CHAPTER 52

ALTERATIONS IN MUSCULOSKELETAL FUNCTION:

RHEUMATIC DISORDERS

LOCAL DISORDERS OF JOINT FUNCTION

• Arthritis is the most common disabling musculoskeletal disorder in the United States• Increasing age is a major factor in many

forms

OSTEOARTHRITIS• A local degenerative joint disorder

associated with aging and wear and tear from repetitive stress• Characterized by loss of articular cartilage,

wear of underlying bone, and the formation of bone spurs; noninflammatory; weight-bearing joints are often affected

OSTEOARTHRITIS (CONT.)• Signs and symptoms are localized including

joint pain and crepitus with movement• Treatment aimed at improving function with

physical therapy and reducing pain with acetaminophen or NSAIDs and intra-articular injections of corticosteroids or visco-supplementation

OSTEOARTHRITIS (CONT.)

INFECTIOUS ARTHRITIS• Joint infection most often due to bacteria

usually by way of the bloodstream• Signs and symptoms are due to localized

infection and the systemic manifestation of inflammation• Appropriate antibiotic therapy over 4-6

weeks with therapeutic joint aspiration, arthroscopy or surgical drainage

JOINT PROSTHESIS INFECTION• Staphylococcus epidermidis is a common

agent in prosthetic joint infection• Generally requires removal of the

prosthesis followed by intravenous antibiotic therapy for 4-6 weeks• Antibiotic beads may also be placed in the

wound • Prosthesis may be replaced when wound

cultures show no growth

SYSTEMIC DISORDERS OF JOINT FUNCTION

• May be related to infectious processes, or have an autoimmune or genetic etiology• Generally cause systemic signs and

symptoms involving multiple joints and other connective tissue structures• Joint destruction is inflammatory and

involves synovial membranes, cartilage, joint capsule, and surrounding ligaments and tendons

RHEUMATOID ARTHRITIS• Possibly related to autoimmune abnormality

in genetically predisposed individuals• American Rheumatism Association criteria

used for diagnosis• DMARDs recommended early in the disease• Treatment may include NSAIDs,

corticosteroids, and biological agents

RHEUMATOID ARTHRITIS (CONT.)

SYSTEMIC LUPUS ERYTHEMATOSUS

• Chronic multisystem, inflammatory, autoimmune disease characterized by periods of exacerbations and remission with multiple organs affected• Results from B-lymphocytic overactivity• Most common features are arthralgias and

synovitis• Treatment includes topical corticosteroids,

avoidance of sun, NSAIDs and/or antimalarial drugs, and immunosuppressive agents

SCLERODERMA• Multisystem inflammatory connective tissue

disease characterized by skin thickening and deposition of collagenous tissue resulting in severe fibrosis• Clinical manifestations may include

Raynaud phenomenon, polyarthritis, sclerodactyly, macular rash, and internal organ involvement• Organ specific symptomatic treatments

ANKYLOSING SPONDYLITIS• Arthritis of the sacroiliac joints that involves

the axial skeleton, and sometimes the peripheral joints• Clinical features may include low back pain,

severe morning stiffness, and limited range of motion• Treatment includes NSAIDs, DMARDs,

agents that inhibit TNF-alpha

POLYMYOSITIS AND DERMATOMYOSITIS

• Idiopathic inflammatory myopathies; focal or extensive degeneration of muscle fibers due to inflammatory infiltrates of lymphocytes and macrophages• Weakness in the proximal limb muscles,

abnormal electromyography and skeletal muscle biopsy; skin and cardiac involvement common• Treatment: corticosteroids,

immunosuppressive agents, and physical therapy

POSTINFECTIOUS SYSTEMIC DISORDERS

• Reactive arthritis (previously named Reiter syndrome) preceded by urethritis, cervicitis, or dysentery• May occur in those genetically susceptible

following a bacterial infection• Oligoarthritis typically appears 2-6 weeks

after infectious episode• Treatment may include NSAIDs, intra-

articular corticosteroids and/or immune-regulating agents

ACUTE RHEUMATIC FEVER• Inflammatory disease that follows a beta-

hemolytic group A streptococcal pharyngeal infection• Onset typically 2-6 weeks after infection• Peak incidence is between 5 and 15 years• Presents with polyarthritis and carditis• Aspirin, NSAIDs, corticosteroids, and

antibiotics used for treatment

POSTPARASITIC DISORDERS• Lyme disease• Caused by Borrelia burgdorferi, a tick-borne

spirochete; carried by deer tick• Tick bite produces red macule or papule

accompanied by flulike symptoms and may develop other organ involvement• Treatment: oral or parenteral antibiotics

JOINT DYSFUNCTION SECONDARY

TO OTHER DISEASES• Neurovascular, hematologic, and metabolic

disorders may lead to associated disorders of joint function• Most related to chronic diseases, such as

diabetes, or hemophilia, or due to altered metabolic processes such as uric acid production and clearance

PSORIATIC ARTHRITIS• Inflammatory arthritis associated with

psoriasis; peak age of onset 30-55 years• Genetic factors are supported• Peripheral joint involvement with

asymmetric oligoarthritis; combination of soft-tissue and peripheral joint disease• Treatment may include NSAIDs and

corticosteroids or immunosuppressive therapy

ENTEROPATHIC ARTHRITIS• Articular manifestations of two

inflammatory bowel diseases; ulcerative colitis and Crohn disease• Peripheral arthritis, spondylitis, and

involvement of muscle and bone• May include ocular manifestations• Treatment may include NSAIDs, COX-2

inhibitors, corticosteroids, or TNF-alpha antagonists

NEUROPATHIC OSTEOARTHROPATHY

• Commonly called Charcot joint• Bone and joint abnormalities due to loss in

normal position sense and pain responses• Most commonly due to diabetes, tabes

dorsalis, and syringomyelia• Management requires protection of involved

joint through immobilization and less weight bearing

HEMOPHILIC ARTHROPATHY• Hemorrhage stimulates a synovial

proliferative response, chronic inflammation with release of degradative proteinase, and changes in cartilage composition with less resistance to stress• Larger joints affected more commonly• Medical treatment to enhance clotting is

imperative as well as education and prevention of joint deformity

GOUT• Heterogeneous disorder in which

disturbance of uric acid metabolism leads to deposition of monosodium urate salts in articular, periarticular, and subcutaneous tissue; risk increases with age• Recurrent attacks of articular and

periarticular inflammation, accumulation of tophi, renal impairment, and uric acid calculi

ASYMPTOMATIC HYPERURICEMIA

• No clinical signs; however, serum urate levels are elevated• In males, can begin at puberty• In females, usually does not appear before

menopause• No treatment required at this stage

ACUTE GOUTY ARTHRITIS• Most common early clinical sign• Weight-bearing joints most commonly

affected; warm, red, and tender to palpation• MTP joint of the great toe most often

involved • Initial attacks can last 1-14 days; later

attacks tend to become more frequent

GOUT

INTERCRITICAL GOUT• Intercritical gout is used to describe the

intervals between acute attacks• No symptoms present but urate crystals

can still be aspirated from involved joints

CHRONIC TOPHACEOUS GOUT• Advanced stage of gout• Tophi begin to appear about 10 years after

initial onset of gout; appear commonly in the synovium, subchondral bone, olecranon bursa, and infrapatellar and Achilles tendons• Tophi can affect tissues of the ears and

eyes, and cardiac and renal structures• Deforming arthritis can develop

GOUT• Treatment: an acute gouty attack usually

requires NSAIDs, corticosteroids, and colchicine• Colchicine may be used at a lower dose to

prevent recurrent attacks• Medications to correct hyperuricemia and

prevent gout flares may target uric acid secretion by the kidneys or uric acid production (allopurinol)

ADULT-ONSET STILL DISEASE• Form of seronegative polyarthritis with a

number of symptoms similar to JRA• High-spiking fever, rash on trunk and

extremities, and possibly sore throat; can involve PIP and MCP joints of the hands and include visceral involvement• Some respond well to high-dose aspirin or

NSAIDs; corticosteroids may be used

PEDIATRIC JOINT DISORDERS• Nonarticular rheumatism: common soft

tissue syndrome with nocturnal pain; also known as ‘growing pains’• Hypermobility of joints: may cause pain in

joints• Juvenile idiopathic arthritis (juvenile

rheumatoid arthritis [JRA]): chronic inflammatory disease affecting the synovium

JUVENILE IDIOPATHIC ARTHRITIS

• Three subtypes• Systemic onset with rash, high fever, fatigue,

lymphadenopathy, splenomegaly, and polyarthritis

• Polyarticular arthritis localized to 5 or more joints• Pauciarticular arthritis affecting 4 or fewer joints

• Treatment: NSAIDs, corticosteroids, DMARDs, biologic-disease modifying agents, PT/OT