Approach to Arthritis

Overview

Arthritis is a nonspecific term that encompasses a group of diseases affecting the musculoskeletal system. There are actually more than 100 Arthritic and Rheumatic diseases affecting all ages of patients. These diseases are among the most frequent reasons for visiting a primary care doctor in Ontario. No matter what area of health care you choose, you will almost certainly see patients with these diseases during your career. In this self-directed module, you will learn to recognize the signs and symptoms that can be used to characterize patients presenting with arthritis. It is particularly important to identify inflammatory types of arthritis in order to initiate treatment at an early stage of illness. While some arthritic conditions can be confirmed with laboratory testing and imaging, most are diagnosed by history and physical examination and identification of characteristic disease patterns and course.

Specific learning objectives upon completion of this section, the student will be able to:

  • Define common terms used to describe different forms of arthritis.
  • Outline an approach to diagnosis in the patient with musculoskeletal symptoms.
  • Categorize an arthritis based on the patient’s presenting symptomatology and findings.

Required references:

Additional recommended reading:

  • Table 1.1 in Arthritis and Related conditions in Ontario: ICES Report – Chapter 1 Emerging Issues and p. 16 in Chapter 2 Burden of Disease.
  • Chapters 78,80,86,and 87 of Cecil’s Essentials of Medicine (6th edition)
  • Chapter 311, Harrison’s Principles of Internal Medicine (16th edition)

The term “arthritis” encompasses a wide spectrum of disease, acute and chronic, articular and non-articular. Nevertheless, it is possible to define a set of goals and subsequent approach to diagnosis that can be applied to most clinical situations. These are outlined in Harrison’s Principles of Internal Medicine (Table 311-1) and summarized below:

Goals

  • Accurate diagnosis
  • Timely provision of therapy
  • Avoidance of unnecessary laboratory testing

Approach

  • Determine the anatomic location of the complaint: is it articular or non-articular?
  • Determine of the pathologic process involved: is it inflammatory or noninflammatory?
  • Determine of chronology of the patient’s complaints: is it acute or chronic?
  • Determine the pattern of joint involvement: Would you describe it to be mono-, oligo-, poly- articular? Is the pattern symmetrical or not?
  • Identify any associated signs/symptoms. See Table 3 in reference article.

You will be presented with five patient scenarios. For each one, categorize the patient’s findings using this scheme.

A 65-year old man presents with right knee pain that began insidiously about a year ago. He has no other rheumatic symptoms. He is a little stiff in the morning, however this resolves after about 10 minutes. The pain is worse as the day goes on and with physical activity. Over the past year, he has had to start using a cart rather than walking 18-holes when he golfs.

Your physical examination reveals the following:

  • No effusion
  • Palpable bony ridges along the medial and lateral edges of the knee joint
  • Tender to palpation along medial and lateral joint lines
  • Crepitus with knee motion
  • Active range of motion from 5 to 100 degrees on the affected knee; from 0 to 120 degrees on the other side. The patient is uncomfortable with motion of the affected knee throughout the full range tested.
  • No instability (Medial/Lateral; Anterior/Posterior)
  • Negative McMurray’s (meniscal provocative) test
  • Negative patellar apprehension
  • Pain on patellar compression
  • Remainder of joints normal
  • General physical examination unremarkable

Answer the questions below to summarize the patient’s presentation:

What is the anatomic location of the patient's complaints?


Is the disorder inflammatory?

Are there any associated systemic signs / symptoms?

Is the disorder acute?

How many joints are affected?


Is the disorder symmetric?

Does the disorder affect the large joints primarily?


A 34-year old female is assessed by her Family Physician for an annual “well-woman” physical examination. She mentions that she has noticed swelling and pain in her hands and wrists that began six months ago. In the mornings, her fingers are swollen and she feels stiff all over. This subsides by mid-morning but by mid-afternoon her feet ache. She feels generally fatigued and has had to give up full-time employment because of this. For the last two months, she has been taking over-the-counter Ibuprofen daily with partial relief of symptoms.

The FPs physical exam reveals:

  • No deformity noted in either upper or lower extremities
  • Tenderness and swelling of both wrists, all MCPs and PIP, right knee and all MTPs
  • Full active range motion of all joints but pain towards the end of range
  • No joint instability noted; McMurray’s test normal in the knees
  • General physical exam reveals no skin lesions, normal vital signs, no organomegaly

Answer the questions below to summarize the patient’s presentation:

What is the anatomic location of the patient's complaints?


Is the disorder inflammatory?

Are there any associated systemic signs / symptoms?

Is the disorder acute?

How many joints are affected?


Is the disorder symmetric?

Does the disorder affect the large joints primarily?


A 36-year old female is seen by her dermatologist for a facial rash worse since a holiday in Cuba three months ago. She mentions that she has also noticed some mouth ulcers that appear every 4-6 weeks and that her hairdresser recently commented on some patchy hair loss. A detailed review of systems reveals episodes of hand and foot pain over the past year interfering with her job as a court reporter. She is stiff in the morning for approximately 90 minutes.

The following findings are noted on physical examination:

  • A red rash involving her cheeks and the bridge of her nose
  • Areas of alopecia (hair loss) in her scalp
  • Apthous ulcers on the roof of her mouth
  • Tenderness to palpation of her MCPs and PIPs
  • Effusions in all MCP and PIP joints
  • Decreased active range of motion of her MCP and PIP joints
  • No instability or deformity noted

Answer the questions below to summarize the patient’s presentation:

What is the anatomic location of the patient's complaints?


Is the disorder inflammatory?

Are there any associated systemic signs / symptoms?

Is the disorder acute?

How many joints are affected?


Is the disorder symmetric?

Does the disorder affect the large joints primarily?


A 53-year old man presents to the “walk-in clinic” at the local shopping mall complaining of right shoulder pain. He has had symptoms for three weeks since joining the squash ladder at work and increasing his physical activity sharply. He complains, in particular, of pain that bothers him at night and prevents him from sleeping on his right side. His morning symptoms are minimal, however any overhead work exacerbates the pain. He is otherwise healthy.

Your physical examination reveals:

  • No deformity of either shoulder
  • Tenderness to palpation along the upper lateral arm on the right hand side
  • Decreased (95o) active shoulder elevation on the right hand side; full (160o) on the left
  • Passive range of shoulder motion full bilaterally but painful from 60-120o on the right hand side
  • No apprehension or instability
  • Remainder of joints normal to examination
  • General physical examination unremarkable

Answer the questions below to summarize the patient’s presentation:

What is the anatomic location of the patient's complaints?


Is the disorder inflammatory?

Are there any associated systemic signs / symptoms?

Is the disorder acute?

How many joints are affected?



Is the disorder symmetric?

Does the disorder affect the large joints primarily?


A 70 year old man comes to the Emergency Room complaining of a swollen and sore ankle. He was woken up by the symptoms and complains of severe pain. No other joints are involved. He has a history of high blood pressure controlled with medication but is otherwise generally well with no fever or other symptoms. The evening prior to the onset of symptoms, his children threw him a six course dinner party to celebrate his birthday.

Your physical exam demonstrates:

  • Temperature 39 degrees Celsius orally
  • Increased skin temperature over affected ankle
  • A unilateral ankle effusion
  • Tenderness to palpation of the ankle joint
  • Active ankle range of motion very reduced
  • Passive ankle range of motion very painful so range difficult to assess

Answer the questions below to summarize the patient’s presentation:

What is the anatomic location of the patient's complaints?


Is the disorder inflammatory?

Are there any associated systemic signs / symptoms?

Is the disorder acute?

How many joints are affected?


Is the disorder symmetric?

Does the disorder affect the large joints primarily?


In this module you have learned some vocabulary related to arthritis as well as a general approach to the diagnosis of a patient presenting with symptoms suggestive of a rheumatologic disorder. At this stage, given a patient presenting with rheumatologic complaints, you should be able to categorize the disorder which will aid in determining a more specific diagnosis. You can learn more about specific types of arthritis in greater detail by reading Chapters 78, 80, 86, and 87 of Cecil’s Essentials of Medicine (6th edition).