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ALL YOU NEED TO KNOW ABOUT JOINT PAIN ! Elena Boby and Nidhi Rege Dr Catharine Kwok Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!Osteoarthritis focus Elena BobyMrs Smith, a 72 yr old woman, presents to her GP with severe pain in her buttocks. How should the GP proceed? First step - always take a good history! ■ She feels the pain most on her right side, it started around 6 months ago and is progressively getting worse ■ She feels a little stiff in the mornings but there is no pain - it comes on after she takes her dog for his morning walk ■ the pain is mostly in her buttocks but sometimes radiates to her groin and outer thigh ■ By the end of the day the pain is usually at its worstF eatures of OA - from the history - Gradual onset of pain - For hip OA, pain is usually felt in the buttocks, groin and outer thigh - Pain is worse after exercise/ activity (ie worse at night) - Pain is relieved by rest (least pain in the morning) - There are no sensory changes (sciatica?)After history of presenting complaint, we would take a full history. Which risk factors should be look out for that support a diagnosis of OA of the hip? Obesity Injury Increasing age Structural abnormalities - when the hip What puts Mrs joint doesn’t fit together Smith at a properly, there Joint overuse greater risk of is more chance osteoarthritis? of bone rubbing against bone. E.g. Perthes disease Female gender Alcohol SmokingInvestigations: at the bedside Joint examination Hip examination - Antalgic gait (shorter stride length with affected leg) - Weakness on movement worsened with resistance - Crepitus - Muscle wasting around the joint - Stiffness (makes it difficult to move and rotate the leg) We also examine the joint below and the joint above so - Knee examination - Spine examination Sensory and motor neurological examination *realistically in an OSCE there will only be time to examine the joint but just mention you would also do neuro examInvestigations - imaging AKA the mainstay of orthopedics So what are we looking for ? L - Loss of joint space O - Osteophyte formation S - Subchondral sclerosis S - subchondral cysts Credits: OrthobulletsOsteoarthritis of the hand CMC + DIP affected more than PIP Nodes (due to osteophyte formation) 1. Heberden's nodes at the DIP joints 2. Bouchard's Nodes at the PIP jointsWhat is the initial management for Mrs Smith ? A) Advise her to try heating pads and ibuprofen gel B) Prescribe her oral ibuprofen C) Prescribe her oral diclofenac with a PPI D) Refer to orthopedics for hip replacement surgery E) Administer intra-articular corticosteroid injectionFramework for Management Conservative 1. Oother aspects of lifestyle like smoking and drinking)nd optimise 2. Gaerobic fitnessut muscle strengthening exercise and general 3. Analgesia - first line is always topical NSAIDsFramework for management Medical 1. Analgesia with oral NSAIDs (+ PPI) 2. Intra-articular steroids for short term pain relief (last around 2-10 weeks)Framework for management Surgical : joint replacement surgery As with any surgery, patients need to be counselled on the risks,these include 1. Perioperative (VTE, infection, nerve injury) 2. Leg length discrepancy 3. Posterior dislocation 4. Aseptic loosening - most common cause for revision if the surgeryWhat is the initial management for Mrs Smith ? A) Advise her to try heating pads and ibuprofen gel B) Prescribe her oral ibuprofen C) Prescribe her oral diclofenac with a PPI D) Refer to orthopedics for hip replacement surgery E) Administer intra-articular corticosteroid injectionLet’s consider some alternative pathologies for a similar presenting complaint aching and morning stiffness in her hip, shoulder and knee joints. This has been ongoing for a month during which she’s been incredibly tired and mentions her clothes have been getting looser but she says this could be because she doesn't want to eat as much because it ‘hurts her jaw.’ should be checked? The GP decides to order some blood tests because the history points towards a diagnosis other than OA - what are some identifiable red flags? Arthritis would have a much longer period of onset Mrs Doe is a 65 year old woman presenting to her GP with aching and morning stiffness in her hip, shoulder and knee joints. This has been ongoing for a month during which she’s been incredibly tired and mentions her clothes have been getting looser but she says this could be because she doesn't want to eat as much because it ‘hurts her jaw.’ Very rare to get systemic features in OA Indicates claudication, again not a feature of OAThe blood tests ran were all normal, besides a raised ESR. What is the most appropriate management at this stage? A) Ibuprofen gel for the affected joints and enrollment to an exercise programme for muscle strengthening B) Administer high dose prednisolone immediately C) Refer for a same day temporal artery biopsy D) Advise a ‘soup only’ diet until further investigation can be doneThe blood tests ran were all normal, besides a raised ESR. What is the most appropriate management at this stage? A) Ibuprofen gel for the affected joints and enrollment to an exercise programmefor muscle strengthening - this would be correct if OA was the most likely diagnosis B) Administer high dose prednisolone immediately - most likely diagnosis is Temporal arteritis, which has a strong association with polymyalgiarheumatica C) Refer for a same day temporal artery biopsy - with GCA, treat first then investigate D) Advise a ‘soup only’ diet until further investigation can be done - not sustainable and does not address the cause of the jaw painPolymyalgia rheumatica - Key points - Features: aching and stiffness in the proximal muscles usually accompanied by fatigue, weight loss and other systemic features Weakness is NOT a symptom - Does not have to appear in conjunction with GCA but if it does -> TREAT ASAP - Blood results will show raised inflammatory markers but creatinine kinase will be normal (unlike myositis, which has a similar presentation) - Management is with glucocorticoids (with bone protection) and patients will dramatically respond to this treatment, if they don’t, consider an alternate diagnosisJohn is a 21 year old male. He has presented to the GP with back pain which started a couple months ago, he is currently doing an apprenticeship as an electrician and he says being at work really helps the pain because it worse in the mornings and while he rests. Amyloidosis (any CaudA equina (any swelling in your ankles issues with your A V node block (any or changes when bowels? ) palpitation or fainting?) passing urine? In a young male with back Anterior uveitis (have pain of insidious onset, the you noticed any working diagnosis would be Apical fibrosis (Have changes in your Ankylosing spondylitis. So we you noticed any vision?) need to ask about the 8 As… problems with your breathing) Achilles tendonitis (any Aortic regurgitation pain in your heel or (similar questions to calf?) Peripheral Arteritis AV node block) (any pain or swelling in your arms or legs)Investigations: Bedside: Spine examination: - Positive schober's test - forward flexion is reduced - Reduced lateral flexion Depending on constitutional systems, its worth doing a full systems examination especially CV and Resp (most likely shows reduced chest expansion Bloods: - HLA - B27 (has little value in diagnosing as it is also +ve in 10% of people without A.S but can be useful to rule it in as 90% will have it) Investigations: X -ray of the sacroiliac joint Syndesmo- Also do CXR -> phytes Apical fibrosis If X-ray is negative -> MRI to confirm Squaring of Bamboo spine lumbar with dagger sign vertebraeHow should John be managed initially? A. Eanalgesiaregular exercise and prescribe topical diclofenac for B. Physio + prescribe prednisolone with bone protection C . Advise limited activity to not agitate the joint further D. Rheumatology referral for infliximab therapy E. Trial rheumatoid arthritis treatment e.g. sulfazine1. analgesia - NSAIDs (starting with topical), regular exercise and physio is the first line management 2. Physio + prescribe prednisolone with bone protection - steroids are not indicated for the management of A.S 3. Advice limited activity to not agitate the joint further - exercise and joint use is the recommendation 4. would be done when A.S is suspected and secondly, anti-TNF is onlyl used for patients with persistently high disease activity 5. Trial rheumatoid arthritis treatment e.g. sulfazine - again, not the initial Mx aslo, only useful if there is peripheral joint involvement Mark is a 78 year old male presenting with a swollen, painful knee which started getting worse last night but has been hurting for the last couple weeks. On examination , it is hot to touch and there is restricted movement. He’s been feeling unwell for quite sometime now and initial observations in A&E showed a temperature of 38 degrees. What is the most likely diagnosis? A) Osteoarthritis B) Reactive arthritis C) Septic arthritis D) Pseudogout E) Rheumatoid arthritisA) Osteoarthritis - Systemic upset would be very rare and pain would worsen gradually as opposed to overnight B) Reactive arthritis - ‘can’t see, pee or climb a tree’, the question will usually talk about conjunctivitis, urethritis and lesions on the soles of the feet. C) Septic arthritis -time of onset, fever and hot tender joint points towards this, most likely caused by S. aureus. Needs joint aspirate to confirm and Mx with flucloxacillin D) Pseudogout - systemic infection makes this unlikely. X- ray would be used to confirm (chondrocalcinosis seen) E) Rheumatoid arthritis - history would have a longer onset period for symptoms and very unlikely just the knee would be affectedRheumatoid Arthritis and other causes Nidhi RegeHow do you feel about Rheumatological causes of Joint pain? 1 - Know nothing 2 - Know bits and bobs 3 - Kind of confident 4 - Very confident 5 - I can teach this myself !A 64 year old woman presents in A+E with bilateral joint pain in her hands and wrists .. What would you like to do? What would you like to do? ALWAYS 1. History structure 2. Examination your answers in 3. Investigations settings!History She tells you that the joint pain is on both hands, she notices some boggy swellings on fingers. Her joints feel stiff as well. with exercise.that the pain is worse in the morning, improves after an hour and She also complains of increasing tiredness and has the odd fever here andthere.History She tells you that the joint pain is on both hands, she notices some boggy swellings on fingers. Her joints feel stiff as well. She tells you that the pain is worse in the morning, improves after an hour and with exercise. She also complains of increasing tiredness and has the odd fever here andthere. Is this osteoarthritis or rheumatoid arthritis?History She tells you that the joint pain is on both hands, she notices some boggy swellings on fingers. Her joints feel stiff as well. She tells you that the pain is worse in the morning, improves after an hour and with exercise. She also complains of increasing tiredness and has the odd fever here and there. These parts in the history suggest systemic disease, pointing you in the direction of RA!What is Rheumatoid Arthritis? Chronic systemic inflammatory disease. It results in symmetrical deforming peripheral arthritis… In what way?Y ou look at the patient’s hands Which of these findings is NOT characteristic of Rheumatoid Arthritis? 1. Ulnar deviation 2. DIP joint involvement 3. Boutonnière Deformity 4. Swan neck deformityY ou look at the patient’s hands Which of these findings is NOT a characteristic finding of Rheumatoid Arthritis? 1. Ulnar deviation 2. DIP joint involvement For your exams: DIP joint 3. Boutonnière Deformity involvement is more indicative of 4. Swan neck deformity Although make sure to look at wider clinical context!Rheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes:Rheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes: Ulnar deviationRheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes: Ulnar deviationRheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes: Boutonnière Deformity Ulnar deviationRheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes: Boutonnière Deformity Ulnar deviationRheumatoid Arthritis - a spot diagnosis! - In early disease the fingers are swollen, painful, and stiff. - Inflamed tendon sheaths may result in a carpal tunnel like syndrome But with disease progression, the joint deformity causes: Boutonnière Deformity Swan Neck Deformity Ulnar deviationIn real life… Early disease Late diseaseAnd you do an X -Ray of her MCP joints which looks like this: Which of these is NOT an X ray finding of Rheumatoid Arthritis? 1) Loss of Joint Space 3) Juxta-articular osteopenia 4) Subarticular SclerosisAnd you do an X -Ray of her MCP joints which looks like this: Which of these is NOT an X ray finding of Rheumatoid Arthritis? 1) Loss of Joint Space 3) Juxta-articular osteopenia 4) Subarticular SclerosisX- ray findings of RAOA x-ray vs RA x-ray Osteoarthritis Rheumatoid ArthritisIn real life… Osteoarthritis Rheumatoid ArthritisY ou can do investigations to aid your diagnosis.. But RA is a clinical diagnosis. Refer to Rheumatology! What would they do? 1. Offer analgesia for the pain 2. Prescribe bisphosphonates 3. bridging prednisolone Disease Modifying Anti Rheumatic Drugs with 4. Prescribe dual therapy Disease Modifying Anti Rheumatic Drugs with bridging prednisoloneWhat is first line in managing Rheumatoid Arthritis? 1. Offer analgesia for the pain 2. Prescribe bisphosphonates 3. Prescribe monotherapy Disease Modifying Anti Rheumatic Drugs with bridging prednisolone 4. Prescribe dual therapy Disease Modifying Anti Rheumatic Drugs with bridging prednisoloneWhat are Disease Modifying Anti-Rheumatic Drugs? (DMARDs) diseases, and some cancers!athies like RA, but also other connective tissue Examples include: - Methotrexate - Sulfasalazine - Leflunomide - HydroxychloroquineMost widely used DMARD - Methotrexate? What is the drug action? - Folate antagonist - Folate agonist - Calcitonin agonist - Calcitonin antagonistMost widely used DMARD - Methotrexate. What is the drug action? - Folate antagonist folic acid with - Folate agonist methotrexate. - Calcitonin agonist contraindicated in pregnancy! - Calcitonin antagonistMore about methotrexate - Give folic acid supplementation alongside - Contraindicated in pregnancy - For monitoring do regular FBC’s and LFT’s As risk of myelosuppression and liver cirrhosis - Another side effect to remember about methotrexate that it can cause methotrexate pneumonitis! Do a pre-treatment CXR - Patients may also experience mouth ulcers2nd Line treatment - But wait… But how do you know treatment isn’t working? What score is used to monitor rheumatoid arthritis? 1. Epworth Score 2. CURB-65 3. DAS28 4. Waterlow Score What score is used to monitor RA? Magic Number = 5.1 Indicates High Disease Activity 1. Epworth Score 2. CURB-65 3. DAS28 - uses a combination of CRP and disease activity 4. Waterlow ScoreFurther treatments 1. Try at least 2 DMARD monotherapy regimes 2. Switch to biologic DMARDs (also known as biologics) TNFa inhibitors - e.g. infliximab, ethenercept, adalimumab Always worth checking for HIV, TB, Hep B/C B cell depletion - e.g. rituximab anything that could cause immunosuppression IL1 and IL6 inhibitors - e.g. tocilizumab Inhibition of T cell costimulation - e.g. abatacept 3. Switch to JAK inhibitors How can you treat flares? 1. Painkillers 2. Steroids 3. DMARDs 4. Biologics How can you treat flares? 1. Painkillers 2. Steroids - these can be intra articular if localised to a joint, or give oral / IM 3. DMARDs 4. BiologicsRheumatoid Arthritis - a systemic disease!Rheumatoid Arthritis - a systemic disease! You can get these on: - Lungss - Heart - CNS - Cause Lymphadenopathy - Cause Vasculitis Rheumatoid NodulesRespiratory Complications - Pulmonary fibrosis - Pleural Effusion - Pulmonary Nodules - Bronchiolitis Obliterans - Methotrexate Pneumonitis - Caplan Syndrome - large fibrotic nodules seen in people with occupational dust exposureCardiac Complications - Interstitial Heart Disease - Pericarditis - Pericardial EffusionOcular Complications - Keratoconjunctivitis Sicca (Dry eye) - most common - Corneal Ulceration - Keratitis - Episcleritis - Scleritis Treatment induced: - Steroid induced cataracts - Chloroquine Retinopathy MDT Management 1. Occupational Therapists Involvement 2. Physiotherapist Involvement 3. Consider Surgical Management Felty Syndrome - a question bank favourite! What is it? 1. Diabetes + Anaemia + Keratitis 2. RA + Diabetes + Keratitis 3. RA + Splenomegaly + Neutropenia 4. RA+ Keratitis + Neutropenia Felty Syndrome - a question bank favourite! What is it? 1.Diabetes + Anaemia + Keratitis 2. RA + Diabetes + Keratitis 3. RA + Splenomegaly + Neutropenia 4. RA+ Keratitis + NeutropeniaA 65 year old man presents with severe acute joint pain over his first metatarsal. He has chronic kidney disease and takes indapamide as part of it. Polarised Light Microscopy shows negatively birefringentneedle shaped crystals What is your most likely differential? 1) Gout 2) Rheumatoid Arthritis 3) Pseudogout 4) OsteoarthritisA 65 year old man presents with severe acute joint pain over his first metatarsal. He has chronic kidney disease and takes indapamide as part of it. Polarised light microscopy of the synovial fluid shows negatively birefringent needle shaped crystals. What is your most likely differential? 1) Gout 2) Rheumatoid Arthritis 3) Pseudogout 4) Osteoarthritis Gout Type of crystal arthropathy - Presents acutely with severe joint inflammation - Mostly at the MTP joint of the big toe, but can get in ankle, wrist, small hand joints Cause: deposition of sodium urate crystals in and near joints Associated with: raised plasma urate Excess Urate Production Decreased Urate Excretion Alcohol Men Beer Elderly people Red meat Post- menopausal women Seafood Impaired Renal Function Myelo/Lympho-proliferative Hypertension disorders Diuretics Psoriasis Antihypertensives Tumour Lysis Syndrome Aspirin Warfarin CytotoxicsA 65 year old man presents with severe acute joint pain over his first metatarsal. He has chronic kidney disease and takes indapamide as part of it. Polarised light microscopy of the synovial fluid shows negatively birefringent needle shaped crystals. What is your most likely differential? 1) Gout 2) Rheumatoid Arthritis 3) Pseudogout 4) OsteoarthritisGout vs Pseudogout Gout: Negatively birefringent needle shaped crystals Pseudogout: (weakly) Positively Birefringent Rhomboid Shaped crystals Gout PseudogoutPseudogout Another type of crystal arthropathy . Usually of larger joints in the elderly Also known as Calcium Pyrophosphate Deposition (CPPD) - Associated with soft tissue calcium deposition on x-ray Risk Factors Old age Hyperparathyroidism Haemochromatosis HypophosphatemiaManagement of Gout and Pseudogout is largely similar High- dose NSAIDS or colchicine Prophylaxis of Gout: Use Allopurinol Allopurinol can precipitate attacks so don’t use until 3 weeks after acute flare and use NSAID cover in betweenA 25 year old woman presents with bilateral joint pain in her wrists and hands. In the cold her hands go blue, and she has a rash that spans across her cheeks and nasal bridge. What is your main differential? 1. Osteoarthritis 2. Dermatomyositis 3. Rheumatoid Arthritis 4.Systemic Lupus Erythematosus(in this case it is)A 25 year old woman presents with bilateral joint pain in her wrists and hands. In the cold her hands go blue, and she has a rash that spans across her cheeks and nasal bridge. What is your main differential? 1. Osteoarthritis 2. Dermatomyositis 3. Rheumatoid Arthritis 4.Systemic Lupus ErythematosusSystemic Lupus Erythematosus Commonly affects women. Presents with bilateral joint pain Raynaud’s phenomenon - hands going blue in the cold Malar Rash - across cheeks and nasal bridge Photosensitivity Mouth Ulcers Lymphadenopathy Bloods will show leukopenia and anaemia DMARDs, and steroidstive (managing symptoms), Hydroxychloroquine andotherMalar Rash Raynaud’s Phenomenon THANKS FOR WATCHING! Tutor 2: Nidhi Rege Please fill out the feedback form on Medall and see you next week!