1. Approach to a patient with
arthritis
Presenter:
Dr Md Mobin Imtiaz
Assistant Registrar
Dept of Medicine
SSNIMCH,Kishoreganj

2. Introduction
• Arthritis: A patient is said to have arthritis if one
has joint pain and swelling, and the origin of “joint
pain” (True arthritis) is from the Joint (articular)
structures, in contrast to pain arising from peri-
articular structures
• Articular structures include Synovium, synovial
fluid, cartilage, intra-articular ligaments, the joint
capsule and the adjacent bone
• Peri-articular structures include ligaments,
tendons, bursae, muscle, fascia , bone and nerve

3. SYMPTOMS
• Pain
• Swelling
• Stiffness
• Limitation of motion
• Loss of function
• Fatigue
• Weakness

4. SIGNS
• Tenderness- In the musculoskeletal examination,
tenderness indicates unusual discomfort on palpating
and putting pressure on articular and periarticular
tissues.
• Crepitation- Crepitation is a palpable or audible grating
or crunching sensation produced by motion. This
sensation may or may not be accompanied by
discomfort.
• Deformity- Deformity of the joints may manifest as a
bony enlargement, articular subluxation, contracture,
or ankylosis in non anatomic positions.
• Instability - Joint instability is present when the joint has
greater than normal movement in any plane.

5. Classification of Arthritis
#Based on Number of joints involved:
• Monoarthritis-Single joint involvement
• Oligoarthritis- 2-4 joint involvement
• Polyarthritis- Pain and swelling involving 5 or
more joints
#Based on duration of Arthritis;
• Acute arthritis-Duration less than 6 weeks
• Chronic arthritis-Duration more than 6 weeks

6. Causes of monoarthritis
• Common
1. Gout 5. Spondyloarthritis
2. Pseudogout 6. Psoriatic arthritis
3. Trauma 7.Reactive arthritis
4. Haemarthrosis 8. Enteropathic arthritis
• Less common
1. Rheumatoid arthritis 5. Tuberculosis
2. Juvenile idiopathic arthritis 6.Leukaemia
3. Pigmented villonodular synovitis 7.Gonococcal
4. Foreign body reaction 8.Osteomyelitis

7. Common causes of polyarthritis
1. Rheumatoid arthritis
2. Viral arthritis
3. Osteoarthritis
4. Psoriatic arthritic
5. Axial spondyloarthritis
and enteropathic
arthritis
6. Systemic lupus
erythematosus
7. Juvenile idiopathic
arthritis
8. Chronic gout
9. Chronic sarcoidosis
10. Poncet’s disease
11. Calcium
pyrophosphate
arthritis

8. Approach to patient with ARTHRITIS
A careful history taking and thorough clinical examination may
guide towards the diagnosis.

9. History taking
• Age, gender, occupation may give clue regarding the diagnosis.
• Age-
<30 = SLE, Ankylosing spondylitis, Reactive Arthritis, JIA
30-50 = RA, Psoriatic arthritis, Systemic sclerosis,
>50 = OA, Gout, Pseudogout
Any age group = Septic arthritis but increased prevalence
with increasing age

10. • Sex:
>Female : SLE, RA, JIA, OA
Male=Female : Psoriatic arthritis, Pseudogout,
Enteropathic arthritis.
>Male : Gout, Ankylosing spodylitis,
Reactive Arthritis.

11. • Occupation: Farmers (hip OA)
Miners (Knee OA)
Professional athletes( Knee and Ankle OA)
• BMI : Obesity is associated with increased risk of
OA, Gout

12. • Past medical history:
1. H/O trauma, surgery, intra-articular injection – Septic
arthritis
2. Myeloproliferative /lymphoproliferative disease- Gout
3. Psoriasis-Gout,Psoriatic arthritis, Axial spondyloarthritis
4. IBD- Axial spondyloarthritis
5. TB, Leprosy, Pneumoia, Gastroenteritis – ReA
6. HIV- Reactive arthritis, Psoriatic arthritis
7. Skin infection or Upper RTI- Septic arthritis

13. • Family history: OA, RA, Psoriatic arthritis, SLE
• Drug history:
Drugs Disease
Thiazide or loop diuretics, ACEi,
Aspirin,Pyrazinamide
Gout
Immunosuppressive drug Septic arthritis
Hydralazine, procainamide,
quinidine, isoniazide,
pyrazinamide, phenytoin,
chlorpromazine
Drug induced lupus

14. • Personal history :
1. IV drug abuser- Septic arthritis
2. Sexual contact- ReA

15. Joint pain elaboration
• Symptom Onset:
• If patients present with abrupt onset of symptoms, consider
septic arthritis, gout, pseudogout
• whereas if symptoms were present for months/years,
rheumatoid arthritis (RA), psoriatic arthritis (PsA), SLE, chronic
infection (e.g. hepatitis, HIV) and OA are differentials.

16. • Pattern of Joint Involvement:
1. DIP,PIP, entheses, large peripheral joint - Psoriatic arthritis
2. PIP,MCP,MTP - Rheumatoid arthritis
3. Spine, sacroiliac -Axial spondyloarthritis.
4. Any but more commonly knee or ankle-Septic arthritis
5. Hip, knee, PIP,DIP, 1st MCP, L/S, C/S – OA
6. Knee, wrist, shoulder- Pseudogout
7. 1st MTP, ankle, midfoot, knee, small joints of hands, wrist and
elbow - Gout
• Symmetry
1. Symmetrical: RA,OA, viral arthritis
2. Asymmetric: (LL>UL) Axial Spondyloarthritis, psoriatic arthritis,
gout

18. • Disease Course:
Patients who have chronic symptoms may describe varying
patterns of presentation ranging from an
1. Intermittent pattern e.g. RA, polyarticular gout, sarcoid
arthritis, Reiter’s syndrome ,psoriatic arthritis, OA
2. Additive pattern e.g. RA, SLE.
3. Migratory pattern e.g. Rheumatic fever, Gonococcal
arthritis, Viral Arthritis

19. • Associated Symptoms
1. Morning stiffness: >1hr= RA,SLE
< 15 min= OA
2. Cardinal signs of inflammation (redness, warmth,swelling, pain
in the morning) may have an inflammatory arthropathy.
3. Pain character :
Aggravated by motion= Mechanical
Relieved by motion= Inflammatory
4. Fever: Septic arthritis, ReA, RA, SLE, Crystal induced arthritis, JIA

20. Other symptoms
•Rash: Viral arthritis, JIA, SLE,
•Weight loss: RA, SLE, ReA, TB, HIV
•Muscle wasting: OA, RA,
•Breathlessness: RA, SLE
•Oral ulceration: SLE,ReA, Behcet’s disease
•Altered consciousness: Gout, Pseudogout, Septic arthritis, SLE
•Blurring/loss of vision, eye pain: RA, SLE, Axial
spondyloarthritis, ReA, JIA, Behcet’s disease.

21. Clinical examination
• Anemia: RA, SLE, axial spondyloarthritis
• Nail change(dystrophy, psoriasis): ReA, Psoriatic arthritis,
• Lymphadenopathy: SLE, RA
• Raised temperature: Septic arthritis, ReA, RA, SLE, Crystal
induced arthritis, JIA

22. Hand examination findings
• Deformity: RA(swan neck. Buttonnier,Z deformity), psoriatic
arthritis(telescoped fingers), Systemic sclerosis( sclerodactyly),
SLE( Jaccoud arthropathy)
• Ulnar deviation: RA , OA
• Raynaud’s phenomenon: SS, SLE
• Heberden’s(DIP) and Bouchard’s(PIP) nodes: OA
• Tophi: Gout
• Nodule: RA, Rheumatic fever
• Tenderness present or not: Indicates active disease

26. Psoriatic arthritis DIP pattern with accompanying nail dystrophy (pitting and
onycholysis)

27. Examination of joint
Articular vs. Periarticular:
• In patients with articular pain, the joint capsule is diffusely
involved; thus, pain is often deep and is associated with a
global decreased range of active and passive motion in all
planes
• Those who have periarticular abnormalities may have point
tenderness in the surrounding soft tissue, and pain occurs only
with active range of motion in a few planes
• The differential diagnoses in patients with periarticular pain
may include FM, fracture, bursitis, tendinitis, enthesitis

28. Arthralgia vs. Arthritis :
• Characteristics that distinguish arthritis include warmth,
erythema, tenderness to palpation and synovial effusion. Any or
all of these findings may accompany arthralgia.
• Range of motion, muscle strength, and function may be limited
around the inflamed joint.
• In an effort to reduce joint volume and pain, the patient often
will involuntarily hold the joint in a position of partial flexion.
Hence, joint contractures may indicate an underlying
inflammatory process (present or past)

29. Look feel and move
• Look for any deformity, signs of inflammation, skin condition
over joint, muscle wasting, posture abnormality
• Feel any crepetation over joint, joint line tenderness, sub-
cutaneuos nodule
• Move both passive and active movement, check range of
movement
• Check gait of the patient

30. Other system examinations
1. Nervous System: SLE, Behcet,vasculitis
2. Respiratory: RA,SLE, SS, sarcoidois, vasculitis
3. Cardiovascular system :RA,SLE, SS, rheumatic fever
4. Renal system: SLE, vasculitis, Polyarticular gout.
5. Elimentary system : Reiter’s, IBD, SS

31. Extra articular manifestations
• Ocular manifestations:
1. Scleritis, episcleritis, keratoconjunctivitis: RA
2. Uveitis : Axial spondyloarthropathy, JIA
3. Conjunctivitis: ReA

32. Episcleritis Scleritis

33. Acute anterior uveitis Conjunctivitis

34. • Skin manifestations:
1. Malar rash, discoid rash, scarring alopecia: SLE
2. Psoriasis: ReA, Psoriatic arthritis
3. Circinate balanitis, keratoderma blennorrhagica : ReA
4. Telangiectasias: SS
5. Livedo reticularis : SLE, APS
6. Pyoderma gangrenosum, ulcers, vasculitic lesions : RA

35. Pyoderma gangrenosum

36. Laboratory investigations
• Acute Phase Reactants:
• Elevations in acute phase reactants such as erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) provide
a surrogate measure of inflammation
• Raised ESR but normal CRP: SLE (unless serositis or co
infection) and SS

37. Complete blood count
1. Anemia: RA, SLE, axial spondyloarthritis
2. Leukocytosis : Septic arthritis
3. Pancytopenia: SLE, RA(Felty syndrome)
4. Neutrophilia: Gout

38. • Baseline Liver function tests, Renal function tests,
examination of urine for proteinuria and active sediments,
Plain chest radiograph, ECG and Echocardiogram should be
done in all chronic inflammatory polyarthritis
• Blood culture is indicated for Septic arthritis

39. Serological tests
• Uric acid concentration: Gout (maybe normal in acute attack)
• Salmonella, brucella Parvovirus serology : ReA
• Hepatitis B and C, Rubella, Chikungunya virus, HIV serology :
Viral arthritis
• Antibody tests:
1. ANA= SLE, SS
2. Anti-dsDNA = SLE
3. RF= RA
4. Anti-CCP antibody = RA
5. Anti-topoisomerase 1, anti-centromere = SS
• Serum C3 level: Low in active SLE

40. Joint X-ray
• Characteristic findings on radiographs of Inflammatory
arthritis may include:
• Soft tissue swelling,
• Chondrocalcinosis
• Joint effusion
• Juxta-articular osteopenia
• Symmetric loss of articular cartilage with joint space
narrowing
• Bony erosions- important markers of progressive damage

41. Disease specific findings
• Rheumatoid arthritis
1.Periarticular osteoporosis
2. Joint subluxation
3.Marginal joint erosions
4. Joint space narrowing
• Osteoarthritis
1.Joint space narrowing
2. Osteophyte
3.Subchondral sclerosis
4. Joint deformity
5. Subchondral cysts

42. Cont.
• Psoriatic arthritis:
1. Proliferative enthesis erosions
2. Syndesmophytes
3. Enthesophytes
4. Bone sclerosis
5. Juxta-articular new bone
6. Sacroiliitis
• Gout: Normal in acute attack, erosion in chronic/topaceous
• Pseudogout: calcification in hyaline cartilage and/or
fibrocartilage or at periarticular entheses.

43. Cont.
• TB: Periarticular osteoporosis, bone erosions and joint space
narrowing. These are non specific.
• AS: X-rays of the sacroiliac joint show irregularity and loss of
cortical margins, widening of the joint space and subsequently
sclerosis, joint space narrowing and fusion.
Lateral thoracolumbar spine X-ray shows anterior ‘squaring’ of
vertebrae, bridging syndesmophytes, ossification of the
anterior longitudinal ligament and facet joint fusion.
combination of these features may result in the typical
‘bamboo’ spine

44. • Reactive arthritis: In contrast to AS, radiographic sacroiliitis is
often asymmetrical and sometimes unilateral, and
syndesmophytes are predominantly coarse and asymmetrical,
often extending beyond the contours of the annulus (‘non-
marginal’)
• Psoriatic arthritis : X-rays may be normal or show juxta-
articular osteoproliferation or erosive change with joint space
narrowing. Features that favour PsA over RA include the
characteristic distribution of erosions with osteoproliferation,
absence of periarticular osteoporosis and osteosclerosis.

45. Swan neck deformity

49. Joint fluid aspiration and study
• Mandatory in Septic arthritis, crystal induced arthritis. Help
to differentiate inflammatory from non-inflammatory
arthritis.
• Polarized microscopy of joint fluid shows Monosodium
urate monohydrate crystal in gout and Calcium
pyrophosphate (CPP) crystals in pseudogout.
• Synovial fluid from an inflamed joint is typically yellow
and turbulent from inflammatory cells. White cell counts
are typically greater than 10,000 cells/mm (range, 5000
to 50,000 cells/mm), with a predominance in neutrophils.
• In contrast TB arthritis shows predominant lymphocyte
and monocyte

50. MSU crystal under polarized microscopy

51. https://www.researchgate.net/publication/239944195/figure/tbl2/AS:202597014216716@1425314300402/Synovial-
fluid-appearance-of-normal-and-diseased-joints-30-cases.png

52. Cont.
 Synovial bopsy is gold standard in TB arthritis.
Also needed for diagnosis of-
• Sarcoidosis,
• Amyloidosis
• Pigmented villonodular synovitis
• Foreign body synovitis

53. Cont.
• MRI: More sensitive in diagnosis of spine TB, Sacroiliitis of
axial spondyloarthritis, enthesitis
• USG of joint: More sensitive in diagnosis of synovitis. Also
used for guided aspiration.

56. Specific diagnostic criteria