Clinical Medicine & Applied pathology

Musculoskeletal disorders

Rheumatoid Arthritis

Rheumatoid arthritis is among the most debilitating of all forms of arthritis, causing joints to ache and throb and eventually become deformed.

Sometimes these symptoms make even the simplest activities — such as opening a jar or taking a walk — difficult to manage.

Causes The cause of rheumatoid arthritis (RA) is unknown. It is

considered autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself. 

RA can occur at any age. It usually occurs in people between 25 and 55. Women are affected more often than men. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.

Risks

Getting older, because incidence of rheumatoid arthritis increases with age. However, incidence begins to decline in women over the age of 80.

Being female. Being exposed to an infection, possibly a virus or

bacterium, that may trigger rheumatoid arthritis in those with an inherited susceptibility.

Inheriting specific genes that may make one more susceptible to rheumatoid arthritis.

Smoking cigarettes over a long period of time.

Symptoms Pain and swelling in your joints, especially in the smaller joints of your

hands and feet Generalized aching or stiffness of the joints and muscles, especially after

sleep or after periods of rest Loss of motion of the affected joints Loss of strength in muscles attached to the affected joints Fatigue, which can be severe during a flare-up Low-grade fever Deformity of your joints over time General sense of not feeling well (malaise) Skin redness or inflammation Paleness Swollen glands Eye burning, itching, and discharge Numbness or tingling Anemia may occur due to failure of the bone marrow to produce enough

new red cells.

Rheumatoid nodules Small lumps, called rheumatoid nodules, may form

under the skin at pressure points and can occur at elbows, hands, feet and Achilles tendons. Rheumatoid nodules may also occur elsewhere, including the back of scalp, over knees or even in lungs. These nodules can range in size — from as small as a pea to as large as a walnut. Usually these lumps aren't painful.

In contrast to osteoarthritis, which affects only bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the linings of heart and lungs, lungs themselves and, in rare cases, blood vessels.

Tests

Blood tests – ESR and RA factor tests can confirm diagnosis

Imaging – X-Rays and MRI scans can also show progression of disease

C-reactive protein Synovial fluid analysis

Complications A life-threatening joint complication can occur when the

cervical spine becomes unstable as a result of RA. Rheumatoid vasculitis (inflammation of the blood vessels) is a

serious , potentially life-threatening complication of RA. It can lead to skin ulcerations and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.

RA may cause the the outer lining of the heart  to swell (pericarditis) and cause heart complications. Inflammation of heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure.

The treatments for RA can also cause serious side effects.

Osteoarthritis

Osteoarthritis is the most common joint disorder. The chronic disease causes the cushioning (cartilage) between the bone joints to wear away, leading to pain and stiffness. It can also cause new pieces of bone, called bone spurs, to grow around the joints.

Its also known as Hypertrophic osteoarthritis; Osteoarthrosis; Degenerative joint disease; OA;

Causes & Risk Most of the time, the cause of osteoarthritis (OA) is unknown.

It is primarily related to aging. However, metabolic, genetic, chemical, and mechanical factors can play a role in its development.

The symptoms of osteoarthritis usually appear in middle age and are present in almost everyone by the age of 70. Before the age of 55, the condition occurs equally in both sexes. However, after 55 it is more common in women.

The cartilage of the affected joint becomes rough and wears down (degenerates). As the disease gets worse, the cartilage disappears and the bone rubs on bone. Bony spurs usually develop around the joint.

OA is classified as primary or secondary. Primary OA occurs without any type of injury or identifiable cause. Secondary OA is osteoarthritis due to another disease or underlying condition. The most common causes of secondary OA are metabolic conditions, such as acromegaly, problems with anatomy (for example, being bow-legged), injury, or inflammatory disorders like septic arthritis.

Symptoms

gradual and subtle onset of deep aching joint pain worse after exercise or weight bearing often relieved by rest joint swelling limited movement morning stiffness grating of the joint with motion joint pain in rainy weather

Tests & Complications

A physical exam can show limited range of motion, grating of a joint with motion, joint swelling, and tenderness.

An x-ray of affected joints will show loss of the joint space, and in advanced cases, wearing down of the ends of the bone and bone spurs.

Decreased ability to walk Decreased ability to perform activities of daily living, such as

personal hygiene, house chores, or cooking Adverse reactions to drugs used for treatment

Lumbago

Lumbago is defined as mild to severe pain or discomfort in the area of the lower back. The pain can be acute (sudden and severe) or chronic if it has lasted more than three months.

Lumbago often occurs in younger people whose work involves physical effort and is not uncommon in people of retirement age.

Causes Small fractures to the spine from osteoporosis Muscle spasm (very tense muscles that remain contracted) Ruptured, slipped or herniated disk Degeneration of the disks Poor alignment of the vertebrae Spinal stenosis (narrowing of the spinal canal) Strain or tears to the muscles or ligaments supporting the back Spine curvatures (like scoliosis or kyphosis) which may be

inherited and seen in children or teens Other medical conditions like fibromyalgia skeletal damage due to tumours or infection.

Risks Work in construction or another job requiring

heavy lifting, lots of bending and twisting, or whole body vibration (like truck driving or using a sandblaster)

Have bad posture Are pregnant Are over age 30 Smoke, don't exercise, or are overweight Have arthritis or osteoporosis Have a low pain threshold, Feel stressed or

depressed

Symptoms Pain across the lower part of the back that sometimes

radiates into the buttocks, the back of the thigh or to the groin. The pain is usually worse on movement.

Limitation in movement of the spine - especially bending forward and leaning back.

Tense spasm of the muscles surrounding the spine, causing a stiff back.

With severe pain and spasm, the back may tilt to one side causing a change in posture.

The pain is sometimes accompanied by a tingling sensation or numbness in the back or buttocks or leg.

Referred pain & Tests

Referred pain from- Bladder infection Kidney stone Endometriosis Ovarian cancer, Ovarian cysts Testicular torsion (twisted testicle)

a myelogram (an X-ray or CT scan of the spine after dye has been injected into the spinal column),

X-ray a CT of the lower spine or MRI of the lower spine.

Muscular Dystrophy

Soft tissue Rheumatism Soft tissue rheumatism is a collection of nonarticular

pain generators that result from pathology of extraarticular and extra osseous periarticular structures.

These soft tissue structures include bursae, tendons and their synovial sheaths, muscles and fasciae.

The focal point to soft tissue rheumatism is that pain is not due to pathology of structures within the true joint (i.e., arthritis).

Soft tissue rheumatism may manifest itself as well defined pathology of a single periarticular site or a regional myofascial pain syndrome.

Examples of single site periarticular pain generators include bursitis, tendonitis or enthesopathy (e.g., plantar fasciitis).

Finding a few of these pain generators in the absence of articular involvement suggests a chronic, low-grade, repetitive trauma disorder or an acute overexertion syndrome that one may find in “weekend warrior” athletes.

Bursitis and tendinitis affect men and women of all age groups whereas fibromyalgia affects more women than men and most are between the ages of 20 and 40.

regional - bursitis and tendinitis generalised – fibromyalgia

Cause & Risk The most common cause of bursitis and tendinitis is

overuse of affected area during daily activities. Bursitis and tendinitis especially occur in people with bad postures or those who use the affected area in a strenuous positions.

Sometimes, the bursa or tendon sheath may become infected. Tendinitis or bursitis may occasionally be associated with diseases like gout and rheumatoid arthritis.

As for fibromyalgia, the cause is unknown. Some believe that fibromyalgia is related to disruptive sleep patterns.

Factors that contribute to the development and continuation of symptoms include stress and immune disorders.

Symptoms When there is inflammation of the bursa and tendon, there is

pain and stiffness near the joints which may be mistaken for arthritis.

The pain is more prominent at night and local swelling can occur. Movements will worsen the symptoms.

The bursa and tendon most affected are located around the shoulder, elbow, wrist, hip, knee, ankle and feet. The inflammation is usually temporary but can recur again.

In fibromyalgia, the muscles become too tight and tense. These leads to multiple painful areas like the back of the neck, shoulder and the bony points of the elbows and hips.

Some people have symptoms of irritable bowel syndrome and tension headaches accompanying fibromyalgia.

Major remedies

Rhus tox Ruta Bryonia Ledum pal Arnica Apis Ars alb