“Painful joints”How is a diagnosis reached?

Classification of rheumatic disease

Terminology – just to be clear!?• -opathy diseased• -itis inflammation• -algia pain

• Arthr- relating to joints• Spondyl- relating to axial joints (ie spine)• Myo- relating to muscles• Dactyl- relating to digits (ie fingers or toes)

• Mono- single• Oligo- several (<5)• Poly- multiple

• And when we are not using classical languages we name them afterhistorical physicians!

– Wegener’s, Heberden’s, Sjogren’s

Joint pain

• The medical term is “arthralgia”• Up to 25% of all GP visits are due to

musculoskeletal pain• Mostly this is due to “soft tissue

rheumatism”• Many have osteoarthritis• A minority of patients have inflammatory

arthritis

• Autoimmune Inflammatory Arthritis

• Rheumatoid arthritis– Seropositive, Seronegative, Anti-

CCP positive, “Nodular”, “Erosive”• Seronegative spondyloarthritis

– Psoriatic arthritis, reactive arthritis, ankylosing spondylitis, inflammatory bowel – related arthritis

• Connective tissue disease– Vasculitis, systemic lupus

erythematosis, systemic sclerosis, Primary Sjogrens, dermatomyositis, PMR

• Clinical diagnoses based on pattern recognition supported by clinical test results

• Non-inflammatory causes of joint pain

• Trauma• Osteoarthritis

– “nodal”, “spondylosis”• Malignancy – usually metastatic• Metabolic

– Pagets• Etc, etc

• Clinical diagnosis often based on imaging

Other inflammatory conditions….

• Septic arthritis– Native or replaced joint– Emergency with up to 50% mortality rate

• Crystal induced arthritis– Gout, pseudogout

• Diagnosis based on joint aspiration• Look identical clinically!

First question..• Is pain due to inflammation?

– Swelling?– Early morning stiffness greater than one

hour?– Raised inflammatory markers?

• Many conditions can cause pain• GPs are excellent at managing joint symptoms with pain relief• Swelling indicates a need for additional more specific treatments• Rheumatologists are “inflammation doctors”

Second question

• What is the pattern of joint swelling?

• How many joints are involved?• Which joints are involved?• Acute or gradual onset?• Duration of swelling?• Associated features?

– Diagnosis is based on pattern recognition

Rheumatoid Arthritis

Commonest reason for chronic DMARD therapy

Rheumatoid diseaseChronic symmetrical deforming arthritis of many small and

large joints. Not only the joints are involved.

CARDIOVASCULAR RISK= DM

osteoporosis

lymphoma

Early rheumatoid arthritis

Methotrexate

Combination DMARDS

Steroid injections

Multidisciplinary team

ESR/CRP likely to be elevated

RF or anti-CCP may be positive or negative

Xrays normal, ultrasound may be used to detect subtle swelling

Non-specific changes to Hb, plt, alk phos, GGT, total protein inkeeping with inflammation

Goals of treatment

• Aim for remission!!

• Treating swelling and tenderness can:-– Prevent joint damage– Maintain function– Protect family roles and independence– Maintain employment

Key points

• Ongoing joint inflammation = ongoing joint damage

• The earlier treatment is started the better• Rheumatoid arthritis may be a chronic

disease but with good treatment the symptoms need not be…..– Don’t be surprised if you come across

patients on multiple treatments whose arthritis does not seem that bad!

Seronegative spondyloarthritis

Inflammatory arthritis that can involve the sacroiliac joints and spine. An

entirely different group of diseases to RA.

Ankylosing spondylitisInflammatory disease of sacroiliac joints and spine. Peripheral joints may also be involved. Uveitis may be associated.

Psoriatic arthritis

• Single or multiple inflamed joints in association with a personal or family history of psoriasis

Seen in up to 90% of patients

DIP swelling Arthritis Mutilans

Dactylitis

Reactive arthritisThe body’s response to a prior infection. Usually secondary to gastroenteritis or sexually transmitted infection. Classically a triad of symptoms - sore where you see, sore when you pee, sore in your knee! Previously known more commonly as Reiter’s disease.

Keratoderma blenorrhagicum

Circinatebalanitis

Asymmetrical lower limb arthritis

conjunctivitis

Inflammatory bowel disease related arthritis

• Seen in association with Crohns and colitis. Asymmetrical sacroiliac joint involvement and peripheral arthritis.

Connective tissue disease

scleroderma

lupus

dermatomyositis

vasculitis

Multisystem disease

Granulomatousvasculitis

autoantibodies

Crystal arthritis

The commonest explanation for joint swelling in general practice

Agony!destructive

Urate crystals

tophi Podagra – gout at the great toe

Any questions?

• Everything you ever wanted to know about terminology but were too afraid to ask….

What is in and what is out…• IN

– Methotrexate– Combination DMARD

treatment– Biologic drugs– Tight control– Musculoskeletal

ultrasound– Anti-CCP testing– Cardiovascular risk– Osteoporosis risk

• OUT– Long-term daily

NSAID– Sequential

monotherapy– Penicillamine, oral

gold, minocycline– Methotrexate and

leflunomidecombination therapy