Chronic Arthritis

Matthew P. Bunyard

RAPID BOARD REVIEW—KEY POINTS TO REMEMBER:

Chronic Noninflammatory Arthritis

Osteoarthritis

The affected joints are more painful with use and improve with rest. Some stiffness on arising in the morning, but usually <30 minutes. Gelling, or a stiffening of the joints during periods of rest, is mild. No systemic symptoms, and absent local signs of inflammation.
The physical examination reveals bony osteophytes on the margins of the joints, joint area may be tender to palpation, the overlying synovium is not usually thickened or inflamed and joint effusions may be present. Crepitus, a sensation of friction within the joint, may be felt.
Over time, the range of motion of the joint is diminished, and angulation deformities may be apparent, especially at the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the fingers, the first metacarpal phalangeal (MTP) joint, and the knees.
Radiographs show an asymmetric loss of joint space, subchondral sclerosis, marginal osteophytes, and subchondral cysts.
Secondary OA is suspected when a joint that is not commonly involved by primary OA shows evidence of OA on physical examination and radiographs.

Chronic Inflammatory Arthritis

Joint pain, morning stiffness that typically last >1 hour. The joints feel better with use, and the worst periods are during the night and on arising in the morning. Gelling is prominent. Systemic symptoms and extraarticular organ manifestations can be present.
An examination of the joint will reveal warmth, tenderness, joint swelling (a mixture of synovial thickening and joint effusion), loss of function, and, occasionally, erythema.

Rheumatoid Arthritis

Usually a symmetric, polyarticular arthritis. Small joints of hands and feet are classic: PIP, MCP, wrist, ankle, MTP (however typically spares DIPs); but almost any joint can be involved: TMJ, elbow, shoulder, C-spine, hip, knee.
With progression: swan neck and boutonniere deformities of the fingers, volar subluxation of the carpus, loss of full extension of the elbows and full abduction of the shoulders, valgus angulation at the knees and ankles, and pes planus.
The serum rheumatoid factor (RF) has 70% to 80% sensitivity and 80% specificity. Antibodies to cyclic citrullinated peptide (anti-CCP) are highly specific for RA (95%), with a sensitivity of about 70%.
Radiographs initially show periarticular osteopenia and soft tissue swelling. As the disease progresses, a symmetric loss of joint space and periarticular marginal erosions appear.
Patients should be started on disease-modifying antirheumatic drugs (DMARDs).

Spondyloarthritides