CHAPTER 52
ALTERATIONS IN MUSCULOSKELETAL FUNCTION:
RHEUMATIC DISORDERS
LOCAL DISORDERS OF JOINT FUNCTION
• Arthritis is the most common disabling musculoskeletal disorder in the United States• Increasing age is a major factor in many
forms
OSTEOARTHRITIS• A local degenerative joint disorder
associated with aging and wear and tear from repetitive stress• Characterized by loss of articular cartilage,
wear of underlying bone, and the formation of bone spurs; noninflammatory; weight-bearing joints are often affected
OSTEOARTHRITIS (CONT.)• Signs and symptoms are localized including
joint pain and crepitus with movement• Treatment aimed at improving function with
physical therapy and reducing pain with acetaminophen or NSAIDs and intra-articular injections of corticosteroids or visco-supplementation
OSTEOARTHRITIS (CONT.)
INFECTIOUS ARTHRITIS• Joint infection most often due to bacteria
usually by way of the bloodstream• Signs and symptoms are due to localized
infection and the systemic manifestation of inflammation• Appropriate antibiotic therapy over 4-6
weeks with therapeutic joint aspiration, arthroscopy or surgical drainage
JOINT PROSTHESIS INFECTION• Staphylococcus epidermidis is a common
agent in prosthetic joint infection• Generally requires removal of the
prosthesis followed by intravenous antibiotic therapy for 4-6 weeks• Antibiotic beads may also be placed in the
wound • Prosthesis may be replaced when wound
cultures show no growth
SYSTEMIC DISORDERS OF JOINT FUNCTION
• May be related to infectious processes, or have an autoimmune or genetic etiology• Generally cause systemic signs and
symptoms involving multiple joints and other connective tissue structures• Joint destruction is inflammatory and
involves synovial membranes, cartilage, joint capsule, and surrounding ligaments and tendons
RHEUMATOID ARTHRITIS• Possibly related to autoimmune abnormality
in genetically predisposed individuals• American Rheumatism Association criteria
used for diagnosis• DMARDs recommended early in the disease• Treatment may include NSAIDs,
corticosteroids, and biological agents
RHEUMATOID ARTHRITIS (CONT.)
SYSTEMIC LUPUS ERYTHEMATOSUS
• Chronic multisystem, inflammatory, autoimmune disease characterized by periods of exacerbations and remission with multiple organs affected• Results from B-lymphocytic overactivity• Most common features are arthralgias and
synovitis• Treatment includes topical corticosteroids,
avoidance of sun, NSAIDs and/or antimalarial drugs, and immunosuppressive agents
SCLERODERMA• Multisystem inflammatory connective tissue
disease characterized by skin thickening and deposition of collagenous tissue resulting in severe fibrosis• Clinical manifestations may include
Raynaud phenomenon, polyarthritis, sclerodactyly, macular rash, and internal organ involvement• Organ specific symptomatic treatments
ANKYLOSING SPONDYLITIS• Arthritis of the sacroiliac joints that involves
the axial skeleton, and sometimes the peripheral joints• Clinical features may include low back pain,
severe morning stiffness, and limited range of motion• Treatment includes NSAIDs, DMARDs,
agents that inhibit TNF-alpha
POLYMYOSITIS AND DERMATOMYOSITIS
• Idiopathic inflammatory myopathies; focal or extensive degeneration of muscle fibers due to inflammatory infiltrates of lymphocytes and macrophages• Weakness in the proximal limb muscles,
abnormal electromyography and skeletal muscle biopsy; skin and cardiac involvement common• Treatment: corticosteroids,
immunosuppressive agents, and physical therapy
POSTINFECTIOUS SYSTEMIC DISORDERS
• Reactive arthritis (previously named Reiter syndrome) preceded by urethritis, cervicitis, or dysentery• May occur in those genetically susceptible
following a bacterial infection• Oligoarthritis typically appears 2-6 weeks
after infectious episode• Treatment may include NSAIDs, intra-
articular corticosteroids and/or immune-regulating agents
ACUTE RHEUMATIC FEVER• Inflammatory disease that follows a beta-
hemolytic group A streptococcal pharyngeal infection• Onset typically 2-6 weeks after infection• Peak incidence is between 5 and 15 years• Presents with polyarthritis and carditis• Aspirin, NSAIDs, corticosteroids, and
antibiotics used for treatment
POSTPARASITIC DISORDERS• Lyme disease• Caused by Borrelia burgdorferi, a tick-borne
spirochete; carried by deer tick• Tick bite produces red macule or papule
accompanied by flulike symptoms and may develop other organ involvement• Treatment: oral or parenteral antibiotics
JOINT DYSFUNCTION SECONDARY
TO OTHER DISEASES• Neurovascular, hematologic, and metabolic
disorders may lead to associated disorders of joint function• Most related to chronic diseases, such as
diabetes, or hemophilia, or due to altered metabolic processes such as uric acid production and clearance
PSORIATIC ARTHRITIS• Inflammatory arthritis associated with
psoriasis; peak age of onset 30-55 years• Genetic factors are supported• Peripheral joint involvement with
asymmetric oligoarthritis; combination of soft-tissue and peripheral joint disease• Treatment may include NSAIDs and
corticosteroids or immunosuppressive therapy
ENTEROPATHIC ARTHRITIS• Articular manifestations of two
inflammatory bowel diseases; ulcerative colitis and Crohn disease• Peripheral arthritis, spondylitis, and
involvement of muscle and bone• May include ocular manifestations• Treatment may include NSAIDs, COX-2
inhibitors, corticosteroids, or TNF-alpha antagonists
NEUROPATHIC OSTEOARTHROPATHY
• Commonly called Charcot joint• Bone and joint abnormalities due to loss in
normal position sense and pain responses• Most commonly due to diabetes, tabes
dorsalis, and syringomyelia• Management requires protection of involved
joint through immobilization and less weight bearing
HEMOPHILIC ARTHROPATHY• Hemorrhage stimulates a synovial
proliferative response, chronic inflammation with release of degradative proteinase, and changes in cartilage composition with less resistance to stress• Larger joints affected more commonly• Medical treatment to enhance clotting is
imperative as well as education and prevention of joint deformity
GOUT• Heterogeneous disorder in which
disturbance of uric acid metabolism leads to deposition of monosodium urate salts in articular, periarticular, and subcutaneous tissue; risk increases with age• Recurrent attacks of articular and
periarticular inflammation, accumulation of tophi, renal impairment, and uric acid calculi
ASYMPTOMATIC HYPERURICEMIA
• No clinical signs; however, serum urate levels are elevated• In males, can begin at puberty• In females, usually does not appear before
menopause• No treatment required at this stage
ACUTE GOUTY ARTHRITIS• Most common early clinical sign• Weight-bearing joints most commonly
affected; warm, red, and tender to palpation• MTP joint of the great toe most often
involved • Initial attacks can last 1-14 days; later
attacks tend to become more frequent
GOUT
INTERCRITICAL GOUT• Intercritical gout is used to describe the
intervals between acute attacks• No symptoms present but urate crystals
can still be aspirated from involved joints
CHRONIC TOPHACEOUS GOUT• Advanced stage of gout• Tophi begin to appear about 10 years after
initial onset of gout; appear commonly in the synovium, subchondral bone, olecranon bursa, and infrapatellar and Achilles tendons• Tophi can affect tissues of the ears and
eyes, and cardiac and renal structures• Deforming arthritis can develop
GOUT• Treatment: an acute gouty attack usually
requires NSAIDs, corticosteroids, and colchicine• Colchicine may be used at a lower dose to
prevent recurrent attacks• Medications to correct hyperuricemia and
prevent gout flares may target uric acid secretion by the kidneys or uric acid production (allopurinol)
ADULT-ONSET STILL DISEASE• Form of seronegative polyarthritis with a
number of symptoms similar to JRA• High-spiking fever, rash on trunk and
extremities, and possibly sore throat; can involve PIP and MCP joints of the hands and include visceral involvement• Some respond well to high-dose aspirin or
NSAIDs; corticosteroids may be used
PEDIATRIC JOINT DISORDERS• Nonarticular rheumatism: common soft
tissue syndrome with nocturnal pain; also known as ‘growing pains’• Hypermobility of joints: may cause pain in
joints• Juvenile idiopathic arthritis (juvenile
rheumatoid arthritis [JRA]): chronic inflammatory disease affecting the synovium
JUVENILE IDIOPATHIC ARTHRITIS
• Three subtypes• Systemic onset with rash, high fever, fatigue,
lymphadenopathy, splenomegaly, and polyarthritis
• Polyarticular arthritis localized to 5 or more joints• Pauciarticular arthritis affecting 4 or fewer joints
• Treatment: NSAIDs, corticosteroids, DMARDs, biologic-disease modifying agents, PT/OT