This document provides an overview of arthritis, including: - Definitions of true arthritis versus periarticular joint pain - Common symptoms of arthritis like pain, swelling, stiffness, limitation of motion - Classification of arthritis based on number of joints involved and duration - Approaches to evaluating monoarthritis and polyarthritis through history, exam, labs, imaging - Details on specific types of arthritis like gout, pseudogout, osteoarthritis

1. ARTHRITIS
Dr Nataraj A R

2. Introduction
• A patient is said to have arthritis if one has joint pain
and swelling, and the origin of “joint pain” (True
arthritis) is from the Joint (articular ) structures, in
contrast to pain arising from periarticular structures.
• Articular structures include Synovium, synovial
fluid, cartilage, intraarticular ligaments, the joint
capsule and the adjacent bone
• Periarticular structures include ligaments, tendons,
bursae, muscle, fascia , bone and nerve.

3. INCIDENCE

4. SYMPTOMS
• Pain-Pain is a subjective hurting sensation or experience
described in various terms, often of actual or perceived
physical damage.
• Swelling-Patients with inflammatory arthritis may describe
swelling of joints in a distribution typical of a specific
disease—symmetric swelling of the metacarpophalangeal
joints and wrists in rheumatoid arthritis, or swelling of several
toes and a knee in psoriatic arthritis
• Stiffness-Discomfort and limitation on attempted movement
of joints after a period of inactivity.
• Limitation of Motion-Duration of restriction and determining
the rapidity.

5. • Loss of Function-The extent of disability may vary from
loss of the ability to use one finger joint due to arthritis to
complete physical incapacitation due to severe
inflammatory polyarthritis.
• Fatigue-Patients with rheumatic diseases experience
fatigue even without activity.
• Weakness-The temporal course of weakness is important
to the differential diagnosis.

6. SIGNS
• Tenderness-In the musculoskeletal examination, tenderness
indicates unusual discomfort on palpating and putting pressure
on articular and periarticular tissues.
• Crepitation-Crepitation is a palpable or audible grating or
crunching sensation produced by motion. This sensation may
or may not be accompanied by discomfort.
• Deformity-Deformity of the joints may manifest as a bony
enlargement, articular subluxation, contracture, or ankylosis in
non anatomic positions.
• Instability -Joint instability is present when the joint has
greater than normal movement in any plane.

7. Classification ofArthritis
Based on Number of joints involved:
• Monoarthritis-Single joint involvement
• Oligoarthritis- 2-3 joint involvement
• Polyarthritis- Pain and swelling involving 4 or more
joints
Based on duration of Arthritis;
• Acute arthritis-Duration less than 6 weeks
• Chronic arthritis-Duration more than 6 weeks

10. MONOARTHRITIS

11. HISTORY
Age-Gout usually occurs in age group of 30-60 years,
Degenervative disorders associated with old age
Occupation- Increased prevalence of OA of the elbows, knees,
and spine in miners, farmers, firefighters, mill workers, unskilled
manual laborers
Drug history- Gout precipitated by Loop and Thiazide diuretics,
Ethambutol, Pyrizinamide.
Sexual history- Gonococcal arthritis, Reactive arthritis

12. • Pain and joint stiffness, its diurnal variation, and
aggravating and relieving factors should be sought,
and a history of swelling should be established.
• Specific features of relevance include trauma, joint
locking.
• Presence of systemic symptoms (fevers ,sweats, rigors,
and weight loss)-suggestive of septic arthritis
• Inquiring about ocular, oral, respiratory,
gastrointestinal, or skin symptoms can facilitate the
diagnosis.

14. EXAMINATION
• Look, feel, and move joints to assess function—comparing the
affected joint and normal side
• In any acutely swollen joint, examination should include looking
for local signs of inflammation (pain, erythema, swelling, heat, and
loss of function).
• Any patient with preceding arthritis should be assessed for chronic
changes to joint structure and disability. Local synovial swelling
and/or effusion, joint instability, limited movement, and deformity
of any single joint necessitate detailed investigation.
• Local monoarticular tenderness without swelling could indicate
enthesitis, tendinitis, bursitis, or bone disease.
• A complete examination should look specifically for ocular signs,
skin rashes,ulcers, and nodules

15. INVESTIGATIONS
1)BLOOD
•Inflammatory, septic, and crystal arthrits cause
elevated (ESR), C-reactive protein (CRP), and white
cell count (WCC), often associated with anemia.
•Systemic disease involvement is assessed by renal,
liver, muscle, or bone biochemical screening and
protein electrophoresis.
•Raised uric acid levels suggest a diagnosis of gout.

16. • In acute hemarthrosis, a platelet count, INR, and
clotting studies are warranted.
• Blood cultures are mandatory in patients with
suspected septic arthritis and should precede
antibiotic prescription
• Viral screening (IgG and IgM antibodies),
antistreptolysin-O test (ASOT), and Lyme serology
can be diagnostic in relevant situations.

17. 2)URINE
•The urinary tract can be a source of gram-negative
bacteria in septic arthritis in the elderly.
•Significant proteinuria and or hematuria and red
cell casts indicate renal damage in SLE, vasculitis, or
subacute bacterial endocarditis

18. IMAGING STUDIES
• A range of imaging studies assist in diagnosis of acute
monoarthritis.
1.Plain radiographs identify soft tissue swelling, calcium in
periarticular tissues, fractures, local bone disease, and loose
bodies, as well as destructive changes in long-standing
arthritis
2.Computed tomography (CT): CT scanning better identifies
fractures, bone diseases, and intra-abdominal and chest
pathology. It is useful when magnetic resonance imaging
(MRI) is contraindicated. In acute arthritis, CT scan can show
osteomyelitis over and above acute inflammation.
3.Musculoskeletal ultrasound (US): In acute monoarthritis US
can show loculated synovial fluid to better target aspiration
and injection and power Doppler views can demonstrate
increased blood flow in active synovitis.

19. 4.MRI: Best technique for soft tissueimaging,MRI can diagnose
internal ligament damage and tendon enthesitis and is most
effective in identifying avascular necrosis of bone. MRI is also useful
when identifying the extent of inflammation in acute monoarthritis
and subclinical joint involvement.
5.Arthrography: Imaging internal joint structure after injection of
radiopaque solutions in association with CT scanning is useful for
hip cartilage tears and in situations when MRI is not feasible.
6.Radionuclide scans.
•Bone scintigraphy is helpful when excluding bone and joint
disorders in patients with chronic pain syndromes.
•Bone scans show differences in the pattern of joint involvement
between inflammatory conditions and osteoarthritis.
• Labeled white cell scans can identify areas of infection, especially
when the source of infection is uncertain in patients with septic
arthritis

20. SYNOVIAL FLUIDANALYSIS
The most useful test in acute monoarthritis is examination
of synovial fluid, which should be analyzed for:
•Color and cloudiness
•Predominant cell type
•Gram stain to detect bacteria
•Polarized light analysis to identify uric acid or calcium
pyrophosphate dehydrate (CPPD) crystals.
•Synovial fluid culture can provide results even when a
Gram stain is negative.

22. SYNOVIAL OR BONEBIOPSY
Arthroscopic synovial biopsy is necessary in
• Tuberculosis
• Sarcoidosis,
• Amyloidosis
• Pigmented villonodular synovitis
• Foreign body synovitis

23. GOUT
• The three stages of gout are asymptomatic hyperuricemia, acute and
intercritical gout, and chronic gouty arthritis.
• Podagra is the classic monoarthritis of the first metatarsophalangeal joint, but
other lower limb joints can be affected.
• Patients tend to be obese males, aged 40 to 50 with hypertension,
and consumers of excess alcohol.
• Increasingly, postmenopausal females with low estrogens . Many drugs raise
serum urate levels and predispose to gout attacks, especially diuretics
,ethambutol ,pyrizinamide
• Tophi are indicative of the diagnosis.
• Blood Investigations reveal increase in White cell count, ESR,and CRP are raised
• Serum uric acid may be raised, but levels are low in 33% during
acute attacks.
• Renal and liver function should be assessed.

24. • Needle-shaped uric acid crystals (that are negatively
birefringent under polarized light) are present in synovial fluid
or tophi aspirate and confirm the diagnosis.
• Routine radiographs frequently show no bony abnormalities
but may identify erosions after repeated or prolonged attacks.
• Diagnostic ultrasound and MRI can identify synovial fluid for
aspiration, tophi, and erosive disease

29. PSEUDOGOUT
• Patients with pseudogout or pyrophosphate (CPPD) arthropathy present
with similar symptoms, usually in the knee or wrist in older females often
concurrent with osteoarthritis.
• Acute attacks often occur following a trigger such as infection, trauma, or
surgery.
• Calcinosis can be seen cartilage, and periarticular tissues can be seen on a
radiograph.
• Ultrasound may assist in the diagnosis of pyrophosphate arthritis because
crystal deposits can be seen.
• Synovial fluid microscopy demonstrates rhomboid-shaped crystals .
• Culture should exclude coexistent septic arthritis.
• Hemarthrosis necessitates review for an occult fracture.
• Repeat imaging (e.g., using MRI) may be necessary to formally exclude
bone injury if clinical suspicion exists.

31. Acute Calcific Periarthritis
•Calcium deposition in periarticular tissues is common adjacent to upper
and lower limb large joints.
•Many patients are asymptomatic, but an acute shoulder
monoarthropathy with loss of function is well recognized.
•Calcium crystals can be associated with subacromial bursitis, identified on
routine radiographs, ultrasound, or MRI.
•Hypercalcemia necessitates that hyperparathyroidism should be excluded.
Calcium Phosphate Crystal Arthritis
•Intra-articular deposits of basic calcium phosphate (BCP) are rare but
present in older female patients with osteoarthritis, with a destructive
shoulder arthropathy usually on the dominant side (Milwaukee shoulder)
as an acute on chronic monoarthritis.
•Synovial fluid can be viscous and blood-stained and may contain calcium
aggregates and cartilage fragments.
•Plain radiographs show upward shoulder dislocation, and MRI exhibits
characteristic features.

32. APPROACH TOPOLYARTHRITIS
1)HISTORY:
•Demographics. Age, sex, and family background may
provide clues to the type of arthritis. Gout is more
common in men ; osteoarthritis affects older patients
more often than younger counterparts, and in
spondyloarthritides familial association
•Symptom Onset. If patients present with abrupt onset
of symptoms, consider infection, gout, pseudogout, or
trauma, whereas if symptoms were present for
months/years, rheumatoid arthritis (RA), psoriatic
arthritis (PsA), chronic infection (e.g., syphilis, hepatitis,
human immunodeficiency virus [HIV]) and OA are
differentials.

33. • Pattern of Joint Involvement.
Patients who present with involvement of distal
interphalangeal joints (DIPs)may indicate osteoarthritis
or psoriatic arthritis
Symptoms in proximal interphalangeal joints (PIPs) and
metacarpophalangeal joints(MCPs) favour rheumatoid
arthritis
Involvement of large joints such as hips and shoulders
may suggest polymyalgia rheumatica or a
spondyloarthritis.

34. • Presence of Inflammation.
History that may provide diagnostic clues to
inflammation, such as morning stiffness and response
to activity.
Cardinal signs of inflammation (redness, warmth,
swelling, pain in the morning) may have an
inflammatory arthropathy.
• Drug history
Drugs like hydralazine, isoniazid, pyrizinamide can
produce a lupus like syndrome with the clinical
presentation of myalgia, arthalgia and ANA positivity.

35. PHYSICALEXAMINATION
Arthralgia vs. Arthritis.
•Characteristics that distinguish synovitis include warmth, erythema, tenderness to
palpation, and synovial effusion. Any or all of these findings may accompany
arthralgia.
•Range of motion, muscle strength, and function may be limited around the
inflamed joint.
•In an effort to reduce joint volume and pain, the patient often will involuntarily
hold the joint in a position of partial flexion. Hence, joint contractures may indicate
an underlying inflammatory process (present or past)
•. In RA, any diarthrodial joint can be affected, but the pattern of involvement
typically involves the MCPs, PIPs, wrist, metatarsophalangeal joints (MTPs), and
ankle joints. This pattern of involvement should be distinguished from osteoarthritis
(DIPs, PIPs, carpometacarpal , knee, hip ,spine), psoriatic arthritis (DIPs, PIPs, wrist,
toes), and pseudogout (knee, wrist, MTPs).

36. Extra-articular Manifestations.
•Extra-articular manifestations of RA (e.g.nodules,
keratoconjunctivitis sicca) are seldom present early in
the disease.
•Extra-articular manifestations are prominent early and
may precede the onset of synovitis in SLE (malar rash,
serositis) reactive arthritis (urethritis, conjunctivitis),
psoriatic arthritis (psoriasis, nail pitting), and
sarcoidosis (lung, fever, uveitis, parotitis).
•Nodules in the seronegative patient are more likely to
be tophi from gout than nodules from RA, because the
latter are seen only in those with high-titer rheumatic
factor (RF) or cyclic citrullinated protein (CCP)
antibodies.

37. Extra-articular manifestations
of rheumatoid arthritis

38. LABORATORY TESTS AND RADIOLOGIC
STUDIES
• Laboratory investigation of polyarthritis is indicated with
chronicity (symptoms longer than 6 weeks), failure to respond to
initial therapy, and the presence of systemic (e.g., fever, rash) or
neurologic symptoms.
Acute Phase Reactants
• Elevations in acute phase reactants such as erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) provide a
surrogate measure of inflammation; both ESR and CRP have been
correlated with poor prognosis and worse radiologic outcomes.
• Some may have elevations in other acute phase reactants such
as ferritin, haptoglobin, ceruloplasmin, and complement levels.
• Anemia of chronic disease and elevated platelets and white cell
count

39. • When clinical suspicion for Vasculitis is high, i.e patient
has arthritis, proteinuria, and active sediments in urine,
suspicious nodules on chest radiograph, Anti-neutrophil
cytoplasmic antibody (ANCA) test should be involved.
• Baseline Liver function tests, Renal function tests,
Examination of urine for proteinuria and active
sediments, Plain chest radiograph ,ECG and
Echocardiogram should be done in all chronic
inflammatory polyarthritis

40. Serologies
• Serum rheumatoid factor (RF),autoantibody (typically
immunoglobulin [Ig]M) that binds to the Fc component of IgG
and may play a role in acute inflammatory arthritis.
• Approximately 20% of patients meeting American College of
Rheumatology(ACR) classification criteria for RA are seronegative.
• The presence of the RF has been found to be predictive of
persistent disease and progression with radiologic damage in
patients with inflammatory arthritis.
• Other serologic markers that have been evaluated for use in early
diagnosis of RA include the Anticitrullinated protein antibodies
(ACPAs or CCP Ab), which are nearly as sensitive as RF but are far
more specific for RA.
• If the CCP Ab test is combined with the RF, one can expect a
sensitivity of 58% with a specificity of 100%; positive and
negative predictive values are 100% and 88%, respectively.

41. Genetic Markers
• Associations have been observed between regions of
the Major histocompatibility complex (MHC) on
chromosome 6 and rheumatic diseases.
• There is a strong association between HLA-B27 and the
Seronegative spondyloarthritides.
• HFE gene found in patients with hereditary
hemochromatosis (HHC). HHC is an autosomal
recessive disorder of iron metabolism; joint pain is the
most common complaint

42. Synovial Fluid Analysis
• In patients with oligoarthritis or in those who present
with joint effusions, arthrocentesis may be useful in
diagnosing patients and relieving symptoms.
• Synovial fluid from an inflamed joint is typically yellow
and turbulent from inflammatory cells. White cell
counts are typically greater than 10,000 cells/mm
(range, 5000 to 50,000 cells/mm), with a
predominance in neutrophils.
• Prompt evaluation under polarized microscopy will
maximize the yield for identifying crystals.

43. Imaging:
Indications for radiography include
(1)History of trauma or injury (to exclude fracture)
(2)Persistence of joint pain and swelling longer
than 6 weeks
(3)Suspicion of septic or gouty arthritis
(4)As a baseline evaluation for a newly diagnosed
polyarticular condition

44. X-RAY
Characteristic findings on radiographs of Inflammatory
arthritis
may include:
•Soft tissue swelling,
•Chondrocalcinosis
•Joint effusion
•Juxta-articular osteopenia
•Symmetric loss of articular cartilage with joint space
narrowing
•Bony erosions- important markers of progressive
damage

46. USG ANDMRI
Helps in detection of synovitis when clinical examination
and
conventional radiographs have failed. Advantages of
these
devices include
Ability to detect subtle synovitis and soft tissue
abnormalities as tendon rupture or tenosynovitis
To permit more accurate placement of the needle in
diagnostic arthrocentesis and therapeutic
Injections.

49. RHEUMATOIDARTHRITIS
• Rheumatoid arthritis (RA) is a complex disease involving numerous
cell types, including macrophages, T cells, B cells, fibroblasts,
chondrocytes, neutrophils, mast cells, and dendritic cells
• The ratio of female-to-male patients is 2 : 1 to 3 : 1

57. Early treatment with a disease modifying drug is
standard of care
Non-disease modifying
–NSAIDs
–Prednisone
Disease modifying
–Methotrexate – most common first line, usually around 15-
20mg/week with daily folate 1mg/day
–Sulfasalazine, leflunomide also effective
–Biological agents such as TNF-alpha blockers, abatacept,
rituximab, and tocilizumab are all second or third line
Treatment

58. Goal of treatment is clinical remission if
possible
Control of disease prevents bone erosions
and subsequent deformity and loss of function
All disease modifying drugs are
immunosuppressive, non-biologics have risk
of GI intolerance and hair loss, TNF blockers
are associated with re-activation of
tuberculosis and rarely an MS-like disease,
other biologics are not currently in wide use
Treatment

59. OSTEOARTHRITIS
• Osteoarthritis is a degenerative joint disease, occurring primarily
in older individuals, characterized by erosion of the articular
cartilage, hypertrophy of bone at the margins (i.e.,osteophytes),
subchondral sclerosis, and a range of biochemical and
morphologic alterations of the synovial membrane and joint
capsule.
• Osteoarthritis is the most common form of arthritis, typically
affecting the hands, hips, knees, spine, and feet.
• These joints may be symptomatic or may be affected only on
radiographs.
• Individuals with OA generally describe pain in the joint(s) that is
worse with activity, with limited morning stiffness (<30 minutes),
and pain and stiffness with rest. This stiffness after inactivity, or
“gelling” phenomenon, is often a main complaint, although
morning stiffness is generally less severe and of shorter duration
than that seen in rheumatoid arthritis

62. X-ray changes
1. Joint space narrowing
2. Subchondral sclerosis
3. Osteophytes
4. Cysts

63. OSTEOARTHRITIS
TREATMENT
1.Protection of affected joints from overloading Weight
loss
Use of walking stick
2.Exercise of supporting muscles around joints to avoid
wasting.
3.Supportive measures such as pain relief by analgesics or
NSAIDs.
4.Hyaluronic acid injections.
5.Glucosamine & chondroitin
6.Surgical treatment

64. OSTEOARTHRITIS : Surgical treatment
Arthroscopy Osteotomy
Arthrodesis Excision
arthroplasty
Replacement arthroplasty

65. SPONDYLOARTHROPATHIES
• The Spondyloarthropathies (SpAs) encompass a group of clinical
syndromes that are linked in terms of disease manifestations and
genetic susceptibility.

68. ANKYLOSINGSPONDYLITIS
• AS is the most common inflammatory disorder of the axial
skeleton.
• The following is a useful rule of thumb: AS occurs in 0.2% of the
general population, in 2% of the B27-positive population, and in
20% of B27-positive individuals with an affected family member.
• There is a male preponderance in the disease, with the male-
to-female ratio ranging from 2.5 : 1 to 5 : 1.
• AS typically begins in young adulthood with an increasing
prevalence of radiographic sacroiliitis. At the other end of the
age spectrum, a small number of patients with late-onset AS
may have sacroiliitis and oligoarthritis.
• The classic manifestation of AS is the onset of low back pain that
persists for more than 3 months, is accompanied by early-
morning stiffness, and is typically improved by exercise.

70. PSORIATICARTHRITIS
• PsA develops in 5 to 7% of patients with psoriasis.Most cases arise in
patients with established cutaneous disease, The age at onset can
range from 30 to 55 years, with an equal predilection for PsA in women
and men. Psoriatic spondylitis has a slight male preponderance.
• The most common form, is an Asymmetrical oligoarthritis that may
involve both large and small joints Dactylitis, arising as sausage digits
• In the second subset there is selective targeting of the Distal
interphalangeal joints, seen in of patients. These changes are strongly
associated with nail dystrophy, of which the features are onycholysis,
subungual keratosis, pitting, and oil drop–like staining.
• The third subset has a Symmetrical polyarthritis that mimics RA in
many ways, except for the absence of rheumatoid nodules and
rheumatoid factor.
• The fourth clinical variant is Psoriatic spondylitis, 50% of such patients
are B27 positive.
• Finally, Arthritis Mutilans (5% of patients) is a destructive, erosive
arthritis that affects large and small joints and can be associated with
marked deformities and significant disability.

71. Radiographic changes in PsA to the appearance of asymmetrical
sacroiliitis with syndesmophytes that are bulky, asymmetrical,
and nonmarginal. The classic “pencil-in-cup” deformity may be
seen in patients with distal interphalangeal joint disease or
arthritis mutilans.

72. ENTEROPATHICARTHRITIS
• EA refers to the arthritis associated with Crohn’s disease (CD)
or ulcerative colitis (UC).
• It is typically an inflammatory, nonerosive polyarthritis, predominantly
of large joints In general, the clinical activity of the peripheral arthritis
parallels the disease activity

73. THANK YOU