infections

(Anti-TNF) May be given with infliximab
MTX or as
monotherapy
 Goals of management
• Focused on relieving pain
• Preventing damage/disability
• Patient education about the disease
• Physical Therapy for stretching and range of motion
exercises
• Occupational Therapy for splints and adaptive
devices
• Treatment should be started early and should be
individualised .
• EARLY AGGRESSIVE TREATEMNT
Key Features:
 Inflammatory axial arthritis (sacroiliitis and
spondylitis)
 Peripheral arthritis (often asymmetric and
oligoarticular)
 Enthesitis
 HLA-B27 positivity
 XRay evidence of erosions + hyperostosis
(reactive bone)
 Extra-axial, Extra-articular Features
INFLAMMATORY BACK PAIN
 Peripheral Arthritis

Arthritis ( Oligoarthritis)
Arthritis ≤ 4

58% patients ever had arthritis1

Enthesitis
 Extra-articular features of SpAs

• Eyes -acute anterior uveitis

• Skin -mucocutaneous lesions
• Heart -aortic valve disease
-heart block
• Lung -apical pulmonary fibrosis
• Nerve -cauda equina syndrome
• Bone -osteoporosis
AS: A Debilitating Rheumatic Disease
Over time, joints in the spine can fuse
together and cause a fixed, bent-forward
posture
Spine Involvement
 Psoriasis Arthritis

 Symmetrical polyarthritis (RA-like) –

50%
 Asymmetrical oligoarthritis - 35%
 DIP disease - 5%
 Spondylitis (axial involvement) – 5%
Arthritis mutilans - 5%
 Cutaneus manifestation
 gluteal cleft
 scalp
 scalp line
 groin
 posterior
auricular regions
Reactive arthritis
Enteropathic arthritis
Thank You