JOINTS

DEGENERATIVE & INFLAMMATORY

CONDITIONS
 Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune disease where the
body’s immune system attacks its own tissues. Rheumatoid
arthritis can affect anyone at any age, and may cause
significant pain and disability.
 Rheumatoid Arthritis:
Key Features
• Symptoms >6 weeks’ duration
• Often lasts the remainder of the patient’s life
• Inflammatory synovitis
• Palpable synovial swelling

• Morning stiffness >1 hour

• fatigue

• Symmetrical and polyarticular (>3 joints)

• Typically involves wrists, MCP, and PIP joints

• Typically spares certain joints

• Thoracolumbar spine

• DIPs of the fingers and IPs of the toes

Rheumatoid Arthritis:
Key Features (cont’d)
• May have nodules: subcutaneous or
periosteal at pressure points
• Rheumatoid factor
• 45% positive in first 6 months
• 85% positive with established disease
• Not specific for RA, high titer early is a bad
sign
• Marginal erosions and joint space
narrowing on x-ray
Adapted from Arnett, et al. Arth Rheum. 1988;31:315–324.
Rheumatoid Arthritis: PIP
Swelling
• Swelling is
confined to the
area of the joint
capsule
• Synovial thickening
feels like a firm
sponge
Rheumatoid Arthritis:
Ulnar Deviation and MCP
Swelling
• An across-the-room
diagnosis
• Prominent ulnar
deviation in the right
hand
• MCP and PIP swelling in
both hands
• Synovitis of left wrist
Rheumatoid Arthritis: Typical
Course
• Damage occurs early in most patients
• 50% show joint space narrowing or erosions
in the first 2 years
• By 10 years, 50% of young working patients
are disabled
• Death comes early
• Multiple causes
Rheumatoid Arthritis
• Key points:
• The sicker they are and the faster they get
that way, the worse the future will be
• Early intervention can make a difference
• Essential to establish a treatment plan early in
the disease
Rheumatoid Arthritis:
Treatment Principles
• Confirm the diagnosis
• Determine where the patient stands in the spectrum of
disease
• When damage begins early, start aggressive treatment
early
• Use the safest treatment plan that matches the
aggressiveness of the disease
• Monitor treatment for adverse effects
• Monitor disease activity, revise Rx as needed
Critical Elements of a Treatment
Plan: Assessment
• Assess current activity
• Morning stiffness, synovitis, fatigue, ESR
• Document the degree of damage
• ROM and deformities

• Joint space narrowing and erosions on x-ray

• Functional status

• Document extra-articular manifestations

• Nodules, pulmonary fibrosis, vasculitis

• Assess prior Rx responses and side effects

Critical Elements of a Treatment
Plan: Therapy
• Education
• Build a cooperative long-term relationship
• Assistive devices

• Exercise
• ROM, conditioning, and strengthening exercises

• Medications
• Analgesic and/or anti-inflammatory
• Immunosuppressive, cytotoxic, and biologic
• Balance efficacy and safety with activity
Rheumatoid Arthritis:
Drug Treatment Options
• NSAIDs
• Symptomatic relief, improved function
• No change in disease progression

• Low-dose prednisone
• May substitute for NSAID

• If used long term, consider prophylactic treatment

for osteoporosis
• Intra-articular steroids
• Useful for flares
Rheumatoid Arthritis:
Treatment Options
• Disease modifying drugs (DMARDs)
• Minocycline
• Modest effect, may work best early
• Sulfasalazine, hydroxychloroquine
• Moderate effect, low cost
• Intramuscular gold
• Slow onset, decreases progression, rare remission
• Requires close monitoring
Rheumatoid Arthritis:
Treatment Options (cont’d)
• Immunosuppressive drugs
• Methotrexate
• Most effective single DMARD

• Good benefit-to-risk ratio

• Azathioprine
• Slow onset, reasonably effective

• Cyclophosphamide
• Effective for vasculitis, less so for arthritis

• Cyclosporine
• Superior to placebo, renal toxicity
Rheumatoid Arthritis: Summary
• Joint damage begins early
• Effective treatment should begin early in most patients
• Aggressive treatment can make a difference
• Assess severity of patient’s disease
• Current activity

• Damage

• Pace
Rheumatoid Arthritis: Summary
(cont’d)
• Choose a treatment plan with enough power to match
the disease
• If in doubt, get help of rheumatologist
• New classes of drugs and biologics offer new
opportunities
• Do no harm
• Monitor for drug toxicity—high index of suspicion and
routine monitoring
• Alter the treatment based on changes in disease
activity
OSTEOARTHRITIS
 Symptoms and Signs

• Pain is related to use • Joint instability

• Pain gets worse during • Bony enlargement
the day • Restricted movement
• Minimal morning stiffness • Crepitus
(<20 min) and after • Variable swelling and/or
inactivity instability
• Range of motion
decreases
Radiographic Features

LOSEC
• Joint space narrowing
• Marginal osteophytes
• Subchondral cysts
• Eburnation
• Bony sclerosis

• Malalignment
Laboratory Tests
• No specific tests
• No associated laboratory abnormalities
• Cartilage degradation products in serum
and joint fluid
Risk Factors
• Why patient develop osteoarthritis?
Risk Factors
• Age: 75% of persons over age 70 have OA
• Female sex
• Obesity
• Hereditary
• Trauma
• Neuromuscular dysfunction
• Metabolic disorders
Distribution of Primary OA
• Primary OA typically
involves variable
number of joints in
characteristic
locations, as shown
• Exceptions may
occur, but should
trigger consideration
of secondary causes
of OA
Distal and Proximal
Interphalangeal Joints
Hip Joint
• X-ray shows osteophytes,
subchondral sclerosis,
and complete loss of joint
space
• Patients often present
with deep groin pain that
radiates into the medial
thigh
Management of OA
• Establish the diagnosis of OA on the basis of history and
physical and x-ray examinations
• Decrease pain to increase function
• Prescribe progressive exercise to
• Increase function

• Increase endurance and strength

• Reduce fall risk

• Patient education:
• Weight loss

• Heat/cold modalities
Pharmacologic Management of
OA
• Nonopioid analgesics
• Topical agents
• Intra-articular agents
• Opioid analgesics
• NSAIDs
• Unconventional therapies
Strengthening Exercise for OA
• Decreases pain and increases function
• Physical training rather than passive therapy
• General program for muscle strengthening
• Warm-up with ROM stretching
• Step 1: Lift the body part against gravity, begin
with 6 to 10 repetitions
• Step 2: Progressively increase resistance with
free weights or elastic bands
• Cool-down with ROM stretching
Reconditioning Exercise
Program for OA
• Low-impact, continuous movement
exercise for 15 to 30 minutes 3 times per
week
• Fitness walking: Increases endurance, gait
speed, balance, and safety
• Aquatics exercise programs
• Exercise cycle with minimal or no tension
• Treadmill with minimal or no elevation
Nonopioid Analgesic Therapy
• First-line—Acetaminophen
• Pain relief comparable to NSAIDs, less toxicity
• Beware of toxicity from use of multiple
acetaminophen-containing products
• Maximum safe dose = 4 grams/day
Nonopioid Analgesic Therapy
(cont’d)
• NSAIDs
• Use generic NSAIDs first
• If no response to one may respond to another
• Lower doses may be effective
• Do not retard disease progression
• Gastroprotection increases expense
• Side effects: GI, renal, worsening CHF, edema
• Antiplatelet effects may be hazardous
Opioid Analgesics in OA
• Tramadol
• Affects opioid and serotonin pathways
• Nonulcerogenic
• May be added to NSAIDs, acetaminophen
• Side effects: Nausea, vomiting, lowered
seizure threshold, rash, constipation,
drowsiness, dizziness
Opioid Analgesics for OA
• Codeine, oxycodone
• Anticipate and prevent constipation
• Long-acting oxycodone may have fewer CNS
side effects
• Morphine and fentanyl patches for severe
pain interfering with daily activity and
sleep
Topical Agents for Analgesia in
OA
• Local cold or heat: Hot packs, hydrotherapy
• Capsaicin-containing topicals
• Use well supported by evidence
• Use daily for up to 2 weeks before benefit

• Compliance poor without full instruction

• Avoid contact with eyes

• Liniments = methyl salicylates

• Temporary benefit
 OA: Intra-articular Therapy
• Intra-articular steroids
• Good pain relief
• Most often used in knees
• With frequent injections,
risk infection, worsening
diabetes, or CHF
• Joint lavage
• Significant symptomatic
benefit demonstrated
• Hyaluronate injections
• Symptomatic relief
• Improved function
• Expensive
• Require series of
injections
• No evidence of long-
term benefit
• Limited to knees
Surgical Therapy for OA
• Arthroscopy
• May reveal unsuspected focal abnormalities
• Results in tidal lavage

• Expensive, complications possible

• Osteotomy: May delay need for TKR for

2 to 3 years
• Total joint replacement: When pain severe and function
significantly limited
Management Summary
• First: Be sure the pain is joint related (not
a tendonitis or bursitis adjacent to joint)
• Initial treatment
• Muscle strengthening exercises and
reconditioning walking program
• Weight loss
• Acetaminophen first
• Local heat/cold and topical agents
Management Summary (cont’d)
• Second-line approach
• NSAIDs if acetaminophen fails
• Intra-articular agents or lavage
• Opioids
• Third-line
• Arthroscopy
• Osteotomy
• Total joint replacement
Biological therapy for OA

• ASC’s :
Adipose tissue derived Stem Cells
… they are one type of mesenchymal stem
cells used to regenerate cartilage in
patient
SPONDYLOSIS
• It refers to degenerative changes in spine such
as bone spurs & degenerating intervertebral
discs b/w the vertebrae.
• Frequently referred to as osteoarthritis.
• It involves changes in bones, discs & joints.
• Cause : normal wear & tear with aging.
• Cervical
• Lumbar
Treatment options:

• NSAIDS
• Corticosteroids
• Muscle relaxants
• Anti seizure madications
• Antidepressants
• Physiotherapy
Exercises:

• Chin tucks to stretch neck

• Press up to stretch spine
• Wall sit for better posture
• Leg raising exercise
• Shoulder rolling
SPONDYLOLYSIS
• Defined as a defect or stress fracture in the pars
interarticularis of the vertebral arch.
(Thin bony segment/ arch in back of spine b/w
the facet joints, joining two vertebrae)
• Common in lower lumbar vertebrae, especially L
5.
• May affect cervical region.
• Spondylolysis, Pars defect, Stress fracture are
interchangeable terminologies
Cause

• Genetic weakness of pars interarticularis

• Repeated stress fractures, caused by
hyperextension of back … gymnastics, foot
ballers
• Traumatic fractures
Treatment

• Bracing to immobilize spine .. 4 months

• Analgesia
• Anti inflammatory
Spondylolisthesis
• It is a slipping of vertebra that occurs, in
most cases, at the the base of spine.
• Spondylolysis can result in vertebral
slipping … precursor to spondylolisthesis
• It can occur backward, forward, or over a
bone below
• Mostly affects lower vertebrae
• Painful
Treatment

• Depends on severity of symptoms

• Non surgical
.. Wearing back brace .. Physical therapy
exercises .. Analgesics .. Epidural steroids
injections
• Surgical
.. Spinal fusion surgery
PYOGENIC ARTHRITIS
JUVINILE ARTHRITIS
TUBERCULOUS ARTHRITIS
GOUTY ARTHRITIS
HAEMOPHILIC ARTHRITIS
NEUROPATHIC ARTHRITIS
PSORIATIC ARTHRITIS
ANKYLOSING SPONDYLITIS
CARPAL TUNNEL SYNDROME
4/23/2019 57
Compressive neuropathy of the median nerve within the carpal tunnel
may result from any space-occupying lesion under the TCL .

A frequent cause is flexor tenosynovitis; other causes are fractures and

dislocations of the floor of the canal and distal radius, and other
space-occupying lesions such as tumors and ganglia.

These space-occupying lesions increase the volume of the contents of

the noncompliant carpal tunnel, raising the pressure on its contents,
which include the median nerve.
In many cases, there are no particular identifiable causes even though
the nerve is clearly compressed. Although many of these cases are
attributed to “nonspecific synovitis,”

4/23/2019 59
4/23/2019 60
Complain = aching or burning pain along the median nerve distribution
and of numbness and tingling in the median-nerve-innervated digits
during night and early morning as well as during activities.
(Numbness may extend into the ulnar digits in some patients.)

These symptoms are aggravated by elevation, repetitive activities, and

prolonged flexion positioning of the wrist. Radiation of symptoms
proximal to the wrist is not unusual.

Complaints of the hand feeling fat, clumsiness in manipulation, and

dropping items are also frequent.

The incidence is greater in women than in men, although the difference

is
decreasing. In the past, postmenopausal women were the most
common patients; commonly associated diagnoses were rheumatoid
arthritis and distal radius malunion.

Recently, a large, younger group of patients with essentially equal

distribution of women and men has emerged. In this group the
carpal tunnel disease has been labeled idiopathic .
4/23/2019 61
Examination includes sensory,
provocative, sudomotor, and strength
testing

4/23/2019 62
the most consistent and reliable way to
evaluate sensibility in nerve compression
is to use threshold testing (Semmes–
Weinstein monofilaments, vibrometry,
and 256 cps vibration testing) .

4/23/2019 63
• Provocative tests compress or percuss
nerve to elicit the median numbness and
paresthesias in the distribution of…

4/23/2019 65
4/23/2019 66
The mild group consists of patients with
intermittent symptoms that have been
present less than 1 year, who have
normal two-point discrimination, no
thenar weakness or atrophy, no
denervation potentials on EMG, and
mildly elevated NCV.
With conservative treatment and steroid
injection, 40% will be free of symptoms
at 12 months.
4/23/2019 67
The severe group consists of those with
profound, persistent symptoms that have
been present longer than 1 year, thenar
weakness or atrophy, and marked
abnormalities on electrodiagnostic studies .

Patients in the severe group fail to respond

adequately to conservative therapy and should
receive operative treatment, which may
include tendon transfers concurrent with
carpal tunnel release.

4/23/2019 68
4/23/2019 69
4/23/2019 70
In the moderate group, conservative
treatment shows findings and gives
results intermediate between those of
the mild and severe groups. The
presence of underlying disorders or
advanced age in any of these patients
diminishes the response to conservative
care.

4/23/2019 71
4/23/2019 72
4/23/2019 73
4/23/2019 74
4/23/2019 75
RICKETS
OSTEOMALACIA
OSTEOPOROSIS
GANGRENE
ISCHEMIC CONTRACTURES
DUPUTRENS CONTRACTURES
MUSCULAR DYSTROPHIES
NEUROPATHIES
AVASCULAR NECROSIS OF BONE
Children & Adults