This document provides an overview of how to approach a patient with arthritis. It describes common symptoms of arthritis and how to differentiate between inflammatory and non-inflammatory types based on history, physical exam findings, pattern of joint involvement, onset and duration of symptoms, and additional features. It discusses specific types of arthritis like osteoarthritis, gout, pseudogout, septic arthritis, rheumatoid arthritis, seronegative spondyloarthritides, and others. It provides guidance on diagnostic tests, imaging, and treatment approaches for different arthritis conditions.
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Approach to arthritis
1. APPROACH TO ARTHRITIS
Guide : Dr. Sanjay Dubey Sir
Candidate : Dr. Sagar Dagdiya
Dept. Of Medicine, M.G.M.M.C. Indore
2. Arthritis is an inflammatory process affecting a
joint/joints and may present with following symptoms:
1. Pain
2. Stiffness
3. Swelling
4. Limitation of Movement
5. Weakness
6. Fatigue
3. History and Physical
Examination
Periarticular
Bursitis/Tendinitis/Ligame
nt Strain/Bone Pathology
Articular
Morning stiffness/Warmth/Erythema
Non
Inflammatory
Osteoarthritis
CTD
Inflammatory
Monoarticular
Infection/Gout/
Pseudogout
Oligoarticular
AS/Reiter'/Reactive
IBD/Psoriatic
Polyarticular
RA/SLE/
Psoriatic/CTD
Absent Present
4. Musculoskeletal Evaluation
Articular
1.Symptoms present throughout the range
of movement
2. Joint Instability
3. Swelling
4. Presence of deformity
Non Articular
1. Symptoms present at a particular point in
the range of movement
2. Joint instability absent
3. Swelling absent
4. Deformity absent
5. Articular
-Pain both at rest and during
motion
-Pain worse at rest
-Stiffness typically lasts for >30mins
-Joint swelling is related to synovial
hypertrophy, synovial effusion &/or
inflammation of periarticular
structures
-Limited range of movement
-Presence of Warmth and Erythema
-Due to alterations in the structure
or mechanics of the joint
-Pain mainly during motion &
improves quickly on rest.
-Stiffness not more 15-30 minutes.
-Swelling results due to formation
of osteophytes or due to soft
tissue swelling related to synovial
cysts, thickening or effusion.
Traumatic Degenerative Mechanical
Inflammatory Non inflammatory
6.
7. D/D on the basis of ONSET OF
SYMPTOMS
Abruptly over few
hours to days
Trauma
Crystal arthritis
Septic Arthritis
Insidiously over
weeks to months
Rheumatoid Arthritis
Osteoarthritis
Seronegative
Spondyloarthropathies
Chronic Gout
8. D/D on the basis of
DURATION OF SYMPTOMS
ACUTE, i.e. , <6weeks CHRONIC, i.e. , >6weeks
Trauma
Juxta-Articular
Septic Arthritis
Reactive Arthritis
Gout
Rheumatic Fever
Rheumatoid Arthritis
SLE
Spondyloarthropathies
OA
Haemochromatosis
9. D/D on the basis of PATTERN OF
JOINT INVOLVEMENT
Migratory Additive/Simultaneous Intermittent
Acute Rheumatic Fever
Disseminated Gonococcal
Infection
Viral Arthritis
RA
SLE
Spondyloarthritids
Gout
Viral Arthritis
Lymes Disease
10. Distribution of affected joints :
DIP involved in Psoriatic Arthritis, OA and Gout.
Axial Skeleton is involved in AS, especially Lumbar Spine
and Sacroiliac Joint.
Weight bearing joints e.g. Knee and Hip Joints are
especially involved in OA.
1st Metatarsophalengeal Joint is usually first involved in
Gout.
Heal Pain due to inflammation at the insertion of Achilles
Tendon &/or Plantar Facia is typically seen in
Spondyloarthritids.
11. 6. Extra-Articular Manifestations (Constitutional
Symptoms) :
Presence of Skin, Nail & Mucous Membrane Lesions may
points to the possibility of SLE, Psoriatic Arthritis,
Scleroderma.
Arthritis of IBD may present with the features of Crohns
Disease or Ulcerative Colitis.
Presence of Urethritis, Conjunctivitis and Arthritis may
points to the possibility of Reiter Syndrome that usually
follows after non-specific GI or GU Infections.
12. DIAGNOSIS TYPE ADDITIONAL
FEATURES
LAB & IMAGING
OA Noninflammatory,
mono/oligo/poly-
articular
Bone Spurs; knee, hip,
PIP, DIP, 1st MTP, 1st CMC.
Normal ESR/CRP,
Osteophytes, Bone
Sclerosis
Gout Inflammatory,
mono/oligo/poly-
articular
Tophi; Acute attacks f/b
spontaneous resolution
Raised UA Levels, + UA Crystals
in joint fluid, Raised ESR/CRP,
Erosions with overhanging
borders
Pseudogout Inflammatory,
mono/oligo/poly-
articular
Acute/Chronic Attacks Raised ESR/CRP Levels, +
CPPD Crystals in joint fluid
Septic Joint Inflammatory
Monoarticular, rerely
Polyarticular
Sepsis, Fever Raised ESR/CRP, + Cultures,
Leucocytosis,
Immunosuppressed
RA Inflammatory
Polyarticular
Extraarticular
Manifestations, DIP
never Involved
Periarticular Osteoporosis, +RF &
Anti-CCP, Raised ESR/CRP
Pso A. Inflammatory Oligo or
Polyarticular
Psoriatic skin rash,
Asymmetric SI Joint
Involvement,
Syndesmophytes
Erosions, Ankylosis
AS Inflammatory Bamboo Spine, Symmetric
SI Joint Involvement,
Ankylosis, Trolly Track Sign,
Dagger Sign
16. Infectious Arthritis
1.Gonococcal Arthritis (50% of all septic arthritis in sexually active
young adults) presents as migratory / additive polyarthralgias f/b
tenosynovitis or arthritis of wrist, ankle or knee with vesiculopustular
skin rashes on extremities.
2. Non Gonococcal Infectious Arthritis ( due mainly to Staphylococcus
Aureus >> Streptococcus species, Gram –ve organisms are rare &
typically seen in cases with IV drug abusers, neutropenia or post
operative cases) usually presents as fever with acute monoarticular
arthritis, though sometimes multiple joints may be involved.
17. Tubercular Arthritis
Monoarticular & most commonly affects Spine and other weight bearing
joints, 10-35% of extra pulmonary TB (hematogenous spread)
Active focus forms in metaphysis(in children) or epiphysis(in adults).
Sometimes the synovium is involved first to develop low grade Synovitis.
Localized osteoporosis is the first radiological sign of active disease.
Synovial Fluid Analysis :
1. Lymphocytes>PMN with High ADA levels
2. PCR analysis is faster and more sensitive(85-95%) but less
specific(70%)
3. The gold standard for diagnosis is synovial biopsy with positive
results in 90% of cases.
4. Culture is positive in 80% of cases.
Sometimes a dry tap can also be seen and in such cases sterile water lavage
can be helpful.
18. Variables Pyogenic Arthritis Tubercular Arthritis
Radiological Progression Rapid, Short History Slow, Insidious Onset
Marginal Erosions Early Late
Joint Space Narrowing Early Late
Periosteitis Common Rare
Sclerosis Present +/-
Osteoporosis Minimal Marked
Ankylosis Bony (common) Fibrous, except in Spine where
Bony
19. Crystal Induced Arthritis
Primary Gouty Arthritis : Mainly due to
underexcretion of uric acid (90%) rather than its
overproduction.
Pseudogout : Due to Calcium Pyrophosphate
Dihydrate Crystals deposited in bone and cartilage are
released in synovial fluid inducing acute inflammation (r/f
older age, advanced OA, neuropathic joint,
hyperparathyroidism, hemochromatosis, DM or
Hypothyroidism).
21. Rheumatoid Arthritis
-Peak incidence 4-6th Decade.
-Symmetric inflammatory polyarthritis with extra-
articular manifestations like Rheumatoid Nodules,
Pulmonary Fibrosis, Serositis, Vasculitis & +ve Serum RF.
-RF may be +ve in about 75-80% and Anti-CCP Ab may
be +ve in 50-60% of patients, Anti-CCP Ab more specific
(>95%).
-RF may be +ve in chronic infections & other CTD’s.
-Felty Syndrome : Triad of RA + Spleenomegaly +
Granulocytopenia.
- Z Deformity, Swan Neck Deformity, Boutonniere
Deformity.
23. Osteoarthritis or Degenerative Joint
Disease
-Most common form of Arthritis (Uncommon before 40yrs of age).
-Prevalence & Impairment increases with age.
-Characterised by deterioration of Articular Surface with
Subsequent formation of reactive new bone at the Articular
Surface & Decreased Joint Space.
-Joints commonly involved are Knee, Hip, PIP(Bouchard’s),
DIP(Haberden’s), 1st CMC.
-Joints spared are Wrist, MCP(except Thumb), Elbow, Ankle.
-Pathophysiology : Abnormal Cartilage repair & remodelling.
(Chondrocytes release Proteolytic Enzymes that destroy Cartilage leading to Subchondral
Sclerosis and Cysts with Marginal Osteophytes.)
28. Ankylosing Spondylitis : Sacroiliatis, Syndesmophytes,
Squaring of Vertebrae Bamboo Spine, Dagger Sign, Trolley
Track Sign on X-Ray, Pain improves with Exercise and
worsens on Rest.
Psoriatic Arthritis : Psoriatic skin changes seen in 60-70%
of cases whereas Nail changes seen in 90% of cases.
Arthritis Mutilans and Pencil in Cup Deformity.
29. Reactive Arthritis :
Triad of Urethritis, Conjunctivitis & Arthritis.
Ocassionally preceded by GI or GU infections.
Syndrome is transient lasting for 1 to several
months but chronic arthritis may develop in 4-19%
of cases.
30.
31.
32. Soft Tissue Rheumatism
-Most common cause of Musculo-Skeletal Pain.
-Mostly associated with Fibromyalgia.
-Characterised by Bursitis, tendonitis or tenosynovitis.
-Improves with Local Steroid Injections.
33. Polymyalgia Rheumatica(PMR)
-Presents in elderly males as proximal limb girdle pain,
morning stiffness and constitutional symptoms.
-Associated with Temporal Arteritis(TA) in 40% of cases.
-Patients with TA presents with headache, scalp
tenderness, jaw & tongue claudication, vision
disturbances and stroke.
-PMR : Elevated ESR
-TA : Elevated ESR (often >100mm/hr.)
