Management Of A Painful Joint ” Part Two

If the joint is thought to be the pathology causing the symptoms the clinician will have to decide the likely process. Of the three major diagnostic categories one is arthritis of an inflammatory cause, involving the synovial joint linings and the bone-ligament and bone-tendon junctions (the entheses). The function and structure of a joint can be affected by arthritic changes not of an inflammatory nature, secondary to meniscal or articular cartilage damage or caused by other joint changes which can be from a number of causes.

In some cases knee pain may be present without obvious pathological change, perhaps due to a pain syndrome such as fibromyalgia or in very early symptoms of a condition. A joint can have several different sorts of disorder at any one period and a joint can become steadily damaged and less stable by being affected by an inflammatory condition. Pain is one of the cardinal signs of inflammatory joint change and is typically not better on rest and increased on activity and movement, especially the beginning. In wear and tear arthritic joint changes the pain is mainly relieved by rest and aggravated by movement or weight bearing.

If the vertebral column or the large joints suffer from significant degenerative changes they may give pain when resting and at night, disturbing sleep. It is less easy to localise accurately the pain from larger joints as compared to smaller ones, with the hip being an example of how pain can be referred to several areas including the fronts of thighs, the groin, the side of the hip and the buttock. Patients perceive difficulty moving a joint, especially when just getting going, as stiffness and this symptom is usually better once the joint has got going and worse again after a rest period. Normal joint stiffness lasts 10-15 minutes but inflammatory stiffness may be for an hour or longer.

There are several changes which can occur in a joint to make it swell. If the joint is affected by non-inflammatory arthritis then bony growths form at the margins of the joints and the end of the fingers or the knees become knobbly joints. Or an effusion, a collection of fluid within a joint capsule, can form secondary to inflammatory disease and can be drawn off by injecting the joint. It is common for an affected joint to show a degree of loss of movement either because the soft tissues have tightened up, the joint is damaged anatomically or by restriction from pain and inflammation.

An arthritic joint or joints can significantly interfere with activities of daily living (ADL) such as climbing stairs, maintaining self care and dressing. Part of these difficulties may be related to atrophy and weakness of muscles, which in combination with pain point to a musculoskeletal cause rather than muscle or nerve pathology. Muscle weakness interferes with normal actions such as gripping objects, standing up from sitting or walking any distance without falling. Fatigue and malaise can be present in systemic arthritis as it affects the whole body. The onset of arthritic symptoms can be rapid or slow and steady, with infections, trauma and crystal causes tending to come on rapidly.

It is more typical for symptoms to develop over a period of weeks or months, and this commonly occurs in rheumatoid arthritis and osteoarthritis, the two most common types. Acute occurs for less than six weeks, sub-acute from six to twelve weeks and chronic if lasting more than twelve weeks. Joint inflammation can persist in affected joints as new joints are affected or episodic occurrence of joint symptoms with pain free periods between such as gout. The number of joints affected also varies, with monoarthritis affected a single joint, oligoarthritis involving two to four and polyarthritis affecting five or more.

Non-symmetrical and symmetrical joint patterns of involvement can occur. SLE and rheumatoid arthritis tend to affect the same joints on each side of the body in a symmetrical pattern while psoriatic arthritis and reactive arthritis involve different joints on each side of the body, the asymmetrical pattern. Joints may be involved in different patterns also, for example distal finger joints in osteoarthritis and psoriatic arthritis but not in rheumatoid arthritis.