Management Of A Painful Joint ” Part Two

If the pain is judged as coming from the joint in question then certain decisions have to be made as to the causes of this. Inflammatory arthritis is the first category to be considered, with inflammatory changes affecting the the synovial membranes and the entheses, the junctions between the bones and the ligaments and tendons. Non-inflammatory arthritis involves changes in the structure and function of the joint, occurring as damage to the menisci or the articular cartilage lining the joint or secondary to changes in the joint which can be from a variety 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 arthritic changes become very advanced in the spine or major joints patients may suffer pain even when they are resting and also at night. Larger joint pain is less clearly localised to the joint than pain from smaller joints, with hip pain possibly referred to the buttock, lateral thigh, groin or front of thigh. Stiffness is common with arthritis and a difficult symptom to define, but it means difficulty moving a joint, especially after a period of resting, which goes off with movement. Inflammatory joint stiffness may last longer, for example half an hour to an hour, while osteoarthritic stiffness may ease after 10-15 minutes.

Joints often exhibit swelling which can occur in several different ways. In inflammatory disease excessive fluid is secreted by the synovial lining of the joint, causing an effusion which is a collection of fluid within a joint cavity, capable of being drawn off with a needle. Osteoarthritic or other non-inflammatory changes respond by forming bony outgrowths at the joint margins which make the joint enlarge in a knobbly fashion. Loss of some of the joint’s movement is common either from inflammation and pain, damage to the structure of the joint or soft tissue contracture.

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.

Joint involvement can either by symmetrical or non-symmetrical in pattern. If the same joints are affected on each side of the body this is symmetrical involvement and commonly shown in rheumatoid arthritis and systemic lupus erythematosus (SLE). If different joints are affected or only one on one side of the body this is asymmetrical joint involvement and shown in reactive arthritis and psoriatic arthritis. Joints are affected in differing patterns with different types of conditions. The end joints of the fingers are affected in osteoarthritis, gout or psoriatic arthritis but not in rheumatoid arthritis.