So, full disclosure. I went running this morning early.
And as my knees swelled to the size of
a basketball as it does when I run,
I thought, hey, I’m going to talk to
the gang about arthritis today.
So, let's cover some arthritis.
And this is – I’ll try to keep my personal
story out of it as much as possible.
But it’s something that all of us are going to
contend with as we get a little bit older.
So, let’s talk about a case.
This is a 68-year-old woman
who complains of left knee and right
hip pain for the past two years.
And these have been been getting slowly worse overall.
The pain is worse in the evening or following activity.
She tried various over-the-counter analgesics
with mild success in improving the pain.
Physical examination revealed some
tenderness over the joints in the hip and the knee,
but no calor,
which means heat, no swelling.
So, what’s the most reasonable action based on this history.
Should we evaluate her hip and knee with an x-ray?
How about an x-ray of her spine, hands and feet,
plus her hips and knees because we’re
worried about a broader arthritis?
How about getting a C-reactive protein
in an antinuclear antibody test
just in case this is an autoimmune arthritis?
Or should we just test for rheumatoid factor alone?
What do you think?
This patient's age,
the slow onset of her symptoms
in her knee and her hips specifically on opposite sides
makes me think that this is very
much likely to be osteoarthritis.
Therefore, we just need to start with their
hip and their knee to confirm that diagnosis,
with the understanding that many
patients without pain at 68 years old
have degenerative changes in those joints as well.
But we'll talk about the workup
and how to differentiate those patients
who need that workup for autoimmune
arthritis versus those who don't.
She does not.
So, look at anatomic patterns first
when you’re thinking about arthritis.
Where's the pain located?
For things like rheumatoid arthritis,
systemic lupus erythematosus,
these patients are going to have
pain in their smaller joints,
often their hands and feet,
and very importantly,
this is the one that gives you symmetric symptoms.
So, it's very rare to have a patient
with rheumatoid arthritis or lupus
with unilateral hand pain with the other hand unaffected.
And they have other types of signs
that may be associated with inflammation.
Fever is a good one.
they don't give you fever, for example.
Now, spondyloarthritis, including
psoriatic arthritis, ankylosing spondylitis,
this is asymmetric types of joints are affected.
by definition affects the sacroiliac joint
whereas psoriatic arthritis can affect
that joint plus the smaller joints as well.
So, it's a multi-joint player.
It can really affect just about any joint in the body.
Osteoarthritis, think about those large joints.
They get affected the most.
The hips and the knees are the most
common and it is asymmetric as well.
So, hopefully, just initiating a history
of the patient, where they have pain,
that’s going to point you to what type of
diagnosis they have in terms of the arthritis.
Other patterns in terms of the pain itself,
inflammatory arthritis is worse in the morning,
it's a symmetric pain and it can occur even at rest
whereas osteoarthritis worse with movement,
worse with weight-bearing, so more with activity.
And septic arthritis, do not want to forget, although very rare,
usually affects large joints.
Of course, it’s going to be asymmetric.
And this is where you get strong constitutional
symptoms like fever and fatigue,
but still can be difficult to diagnose,
particularly if there's other things going on,
maybe like a cognitive decline where patients
can't really elucidate their symptoms as well.
So, first of all, with
a laboratory evaluation,
not everybody who comes in
needs measures of inflammation,
needs specific testing for a rheumatologic condition.
We overuse this testing in general.
And a lot of patients, like our case,
absolutely don't need it in any way, shape or form.
Just remember that many adults have
both a positive ANA and RF testing
and they have zero illness whatsoever.
A few notes about some of these tests.
ANA is really helpful if it's negative.
It's not very helpful, particularly
if it’s low-level positive.
When it’s negative, it almost rules out systemic lupus.
The favorites of using a SED rate or a C-reactive protein,
again, most helpful if they’re negative.
But remember that 3% of patients with
rheumatoid arthritis can have a normal SED rate.
Rheumatoid factor, often false positive.
It's associated with chronic infections,
but in some patients, without
any reason, it's positive.
They carry a positive test even though
they don't have rheumatoid arthritis.
And then uric acid, it’s frequently high
even among patients without gout,
particularly those who eat more cured meats,
drink more beer get more uric acid.
How about other ancillary studies?
Like using radiographs.
And here's our radiograph with some severe degenerative
changes that you would see in rheumatoid arthritis.
So, the x-ray is really important for osteoarthritis.
That one, you can expect when the patient comes in,
you will see positive findings of
degeneration right when they get their films.
Whereas in early rheumatoid arthritis,
when treatment is really quite critical,
when they want to initiate disease modifying treatment,
the x-ray might be negative.
It takes a while.
And don't forget that really what
you want you in cases of gout
or calcium pyrophosphate disease or septic arthritis,
you really need synovial fluid.
That's the ideal,
and especially if it’s in a smaller joint.
Sometimes, it's worth thinking about using rheumatology,
you will wonders with needles and
drawing out small amounts of fluid
to evaluate them,
do the procedure of the arthrocentesis
to get the diagnosis right.