Arthritis

Arthritis is a spectrum of disorders involving the joints of the body. The most common two are osteoarthritis and rheumatoid arthritis, the former being a degenerative disease of the cartilage within a joint and the latter is an autoimmune attack on the joints. Both cause inflammation and pain. Osteoarthritis is limited to the joint and has no systemic effects whereas rheumatoid arthritis has systemic actions.

Signs and symptoms

• Distinctive pain with swelling and eventual deformity
• Morning stiffness of the affected joint
• Pain worsens throughout the day with use
• Flare of symptoms resulting in an acutely swollen, very tender, hot joint
• Heberden’s nodes swellings to the bone at the distal joints in the fingers
• Bouchard’s nodes swelling to the bone at the proximal joints in the finger (NHS, 2018)

Osteoarthritis

Throughout life, the body constantly experiences varying degrees of trauma causing different levels of damage. In the vast majority of occasions, the body repairs itself and symptoms are not experienced. Within the joint there is an extremely smooth articular surface called cartilage that allows for near frictionless articulation between the bones in the joint. In osteoarthritis the cartilage gets damaged and worn away. osteoarthritis is a mechanism by which the body tries to heal the damage with bony remodelling and inflammation. When the joint is overwhelmed with inflammation or the body’s healing mechanisms are compromised and then the symptomatic nature of osteoarthritis begins (see osteoarthritis).

Rheumatoid arthritis

In rheumatoid arthritis there is an autoimmune attack on the membranous capsule of the joint called the synovium. This synovial layer becomes inflamed and irritated and releases chemicals which over time can lead to irreversible damage to the cartilage, bone, tendons and

Osteoarthritis

Risk factors for developing osteoarthritis include:

• Direct trauma such as fracture or ligamentous injury
• Overuse such as athletes
• Previous or existing conditions that can affect joints such as Gout or rheumatoid arthritis.
• Occupational factors eg. manual labour, athletes
• Obesity as an abnormal load is pushed through the joint
• Age - as age increases there is more time for damage to occur
• Female - being of female sex increases risks of osteoarthritis
• Family history - although there has been no isolated gene associated with osteoarthritis, it may well run-in families (Felson, 2004; Spector & MacGregor, 2004). 

Rheumatoid arthritis

Due to the long-term latent effect of rheumatoid arthritis risk factors are vague however some links have been made with the following.

• Family history- rheumatoid arthritis can run in families
• Female sex
• Genetic links - shared epitope
• Smoking - the only environmental factor that has been proven to increase risk (Aho &

Osteoarthritis

Diagnosis of arthritis begins with a careful history and examination. Risk factors and disease history are important when deciding a list of differentials. Osteoarthritis can be diagnosed clinically with a patient who meets the following criteria:

• >45yrs
• Activity related joint pain
• Joint related morning stiffness that lasts less than 30 minutes

As osteoarthritis affects the joint as a whole, differing imaging modalities can be used to visualise specific structures however the mainstay of imaging is simple radiography. The radiographic findings of osteoarthritis include:

• Loss of joint space
• Subchondral cysts
• Subchondral sclerosis
• Osteophytes - bony overgrowth (Braun & Gold, 2012; Weinans et al, 2012)

Rheumatoid arthritis

Rheumatoid arthritis usually presents as a poly-arthropathy (multiple joints) with synovitis of the small joints such as those in the hand or feet. If rheumatoid arthritis is suspected a series of blood tests are done these include:

• Rheumatoid factor
• Anti-CCP antibodies
• Inflammatory markers

Osteoarthritis

The mainstay of management of osteoarthritis is:

• Lifestyle advice
  • Maintaining or reducing to a healthy weight
  • Continuing to have regular exercise
• Analgesics
  • Simple analgesia such as paracetamol and NSAIDS (with appropriate gastric protection) can be very beneficial
  • Opioids can be of benefit if simple analgesia is not enough
  • Capsaicin creams/gels- help block pain receptor nerves
• Supportive therapies
  • Physiotherapy can help strengthen supporting muscle groups which can help with symptomatic control
  • Transcutaneous electrical nerve stimulation (TENs) machines can help people with pain
  • Adaptations to footwear or walking aids can help diminish the load over an inflamed joint (NICE, 2022)

Rheumatoid arthritis

Management options include the initiation of non-steroidal anti-inflammatory drugs (NSAIDs) and cox II selective inhibitors, these provide basic analgesia. Symptomatic control with NSAIDs needs careful consideration as they have a variety of side effects. The lowest possible effective dose should be used for the shortest amount of time and a PPI should

Osteoarthritis

Once management options have been established then treatments can be initiated as there will be further degeneration of the joint over time. Hydrocortisone (steroid) injections can be used in the joint to help reduce the inflammatory process that occurs in osteoarthritis. This can provide an excellent amount of analgesia and allow the patient to continue with their lives as normal however there is only a finite number of injections that can be given as the duration of relief of symptoms reduces each time. Therefore, when all other treatment options have been exhausted, one is then put forward for consideration of surgery.

Surgery for osteoarthritis includes joint replacement (arthroplasty) joint fusion (arthrodesis) or joint modification (osteotomy). Unfortunately, surgical treatment does not guarantee complete symptom relief. However, it can be of huge symptomatic benefit to patients.

Arthroplasty (commonly of hips and knees) involves replacing the articular surface of the joint that

References

Aho K, Heliövaara M. Risk factors for rheumatoid arthritis. 2009;36(4), 242–251. https://doi.org/10.1080/07853890410026025

Braun HJ, Gold GE. Diagnosis of Osteoarthritis: Imaging. Bone. 2012;51(2):278-288 https://doi.org/10.1016/J.BONE.2011.11.019

Deane KD, Demoruelle MK, Kelmenson LB et al. Genetic and environmental risk factors for rheumatoid arthritis. Best Prac Res Clin Rheumatol. 2017;31(1), 3–18. https://doi.org/10.1016/J.BERH.2017.08.003

Felson, D. T. Risk factors for osteoarthritis: Understanding joint vulnerability. Clin Orthop Relat Res. 2004;(427 Suppl:S16-21. https://doi.org/10.1097/01.BLO.0000144971.12731.A2

NHS. Arthritis. 2018. https://www.nhs.uk/conditions/arthritis/ (accessed December 2021)

NICE. Osteoarthritis in over 16s: diagnosis and management 2022. https://www.nice.org.uk/guidance/ng226 (accessed 23 November 2022)

NICE. Methotrexate. 2021. https://bnf.nice.org.uk/drug/methotrexate.html#monitoringRequirements (accessed December 2021)

Spector TD, MacGregor AJ. Risk factors for osteoarthritis: genetics. Osteoarthritis and Cartilage. 2004;12 SupplA:39–44. https://doi.org/10.1016/J.JOCA.2003.09.005

Weinans H, Siebelt M, Agricola R et al. Pathophysiology of peri-articular bone changes in osteoarthritis. Bone, 2012;51(2), 190–196. https://doi.org/10.1016/j.bone.2012.02.002