PBL JOINT PAIN

1) What are the signs and symptoms of gout?

Gout usuay de!eops after a num"er of years of "uidup of uri# a#id #rystas in the $oints and surrounding
tissues% &ymptoms in#ude'
Warmth( pain( s)eing( and e*treme tenderness in a $oint( usuay a "ig toe $oint% This symptom is
#aed podagra% &ymptoms sometimes start in a different $oint( su#h as the an+e or +nee%
Pain that starts during the night and is so intense that e!en ight pressure from a sheet is intoera"e%
,apid in#rease in dis#omfort( asting for some hours of the night and then easing during the ne*t fe)
days%
As the gout atta#+ su"sides( the s+in around the affe#ted $oint may pee and fee it#hy%
Other symptoms may in#ude'
-ery red or purpish s+in around the affe#ted $oint( )hi#h may appear to "e infe#ted%
Limited mo!ement in the affe#ted $oint%
&ymptoms of gout !ary%
&ymptoms may o##ur after an iness or surgery%
&ome peope may not e*perien#e gout as many painfu atta#+s "ut rather de!eop #hroni# gout% .hroni#
gout in oder aduts may "e ess painfu and #an "e #onfused )ith other forms of arthritis%
Gout may first appear as nodues /tophi) on the hands( e"o)s( or ears% There may "e no #assi#
symptoms of a gout atta#+%
By the time you ha!e the symptoms of a gout atta#+( uri# a#id has "een "uiding up in your "ood( and uri# a#id
deposits ha!e "een forming on one or more of your $oints% The "ig toe $oint is most #ommony affe#ted% But the
$oints of the feet( an+es( +nees( )rists( fingers( and e"o)s may aso "e in!o!ed% Infammation of the fuid sa#s
/"ursae) that #ushion tissues may o##ur( parti#uary in the e"o) /oe#ranon"ursitis) and +nee /prepatear
"ursitis)% There are many other #onditions )ith symptoms simiar to gout%
0) What #auses re#urrent atta#+s and s)eing of "oth +nees and sma $oints of fingers?
1 The e2uii"rium "et)een ana"oism and #ata"oism is )eighted in fa!or of degradation
1 3isruption of the integrity of the #oagen net)or+ as o##urs eary in OA ao)s hyperhydration and redu#es
stiffness of #artiage
1 .ata"oism of #artiage resuts in reease of "rea+do)n produ#ts into syno!ia fuid )hi#h then initiates an
infammatory response "y syno!io#ytes
1 These antigeni# "rea+do)n produ#ts in#ude' #hondrointon sufate( +eratan sufate( PG fragments( type II
#oagen peptides and #hondro#yte mem"ranes
1 A#ti!ated syno!ia ma#rophages then re#ruit P4Ns esta"ishing a syno!itis
1 They aso reease #yto+ines( proteinases and o*ygen free radi#as /supero*ide and nitri# o*ide) into ad$a#ent
and syno!ia fuid
1 These mediators a#t on #hondro#ytes and syno!io#ytes modifying synthesis of PGs( #oagen( and hyauronan
as )e as promoting reease of #ata"oi# mediators
1 ,esuts in in#reased infammatory rea#tion as )e as in$ury in the #artiaginous $oint that )i e!entuay ead
to infammation too as a sef prote#tion me#hanism%
1 The s)eing and re#urrent atta#+s of the $oints are due to the infammatory rea#tion%
IN5LA44ATO,6 ,7&PON&7
Infammation pro"a"y pays at most a minor roe in the formation of osteoarthritis and is more i+ey to "e a
resut 88 not a #ause 88 of the disease% 9o)e!er( infammation may pay an important roe in the progression of
osteoarthritis and in its #hroni# nature% The effe#ts of the infammatory response in osteoarthritis are i+ey to "e
different( and ess se!ere( from those in rheumatoid arthritis%
5i!e #assi#a signs of Infammation'
1 3oor 8 Latin term for :pain:
1 .aor 8 Latin term for :heat:
1 ,u"or 8 )hi#h in Latin means :redness:
1 Tumor 8 a Latin term for :s)eing:
1 5un#tio aesa 8 )hi#h in Latin means :in$ured fun#tion:( )hi#h #an aso mean oss of fun#tion
The ists "eo) sho) the differen#e "et)een #hroni# and a#ute infammation regarding the #ausati!e agents(
)hi#h ma$or #es are in!o!ed( features regarding onset( duration( and out#omes' A#ute Infammation
1 .ausati!e agents 8 harmfu "a#teria or in$ury to tissue
1 4a$or #es in!o!ed 8 mainy neutrophis( "asophis /in the infammatory response)( and eosinophis /response
to parasites and )orms)( and mononu#ear #es /ma#rophages( mono#ytes)
1 Primary mediators 8 ei#osanoids( !asoa#ti!e amines
1 Onset /)hen does the infammation start) 8 straight a)ay
1 3uration 8 short8i!ed( ony a fe) days
1 Out#omes 8 the infammation either gets "etter /resoution)( de!eops into an a"s#ess( or "e#omes a #hroni#
infammation
.hroni# infammation
1 .ausati!e agent 8 non8degrada"e pathogens that #ause persistent infammation( infe#tion )ith some types of
!iruses( persistent foreign "odies( o!era#ti!e immune system rea#tions
1 4a$or #es in!o!ed 8 4a#rophages( ympho#ytes( pasma #es /these three are mononu#ear #es)( and
fi"ro"asts
1 Primary mediators 8 rea#ti!e o*ygen spe#ies( hydroyti# en;ymes( I5N8< and other #yto+ines( gro)th fa#tors
1 3uration 8 from se!era months to years
1 Out#omes 8 the destru#tion of tissue( thi#+ening and s#arring of #onne#ti!e tissue /fi"rosis)( death of #es or
tissues /ne#rosis)
=) &IGN&> &64PTO4& O5 A,T9,ITI&
Joint &tiffness
Osteoarthritis of the +nees is often asso#iated )ith e*#ess upper "ody )eight( )ith o"esity( or a history of
repeated in$ury and?or $oint surgery% Progressi!e #artiage degeneration of the +nee $oints #an ead to deformity
and out)ard #ur!ature of the +nees( )hi#h is referred to as "eing :"o)egged%: Peope )ith OA of the )eight8
"earing $oints /su#h as the +nees) #an de!eop a imp% The imping #an )orsen as more #artiage degenerates% In
some patients( the pain( imping( and $oint dysfun#tion may not respond to medi#ations or other #onser!ati!e
measures% Therefore( se!ere OA of the +nees is one of the most #ommon reasons for tota +nee repa#ement%
Limited ,ange of 4otion
OA #auses the formation of hard( "ony enargements of the sma $oints of the fingers% .assi# "ony enargement
of the sma $oint at the end of the fingers is #aed a 9e"erden@s node% The "ony deformity is a resut of the "one
spurs from OA at the $oint% Another #ommon "ony +no" /node) o##urs at the midde $oint of the fingers in many
patients )ith OA and is #aed a Bou#hard@s node% 9e"erden@s and Bou#hard@s nodes may not "e painfu( "ut they
are often asso#iated )ith imitation of motion of the $oint% The #hara#teristi# appearan#es of these finger nodes
#an "e hepfu in diagnosing OA% OA of the $oint at the "ase of the "ig toe of the foot eads to the formation of a
"union%
Tenderness of Joints
OA of the #er!i#a spine or um"ar spine #auses pain in the ne#+ or o) "a#+% Bony spurs( #aed osteophytes(
that form aong the arthriti# spine #an irritate spina ner!es( #ausing se!ere pain that #an radiate from the spine
as )e as num"ness and tinging of the affe#ted parts of the "ody%
,edness and Warmth
Bursitis is infammation of a "ursa( a fuid8fied sa# o#ated "et)een "one and tendons or mus#e that ser!es to
pre!ent fri#tion "et)een tissues( ao)ing them to gide easiy o!er ea#h other% As "ursa is infe#ted( the s+in
o!er the +nee may "e red and )arm%
A) Norma anatomy and physioogy of $oints( syno!ia $oints and fuids
Joints are the areas )here t)o "ones meet% 4ost $oints are mo"ie( ao)ing the "ones to mo!e% Joints
#onsist of the foo)ing'
#artiage 8 a type of tissue that #o!ers the surfa#e of a "one at a $oint%% .artiage heps redu#e the
fri#tion of mo!ement )ithin a $oint%
syno!ia mem"rane 8 a tissue #aed the syno!ia mem"rane ines the $oint and seas it into a $oint
#apsue% The syno!ia mem"rane se#retes syno!ia fuid /a #ear( sti#+y fuid) around the $oint to
u"ri#ate it%
igaments 8 strong igaments /tough( easti# "ands of #onne#ti!e tissue) surround the $oint to gi!e
support and imit the $oint@s mo!ement%
tendons 8 tendons /another type of tough #onne#ti!e tissue) on ea#h side of a $oint atta#h to mus#es
that #ontro mo!ement of the $oint%
"ursas 8 fuid8fied sa#s( #aed "ursas( "et)een "ones( igaments( or other ad$a#ent stru#tures hep
#ushion the fri#tion in a $oint%
syno!ia fuid 8 a #ear( sti#+y fuid se#reted "y the syno!ia mem"rane%
femur 8 the thigh "one%
ti"ia 8 the shin "one%
patea 8 the +nee8#ap%
menis#us 8 a #ur!ed part of #artiage in the +nees and other $oints%
.assifi#ation of Joints'
5i"rous $oints are hed together "y fi"rous #onne#ti!e tissue% No $oint #a!ity is present% 5i"rous $oints
may "e immo!a"e or sighty mo!a"e%
.artiaginous $oints are hed together "y #artiage /hyaine or fi"ro#artiage)% No $oint #a!ity is present%
.artiaginous $oints may "e immo!a"e or sighty mo!a"e%
&yno!ia $oints are #hara#teri;ed "y a syno!ia #a!ity /$oint #a!ity) #ontaining syno!ia fuid% &yno!ia
$oints are freey mo!a"e and #hara#teri;e most $oints of the "ody% 5igure 1 ists other features of a
syno!ia $oint( in#uding the foo)ing'
o Articular cartilage (hyaline cartilage), )hi#h #o!ers the end of ea#h "one%
o A synovial membrane( )hi#h surrounds the syno!ia #a!ity% Its areoar #onne#ti!e
tissue se#retes a u"ri#ating syno!ia fuid into the syno!ia #a!ity%
o A fibrous capsule outside the syno!ia mem"rane( )hi#h surrounds the $oint% It often
#ontains "undes of dense( irreguar( #onne#ti!e tissue #aed ligaments% The
igaments pro!ide strength and fe*i"iity to the $oint%
o The articulate capsule( #omposed of the syno!ia mem"rane and fi"rous #apsue%
o Accessory ligaments( )hi#h ie outside the arti#uar #apsue /e*tra#apsuar
igaments) or inside the syno!ia #a!ity /intra#apsuar igaments)%
B) What .auses 4orning &tiffness?
One theory a"out morning stiffness is referred to as the ge phenomenon% The ge phenomenon
essentiay means that stiffness de!eops after ong periods of sitting or ina#ti!ity% This is
#hara#teristi# of non8infammatory #onditions%
&ome resear#hers note that morning stiffness is a #ir#adian symptom that is not fuy understood%
&ome suspe#t there may "e insuffi#ient #ortiso reeased in the "ody during the night to offset
ee!ated pro8infammatory #yto+ines i+e IL8C( "ut )a+ing up in the midde of the night to ta+e
gu#o#orti#oids to redu#e the infammation )oud "e in#on!enient and not )ithout its o)n side
effe#ts%
C) 3eformity of fingers
What' 3istortion or a"norma appearan#e of the fingers%
.auses' there are =B0 #auses( reated'
1% Rheumatoid arthritis' A #hroni# progressi!e disease #ausing infammation in the $oints and
resuting in painfu deformity and immo"iity( esp% in the fingers( )rists( feet( and an+es
0% Osteoarthritis/degenerative arthritis' 3egeneration of $oint #artiage /#ushioning #artiage
that #o!ers the "one surfa#e "egins to )ear out) and the underying "one( most #ommon from
midde age on)ard% it #auses pain and stiffness( esp% in the hip( +nee( and thum" $oints
=% Dislocation' In$ury or disa"iity #aused )hen the norma position of a $oint or other part of
the "ody is distur"ed
A% Mallet finger' An in$ury of the e*tensor digitorum tendon of the fingers at the dista
interphaangea $oint% %%%
B% racture' A #ra#+ or "rea+ in a hard o"$e#t or materia( typi#ay a "one or a "ody of ro#+
in smaer $oints( su#h as at the fingers( hard "ony enargements( #aed 9e"erden@s nodes /on the dista
interphaangea $oints) and?or Bou#hard@s nodes /on the pro*ima interphaangea $oints)( may form( and
though they are not ne#essariy painfu( they do imit the mo!ement of the fingers signifi#anty%
OA/osteoarthritis) at the toes eads to the formation of "unions( rendering them red or s)oen% &ome
peope noti#e these physi#a #hanges "efore they e*perien#e any pain%
In$ury to a $oint(
su#h as a "ad
sprain or
fra#ture( #an
#ause damage to
the arti#uar
#artiage% An
in$ury to any of
the $oints of the
fingers( e!en if it
does not in$ure
the arti#uar
#artiage
dire#ty( #an
ater ho) the $oint )or+s% After a fra#ture( the "one fragments may hea in sighty different positions%
This may ma+e the $oints ine up differenty% When an in$ury #hanges the )ay the $oint ines up and
mo!es( for#e #an start to press against the surfa#e of the arti#uar #artiage% This is simiar to ho) a
ma#hine that is out of "aan#e )ears out faster%
O!er time( this im"aan#e in the $oint #an ead to damage to the arti#uar surfa#e% &in#e arti#uar
#artiage #annot hea itsef !ery )e( the damage adds up% 7!entuay( the $oint #an no onger
#ompensate for the in#reasing damage( and symptoms "egin% The damage in the $oint starts )e
"efore the symptoms of arthritis appear%
O!er time( this im"aan#e in the $oint #an ead to damage to the arti#uar surfa#e% &in#e arti#uar
#artiage #annot hea itsef !ery )e( the damage adds up% 7!entuay( the $oint #an no onger
#ompensate for the in#reasing damage( and symptoms "egin% The damage in the $oint starts )e
"efore the symptoms of arthritis appear%
D) What is the differen#e "et)een rheumatoid arthritis and osteoarthritis?
,heumatoid arthritis and osteoarthritis are different types of arthritis% Athough they share some simiar
#hara#teristi#s( ea#h has different symptoms and re2uires different treatment%
.hara#teristi#s of
rheumatoid arthritis
and osteoarthritis
,heumatoid arthritis Osteoarthritis
Age at )hi#h the
#ondition starts
It may "egin any time in ife% It usuay "egins ater in ife%
&peed of onset ,eati!ey rapid( o!er )ee+s to months &o)( o!er years
Joint symptoms Joints are painfu( s)oen( and stiff% Joints a#he and may "e tender "ut ha!e
itte or no s)eing%
Pattern of $oints that
are affe#ted
It often affe#ts sma and arge $oints on
"oth sides of the "ody /symmetri#a)(
su#h as "oth hands( "oth )rists or
e"o)s( or the "as of "othfeet%
&ymptoms often "egin on one side of the
"ody and may spread to the other side%
&ymptoms "egin graduay and are often
imited to one set of $oints( usuay the
finger $oints #osest to the fingernais or
the thum"s( arge )eight8"earing $oints
/hips( +nees)( or the spine%
3uration of morning
stiffness
4orning stiffness asts onger than 1
hour%
4orning stiffness asts ess than 1 hourE
returns at the end of the day or after
periods of a#ti!ity%
Presen#e of symptoms
affe#ting the )hoe
"ody /systemi#)
5re2uent fatigue and a genera feeing of
"eing i are present%
Whoe8"ody symptoms are not present%
Osteoarthritis is the most #ommon form of arthritis% ,heumatoid arthritis affe#ts a"out one8tenth as many peope
as osteoarthritis% The main differen#e "et)een osteoarthritis and rheumatoid arthritis is the #ause "ehind the
$oint symptoms% Osteoarthritis is #aused "y me#hani#a )ear and tear on $oints% ,heumatoid arthritis is an
autoimmune disease in )hi#h the "ody@s o)n immune system atta#+s the "ody@s $oints%
F) LO.G73 GN77
What?
A o#+ed +nee is a #ondition )here( on "ending the +nee( it "e#omes fi*ed in position( often at a AB
degree ange( and the person is una"e to straighten the eg or "end it any farther% It is usuay possi"e
to maneu!er the eg "a#+ into a straightened position using the hands%
Why?
Often( a o#+ed +nee is #aused "y a tear in a pie#e of #artiage( #aed a menis#us( )hi#h ies inside the
$oint% When the +nee $oint mo!es( the fragment of torn menis#us "e#omes #aught and pre!ents the
mo!ement from #ontinuing normay% Where a o#+ed +nee is #aused "y a menis#us tear( the pro"em
is usuay treated surgi#ay( and the torn se#tion of #artiage is remo!ed so it no onger interferes )ith
$oint mo"iity%
Other #auses of a o#+ed +nee #an in#ude a igament in$ury( oose tissue fragments other than
#artiage "e#oming odged inside the $oint( and #ertain fra#tures% &ometimes a s)oen( in$ured +nee
may appear to "e o#+ed( "ut the a#+ of mo!ement is "e#ause the mus#es ha!e gone into spasm% A
torn menis#us is pro"a"y the most #ommon +nee disorder that resuts in a o#+ed +nee% Whie a
igament in$ury #an #ause o#+ing( it is more typi#ay asso#iated )ith the +nee gi!ing )ay( a
#ondition sometimes referred to as ha!ing a tri#+ +nee%
9o)?
Inside ea#h +nee there are t)o menis#i( +no)n as the media menis#us and the atera menis#us% 7a#h
one is )hat is #aed a semiunar #artiage( )hi#h is a #res#ent8shaped pie#e of strong( fe*i"e tissue%
The shin"one and the thigh"one meet at the +nee and the semiunar #artiages are positioned "et)een
the ends of these "ones in su#h a )ay that they hep distri"ute the )eight8"earing for#es a#ting on the
$oint% If a t)isting mo!ement is made )hie the $oint is "earing )eight( one of the #artiages may
"e#ome trapped( eading to a tear% The deta#hed portion of #artiage may then )edge inside the $oint(
#ausing it to sei;e up and resuting in a o#+ed +nee%
BH,NING &7N&ATION
What?
A "urning sensation in the +nee may "e reated to a num"er of different pro#esses or disorders% 5or
e*ampe( any type of "urn to the s+in /therma( ee#tri#a or #hemi#a "urn) #auses pain and "urning at the site of
the trauma% 3amage to the ner!es of the egs /periphera neuropathy) #auses a "urning or tinging sensation
medi#ay +no)n as paresthesia% 3ia"etes and a#oho a"use are t)o #ommon #auses of periphera neuropathy%
The different forms of arthritis /infammation of the $oints) #an produ#e pain and stiffness of the $oints
in#uding the +nee $oint( and this pain may "e per#ei!ed as a "urning sensation in some #ases%
When the arteries that suppy the egs are narro)ed due to atheros#erosis( a #ondition +no)n as
periphera artery disease( pain o##urs intermittenty in the egs )hie )a+ing /#audi#ation)% This may aso "e
e*perien#ed as a "urning sensation and o##urs )hen there is inade2uate o*ygen dei!ery to the tissues in the
egs due to the narro)ed arteries%
The sudden onset of a "urning or tinging sensation in the eg on one side of the "ody may o##ur )ith
other symptoms that might indi#ate a serious or ife8threatening #ondition su#h as stro+e%
Why?
The pain and "urning sensation in the +nees is often #aused due to the damage to the stru#tures in and
around the +nee $oint%
Wear and tear of +nee $oint #artiage is the most #ommon reason%
The other #ause #an "e igament tear( "ursitis%
Often( the #hara#teristi# "urning sensation in the +nee $oint is due to Iioti"ia "and fri#tion% It is a #ommon
#ause for +nee pain in athetes% Iioti"ia "and originates from the hip $oint and runs a the )ay to the +nee
$oint% It atta#hes at the atera /outer) side of the +nee% Together )ith 2uadri#eps mus#es of the thigh(
Iioti"ia "and heps sta"ii;e the +nee )hie )a+ing and running%
O!eruse( differen#e in ength of egs( in#rease in training pra#ti#e( running on une!en roads are some of the
#auses for Iioti"ia "and fri#tion and "urning +nee%
9o)?
The ma$or pro"em in osteoarthritis of the +nee $oint is that the smooth #artiage ining the inside of
the $oint )ears a)ay% This resuts in a narro)ing of the $oint spa#e )ith the de!eopment of #ysts and
erosions in the "one ends% As a resut( "one #omes dire#ty in #onta#t )ith "one( )hi#h )i "e
painfu% Bone spurs /sma "one gro)ths) form around the $oint% A of these #hanges utimatey ead
to in#reasing pain and stiffness of the $oint%
.,A.GLING NOI&7&
What?
.repitus refers to $oint
noises( su#h as popping
and #ra#+ing in the
$oints( espe#iay the
+nees% &u#h $oint noise
#an "e 2uite distur"ing
and #ause #on#ern(
parti#uary if it sho)s
up suddeny% In most
#ases( these noises are
not indi#ati!e of any
underying pro"em%
4ost $oint #repitus(
#ra#+ing and popping
usuay has a @"ar+ that is
)orse than its "ite%@ Joint
noises often persist for years )ithout any signifi#ant pro"ems de!eoping%
Why and ho)?
7s#aping gases' &#ientists e*pain that syno!ia fuid present in your $oints a#ts as a u"ri#ant% The
fuid #ontains the gases o*ygen( nitrogen( and #ar"on dio*ide% When you pop or #ra#+ a $oint( you
stret#h the $oint #apsue% Gas is rapidy reeased( )hi#h forms "u""es% In order to #ra#+ the same
+nu#+e again( you ha!e to )ait unti the gases return to the syno!ia fuid%
4o!ement of $oints( tendons and igaments' When a $oint mo!es( the tendonIs position #hanges and
mo!es sighty out of pa#e% 6ou may hear a snapping sound as the tendon returns to its origina
position% In addition( your igaments may tighten as you mo!e your $oints% This #ommony o##urs
in your +nee or an+e( and #an ma+e a #ra#+ing sound%
,ough surfa#es' Arthriti# $oints ma+e sounds #aused "y the oss of smooth #artiage and the
roughness of the $oint surfa#e%
3I55I.HLT6 IN A,I&ING 5,O4 A &7AT73 PO&ITION
What?
9erniated dis#s #an #ause mus#e )ea+ness( ma+e it hard to get up )hen you@!e "een sitting or ying
do)n
Why and ho)?
.artiage reies on mo!ement for nourishmentE it does not #ontain "ood !esses% As you shift your
)eight onto and off of your eg( the #hanges in pressure in the +nee $oint #ause the $oint fuid to mo!e
into and out of the #artiage( #arrying nourishing su"stan#es in and )ashing un)anted su"stan#es
a)ay% This #auses diffi#uty or pain )hen getting up from sitting do)n% Not using your +nee $oint #an
#ause pain "e#ause )ithout mo!ement the #artiage doesn@t re#ei!e enough fuid8"orne nourishment%
97B7,37N@& AN3 BOH.9A,3@& NO37&
What?
Bony
"umps on
the finger
$oint #osest
to the
fingernai
are #aed
9e"erden@s
nodes%
Bony
"umps on
the midde
$oint of the
finger are
+no)n as
Bou#hard@s
nodes%
Bony "umps are aso #ommon at the "ase of the thum"% These "umps do not ha!e a ni#+name( "ut the
$oint is #aed the .4. or #arpometa#arpa $oint% The name #omes from the "one of the )rist /#arpa)
and the "one of the thum" /meta#arpa)%
Why?
9e"erden@s nodes are #aused dire#ty "y osteoarthritis due to the #onsistent trauma the "ones must
endure )hen $oints a#+ #artiage% The s)oen "oney outgro)ths appear at the end of the finger@s or
toes%
The Bou#hard@s node is ess #ommon than 9e"erden@s node% They are "eie!ed to "e #aused "y
osteophytes%
9o)?
The "ony deformity is a resut of the "one spurs from the osteoarthritis in that $oint%
BAG7,I& .6&T
What?
Ba+er@s #yst is a "uidup of $oint fuid /syno!ia fuid) that forms a #yst "ehind the +nee% A Ba+er #yst
is sometimes #aed a popitea #yst% When an e*#ess of +nee $oint fuid is #ompressed "y the "ody
)eight "et)een the "ones of the +nee $oint( it #an "e#ome trapped and separate from the $oint to form
the fuid8fied sa# of a Ba+er #yst%
Why?
Ba+er #ysts are not un#ommon and #an "e #aused "y !irtuay any #ause of $oint s)eing /arthritis)%
The e*#ess $oint fuid /syno!ia fuid) "uges to the "a#+ of the +nee to form the Ba+er #yst% The most
#ommon type of arthritis asso#iated )ith Ba+er #ysts is osteoarthritis( aso #aed degenerati!e
arthritis%
9o)?
When an e*#ess of +nee $oint fuid is #ompressed "y the "ody )eight "et)een the "ones of the +nee
$oint( it #an "e#ome trapped and separate from the $oint to form the fuid8fied sa# of a Ba+er #yst%
J) ,ain and $oint pain?
Who 7*perien#es ,ain ,eated Joint Pain?
Peope )ho e*perien#e rain8reated $oint pain often suffer from osteoarthritis( rheumatoid arthritis and
other arthritis #onditions% Indi!iduas )ith pre!iousy "ro+en "ones and those )ith mutipes s#erosis
and other neuroogi#a diseases are aso affe#ted%
What Is Affe#ted?
Any )eight8"earing $oint #an "e affe#ted and fee pain% Typi#ay( pain is fet in the hips( +nees(
e"o)s( shouders and hands%
Why?
The "ody@s $oints ha!e sensory ner!es% These ner!es are #aed "aro8re#eptors and they do respond to
#hanges in the atmosphere% When the "arometri# pressure drops or is o)( it signifies that the air has
"e#ome moist( signaing a #han#e for rain% The "ody@s ner!e re#eptors respond to o) "arometri#
pressure%
7*panation
When air and en!ironmenta pressure #hanges and fas( the amount of fuid or pressure in the "ody@s
$oints !aries% Peope )ith arthritis )i fee the #hange more signifi#anty "e#ause they ha!e ess
#artiage that #ushions the "ody@s $oints%
Hps and 3o)n
Peope )ith $oint pain often +no) a"out the )eather "efore it o##urs% When the "arometri# pressure
goes do)n immediatey "efore a storm( their pain goes up%
1K) What aging does to "ones and $oints?
Age8reated #hanges in "one' Bone is i!ing tissue% Throughout ife( "ones #onstanty #hange through
a pro#ess of a"sorption and formation #aed :remodeing%: As )e age( the "aan#e "et)een "one
a"sorption and "one formation #hanges( resuting in a oss of "one tissue% Bones "e#ome ess dense as
)e age for a num"er of reasons( in#uding'
An ina#ti!e ifestye #auses "one )astage%
9ormona #hanges L in )omen( menopause triggers the oss of mineras in "one tissue% In
men( the gradua de#ine in se* hormones eads to the ater de!eopment of osteoporosis%
Bones ose #a#ium and other mineras%
Ligaments( #onne#ti!e tissues "et)een "ones( "e#ome ess easti#( redu#ing fe*i"iity%
Age8reated #hanges in $oints' In a $oint( "ones do not dire#ty #onta#t ea#h other% They are #ushioned
"y #artiage that ines your $oints /arti#uar #artiage)( syno!ia mem"ranes around the $oint and a
u"ri#ating fuid inside your $oints /syno!ia fuid)% As you age( $oint mo!ement "e#omes stiffer and
ess fe*i"e "e#ause the amount of u"ri#ating fuid inside your $oints de#reases and the #artiage
"e#omes thinner%
Ligaments aso tend to shorten and ose some fe*i"iity( ma+ing $oints fee stiff%
11) PAT9OG7N7&I& O5 OA
A"norma stress and oading eading to me#hani#a #artiage damage pay roe in se#ondary
OA%
O"esity may in#rease s+eeta mass in#rease #artiage !oume%
.oagenases /44P81 and 44P81=) #ea!e #oagen and other meoprteinasesau#h as
stromeysin /44P8=) and geatinases /44P80 and 44P8J) are aso present in e*tra#euar
matri*% 44Ps se#reted "y #hondro#ytes in an ina#ti!e form% 7*tra#euar a#ti!ation then
eads to degradation of "oth #oagen and proteogy#an around #hondro#ytes%
Tissue inhi"itors of meoproteinases /TI4Ps) reguate the 44Ps% 3istur"an#es of this
reguation may ead to an in#rease in #artiage degradation o!er synthesis and #ontri"ute to
the de!eopment of OA%
Osteoprotegerin /OPG)( ,ANG and ,ANG igand /,ANGL) may #ontro the remodeing of
su"#hondra "one remodeing% Their e!es are signifi#anty different in OA #hondro#ytes%
Inhi"iting ,ANGL may pro!e ne) therapeuti# approa#h in OA%
Aggre#anase produ#tion is stimuated "y proinfammatory #yto+ines and aggre#an /the ma$or
proteogy#an) e!es fa%
&yno!ia infammation is present in OA( and .8,ea#ti!e Protein /.,P) in the serum may "e
raised% IL81 and TN5 reease stimuates meoproitenase produ#tion and IL81 inhi"its type II
#oagen produ#tion% IL8C and IL8F may aso "e in!o!ed% Produ#tion of #yto+ine "y
ma#rophages and of 44Ps "y #hondro#ytes in OA are dependent on trans#ription fa#tor N58
+B may ha!e a therapeuti# roe in OA%
IL81 re#eptor antagonist genes are asso#iated )ith radiographi# se!erity of +nee OA%
Gro)th fa#tor in#uding insuin8i+e gro)th /IG581) and transforming gro)th fa#tor /TG58B)
are in!o!e in #oagen synthesis and their defi#ien#y may pay a roe in impairing matri*
repair% 9o)e!er( in#rease TG58B #an #ause in#reased su"#hondra "one density%
.artiage "rea+do)n produ#ts ead to ma#rophage infitration and !as#uar hyperpasia and
IL18B and TN58a may #ontri"ute to further #artiage degradation%
-as#uar endotheia gro)th fa#tor /-7G5) from ma#rophage is a potent stimuator of
angiogenesis and may #ontri"ute to infammation and neo!as#uari;ation in OA% Inner!ation
#an a##ompany !as#uari;ation of arti#uar #artiage%
4utations in the gene for type II #oagen /.OL0A1) ha!e "een asso#iated )ith eary
poyarti#uar OA%
10) What is 7&, test #ondu#ted for?
Bood tests for 7&, or 7rythro#yte &edimentation ,ate is a measure that is traditionay used
to #he#+ for infammation in the "ody% Infammation is a response that is mounted "y the
"ody@s immune system due to some +ind of trigger i+e infe#tion or as part of the geneti#
programming mista+es that #an sometimes happen in the "ody% At many times( one )oud not
e!en +no) that there is infammation in the "ody% This is usuay )hat happens in the #ase of
autoimmune diseases that systemati#ay destroy organs and important tissues( )ith the !i#tim
not e!en reai;ing it( unti it is mu#h too ate%
Reasons or !onducting the Test
7&, "ood testing is #aed for )hen there is a suspi#ion of an infammatory pro#ess
under)ay in the "ody% The pro"em )ith the 7&, test )ith "ood is that it doesn@t reay state
)hat e*a#ty the #ause of the infammation is% 5or this reason( other tests need to "e
#ondu#ted i+e #ompete "ood #ounts for )hite "ood #es and ympho#ytes% Another test
that is generay #ondu#ted is the .8rea#ti!e protein test% 7&, and .,P "ood tests #an
generay ma+e for a more definiti!e diagnosis a"out the presen#e of infammation%
"nterpretation of Test Results
A high 7&, #ount #oud mean that one is suffering from some +ind of infe#tion( an
infammation of the ma$or arteries( upus( or e!en anemia% The entire premise of the test is
that during an infammatory phase the e!es of #oaguant fi"rinogen in the "ood #auses the
red "ood #es to #ump together and fa to the "ottom of a measuring tu"e% 9o)e!er( this
same effe#t #an aso happen in #onditions i+e anemia as )e%
When you are diagnosed )ith a high 7&,( )hi#h is #a#uated "y di!iding your age "y 0 that
)i gi!e you a !aue to )hi#h you add the metri# mm?hr% Women shoud add 1K to their age
and then perform the di!ision% If your 7&, is high( it means that you shoud aso as+ for a .8
rea#ti!e protein test and a #ompete )hite "ood #e #ount% 7&, is ony an indi#ation that
something is )rong )ith the "ody and that it re2uires further in!estigation% 7nsure that your
do#tor has the #orre#t e2uipment to perform these tests% The .,P test is something that )on@t
"e a!aia"e in hospitas that are "eo) a #ertain standard%
#$) %&ray result of osteoarthritis 'nee
A% spi'ing tibia/ spurring tibial spine ' Bone spurs( aso +no)n as osteophytes% 5ri#tion "et)een
the "ones may #ause sma deposits of "one #aed "one spurs to form on the edges of the $oint%
Gnee Osteoarthritis' One of the most #ommon reasons for "one spurs in the +nees is +nee
osteoarthritis( )hi#h is #hara#teri;ed "y #onstant )ear and tear of the +nee $oints% With e*#essi!e
pressure( #onstant fri#tion "et)een the +nee $oints and stret#hing of the $oints( the #artiage in the
"ones tend to )ear out% The "ody attempts to repair this damage done to the #artiage "y #reating "one
spurs "et)een these $oints% The e*tra surfa#e pro!ided "y the "one spurs is used for oad8"earing and
for pre!enting further damage to the +nees%
Gnee In$uries' In$ury to the #artiage tissue( aso +no)n as a menis#us in$ury( #an aso ead to "one
spurs% When the #res#ent8shaped sho#+ a"sor"ers "et)een the femur and the ti"ia( aso +no)n as
menis#us( are damaged or torn( it #an ead to "one spurs%
Other .auses' &ome of the other #auses of this #ondition are o"esity( aging( a#+ of physi#a a#ti!ity(
poor posture( stru#tura a"normaities during "irth( and nutritiona defi#ien#ies% Buidup of #a#ium
deposits in the "ody( degeneration of the $oints( and hereditary fa#tors #an aso ead to the appearan#e
of "one spurs%
B% s(uaring of the
edges of the
femorotibial
compartments'
#a#ifi#ation
.% marginal
ostephytes' for
formation of spi+ing
ti"ia( Osteophytes
typi#ay de!eop as
a reparati!e response
"y the remaining
#artiage%
3% subchondral
bone/subchondral
sclerosis' in#reased "one formation around the $oint% &u"#hondra "one is the ayer of "one $ust
"eo) the #artiage% When someone has osteoarthritis( there is in#reased "ood fo) and other
#hanges that de!eop in the su"#hondra ayer 88 su"#hondra s#erosis /in#reased "one density)
7% eburnation' With progression of the disease( there )i "e #ontinous oss of arti#uar #artiage
eads to e*posure of su"#ondria "one 8 )hi#h appears as shiny fo#i on the arti#uar surfa#e
/+no)n as 7BH,NATION)% &e#ondary #hanges are fre2uenty seen in the underying "one su#h
as fi"rosis( #ysti# #hange > ne) "one formation% Progressi!e oss of arti#uar #artiage stimuates
ne) "one formation( usuay in the form of nodues /+no)n as O&T7OP96T7&) at the "ony
edges%

1A) .omposition
of syno!ia fuids
&yno!ia
fuid is a
thi#+(
stringy
fuid
found in
the
#a!ities of
syno!ia
$oints% It
redu#es
fri#tion
"et)een
the arti#uar #artiage and other tissues in $oints "y u"ri#ating and #ushioning them during
mo!ement%
&yno!ia fuid is made of hyauroni# a#id and u"ri#in( proteinases( and #oagenases%
o Lu"ri#in is se#reted "y syno!ia #es that is #hiefy responsi"e for so8#aed
"oundary8ayer u"ri#ation( )hi#h redu#es fri#tion "et)een opposing surfa#es of
#artiage% It may aso ha!e a roe in syno!ia #e gro)th%
o 9yauroni# a#id( synthesi;ed "y syno!ia ining #es( is se#reted into the syno!ia
fuid( ma+ing the fuid !is#ous%
Physi#a #hara#teristi#s'
o .ooress and transparent
o Amount L thin fim #o!ering surfa#es of syno!ium and #artiage )ithin $oint spa#e
#)) *hat is the
morphological
changes of
osteoarthritis+
A% G,O&&
ANATO46'
NO,4AL O&T7OA,T9I&TI& JOINT
Thi#+ #artiage and spa#es "et)een the
#artiages/)ith pure syno!ia fuid)
Thin?u#erated?eroded #artiage( $oint spa#e
narro)ing
Norma #apsue Thi#+ening of #apsue
No margina osteophytes 4argina osteophytes 8 "one spurs
&#eroti# "one
&u"#hondra s#erosis > #yst
&yno!ia fuid #ontains )orn8a)ay #artiage
B% 9I&TOLOG6'
1C) Type of
osteoarthritis '
a, -rimary
This type
of OA is a
chronic
degenerative disorder
,eated to "ut not #aused "y aging( as there are peope ha!e no #ini#a or fun#tiona signs of this
disease
As human aged( the #artiage )ater #ontents de#reases as a resut of a redu#ed proteogy#an
#ontent%
.ause the #artiage to "e ess resiient
The prote#ti!e effe#ts of the proteogy#an "e#ome diminished% It #auses the #oagen fi"ers of the
#artiage to "e#ome sus#epti"e to degradation and undergoes degeneration%
Infammation of the surrounding $oint #apsue #an aso o##ur /often mid#ompared to that )hi#h
o##urs in rheumatoid arthritis)
This #an happen as "rea+do)n produ#ts from the #artiage are reeased into the syno!ia spa#e(
and the #es ining the $oint attempt to remo!e them
Ne) "one outgro)ths( #aed :spurs: or osteophytes( #an form on the margins of the $oints(
possi"y in an attempt to impro!e the #ongruen#e of the arti#uar #artiage surfa#es
These "one #hanges( together )ith the infammation( #an "e "oth painfu and de"iitating%
b, .econdary
This type of OA is #aused "y other fa#tors "ut the resuting pathoogy is the same as for primary OA'
.ongenita disorders?Geneti#'
o .ongenita hip u*ation
o Peope )ith a"normay8formed $oints /hip dyspasia)( as added stress is spe#ifi#ay pa#ed on the
$oints )hene!er they mo!e
o 3ia"etes
Infammatory diseases /su#h as Perthes@ disease)( /Lyme disease)( and a #hroni# forms of arthritis /e%g%
#osto#hondritis( gout( and rheumatoid arthritis)
In gout( uri# a#id #rystas #ause the #artiage to degenerate at a faster pa#e%
In$ury to $oints( as a resut of an a##ident
A $oint infe#tion /due to in$ury)
9ormona disorders
Ligamentous deterioration or insta"iity may "e a fa#tor
O"esity% O"esity puts added )eight on the $oints( espe#iay the +nees%
&ports in$uries( or simiar in$uries from e*er#ise or )or+% In$uries resuting in "ro+en igaments #an
ead to insta"iity of the $oint and o!er time to )ear on the #artiage and e!entuay osteoarthritis%
Pregnan#y
&tru#tures
of OA
+nee'
.an o##ur at'
Inter!erte"ra $oint
Gnee $oint
9ip $oint
9and $oint /interphaangea $oint( meta#arpaphaangea $oint( #arpameta#arpa $oint)
Wrist $oint
5oot $oint /interphaangea $oint( metatarsophaangea $oint)
1D) 4e#hanism of
N&AI3 and side
effe#t
1% ,eationship of N&AI3 and #yoo*ygenase'
.y#oo*ygenase is en;yme responsi"e for synthesis of #e mediator )hi#h the prostanoid
/prostagandin( prosta#y#in( throm"o*ane)
!O/#
L .ontinuousy stimuated "y the"ody
L .onstituti!e /Its #on#entration inthe "ody remain sta"e)
L .reates prostagandins used for "asi# house8+eeping throughout "ody
L Prostagandins stimuate norma"ody fun#tions su#h as stoma#h mu#ous produ#tion(
reguationof gastri# a#id and +idney )atere*#retion
M .o* 0
L Indu#ed / normay not inpresent in #es)
L Buit ony in spe#ia #es /7N aBAJung #es)
L Hsed for signaing pain andinfammation
L Produ#es prostagandins forinfammatory response
L &timuated ony as part ofimmune response
L Produ#tion is stimuated "yinfammatory #yto+ines andgro)th fa#tors N&AI3 a#tion is to
inhi"it #o*81 and #o*80
0% Non8steroida anti infammatory drug /N&AI3) me#hanism'
4ost N&AI3s #urrenty used today sho)s no see#ti!ity to .ON1 and .ON0 / Aspirin)
This non see#ti!ity eads to !arious side effe#ts
o Aspirin and other simiar N&AI3s ead to e*#essi!e produ#tionof stoma#h a#id as
)e as u#eration and gastrointestina"eeding
This is due to the inhi"iting of .ON1 house +eeping roe as)e as .ON0 infammatory
response
o ,esent resear#h has "een dire#ted at the see#ti!ity of .ON0 o!er .ON1
Nonsteroida Anti8Infammatory 3rugs )or+ "y interfering )ith the #y#oo*ygenase path)ay%
3ifferent me#hanisms stimuate the t)o different types of #y#oo*ygenase
.ON81 is stimuated #ontinuousy "y norma "ody physioogy% The .ON81 en;yme is
#onstituti!e( meaning that its #on#entration in the "ody remains sta"e% It is present in most
tissues and #on!erts ara#hidoni# a#id to prostagandins
These prostagandins in turn stimuate "ody fun#tions( su#h as stoma#h mu#ous produ#tion
and +idney )ater e*#retion( as )e as pateet formation%
The o#ation of the .ON81 en;yme di#tates the fun#tions of the prostagandins it reeases% 5or
e*ampe( .ON81 in the stoma#h )a produ#es prostagandins that stimuate mu#ous
produ#tion%
In #ontrast( the .ON80 en;yme is indu#ed% It is not normay present in #es "ut its
e*pression #an "e in#reased dramati#ay "y the a#tion of ma#rophages( the s#a!enger #es of
the immune system
.ON80 pays a !ery important roe in infammation% .o*80 is in!o!ed in produ#ing
prostagandins for an infammatory response
.ON81 is stimuated #ontinuay( and .ON80 is stimuated ony as a part of an immune
response%
=% N&AI3 side effe#t'
There are se!era fa#tors that seem to affe#t the #han#es of side effe#ts )ith N&AI3s%
In#udes'
The dosage and type of N&AI3
6our age
Other medi#a #onditions you may ha!e
Other medi#ines you may "e ta+ing
.ommon &ide 7ffe#ts of N&AI3s
A N&AI3s ha!e "een studied e*tensi!ey in #ini#a trias( )ith many peope )ord)ide
ha!ing "een e!auated
Based on these studies( the most #ommon N&AI3 side effe#ts in#ude'
1% Nausea
0% A"domina pain /stoma#h pain)
=% 9eart"urn
A% 3i;;iness
B% An une*pained rash
C% .onstipation
D% 3iarrhea
F% Gas
J% -omiting
Terms to +no)
,heumatoogy #ini#s
Rheumatology is a su"8spe#iaty in interna medi#ine and paediatri#s( a "ran#h of medi#ine
spe#iai;ing in the study of pathoogies in the mus#es( tendons and $oints( de!oted to the diagnosis
and therapy of rheumati# diseases/diseases of infammation and auto8immunity( su#h as arthritis( gout(
upus erythematosus( s#eroderma( and Lyme disease)% .ini#ians )ho spe#iai;e in rheumatoogy are
#aed rheumatoogists )ho dea mainy )ith #ini#a pro"ems in!o!ing $oints( soft tissues and the
aied #onditions of #onne#ti!e tissues%
The ,heumatoogy #ini# offers #ini#a #are( resear#h( and edu#ation% The #omprehensi!e and
#oordinated mutidis#ipinary team pro!ides diagnosis and treatment for #hidren and adoes#ents )ith
rheumati# diseases% These diseases in#ude'
#hroni# arthritis /$u!enie idiopathi# arthritis)
systemi# upus erythematosus
dermatomyositis
s#eroderma
!as#uitis
mus#uos+eeta pain syndromes
Purpura
Purpura is purpe8#oored spots and pat#hes that o##ur on the s+in( organs( and in mu#us mem"ranes(
in#uding the ining of the mouth% Purpura o##urs )hen sma "ood !esses $oin together or ea+
"ood under the s+in%Purpura may aso o##ur in the mu#ous mem"ranes( espe#iay of the mouth( and
in the interna organs% Purpura is not a disease per se "ut is indi#ati!e of an underying #ause of
"eeding%
When purpura spots are !ery sma( they are #aed pete#hiae% Large purpura are #aed e##hymoses%
Pateets hep the "ood #ot% A person )ith purpura may ha!e norma pateet #ounts
/nonthrom"o#ytopeni#purpuras) or o) pateet #ounts /throm"o#ytopeni# purpuras)%
.auses
Nonthrom"o#ytopeni#purpuras may "e due to'
Amyoidosis
Bood #otting disorders
.ongenita #ytomegao!irus
.ongenita ru"ea syndrome
3rugs that affe#t pateet fun#tion
5ragie "ood !esses /senie purpura)
9emangioma
Infammation of the "ood !esses /!as#uitis)( su#h as 9eno#h8&#honeinpurpura( )hi#h
#auses a raised type of purpura
Pressure #hanges that o##ur during !agina #hid"irth
&#ur!y
&teroid use
Throm"o#ytopeni# purpura may "e due to'
3rugs that pre!ent pateets from forming
Idiopathi# throm"o#ytopeni# purpura /ITP)
Immune neonata throm"o#ytopenia /#an o##ur in infants )hose mothers ha!e ITP)
4eningo#o##emia 88 a raised type of purpura
Hrti#aria esion
Hrti#aria des#ri"es a group of #onditions in )hi#h there are )heas /or )eas) in the s+in( it#hy )hite
or red umps% Hrti#aria #an o##asionay "e a sign of systemi# disease%
Hrti#aria /hi!es) is a !as#uar rea#tion of the s+in mar+ed "y the transient appearan#e of smooth(
sighty ee!ated pat#hes /)heas) that are erythematous and that are often attended "y se!ere pruritus%
Indi!idua esions reso!e )ithout s#arring in se!era hours% 4ost #ases of urti#aria are sef8imited
and of short durationE the eruption rarey asts more than se!era days( it "ut may "e re#urrent o!er
)ee+s% .hroni# urti#aria is defined as urti#aria )ith re#urrent episodes asting onger than C )ee+s%
The de!eopment of urti#aria is often an isoated e!ent )ithout systemi# rea#tion% ,arey( it #an "e a
preude to the de!eopment of an anaphya#ti# /eg( hypotension( respiratory distress( stridor(
gastrointestina distress( s)ao)ing pro"ems( $oint s)eing( $oint pain)
7"urnation
It is a #on!ersion of "one into a hard( i!ory8i+e mass at )hi#h a #hange in e*posed su"#hondra "one
in degenerati!e $oint disease )here"y it is #on!erted into a dense su"stan#e )ith a smooth surfa#e i+e
i!ory )hi#h is aso +no)n as "one s#erosis%