The main features are listed and some of these points are discussed below.
This may be helpful in assessing the type of arthritis. For example:
AGE. Osteoarthritis commonly presents at 50 years of age.
SEX. Rheumatoid arthritis is commoner in women, whilst Reiter’s syndrome is commoner in men.
RACE. Some arthropathies are particularly associated with diseases occurring in particular races, e.g. in sickle cell disease.
OCCUPATION. This can be an important factor in softtissue rheumatism or osteoarthritis.
The type of pain is of little help as all joint pains feel much the same to the patient. The following points are of some value:
1 Duration. For example, a long history is suggestive of rheumatoid arthritis, whilst a short history may suggest gout.
2 Onset. Some conditions like gout start suddenly. 3 Precipitating factors. For example, injury may lead to osteoarthritis, diuretic therapy can precipitate gout, and a sore throat precedes rheumatic fever.
(a) Site of the pain-this usually indicates the site of the pathology although hip disease may present with knee pain and pain in the arm or leg may arise from the neck or back.
(b) Radiation-a lesion of the cervical or lumbar spine will give pain in the distribution of the affected roots.
(c) Severity-excruciating pain is characteristic of acute gout.
(d) Aggravating and relieving factors-inflammatory joint pains are usually better with activity; patients are stiff and painful after rest. Mechanical problems are made worse by activity and relieved by rest.
(e) Diurnal variation-pain due to inflammation is characteristically worst in the mornings and improves during the day.
(d) Episodic arthritis-the frequency, regularity and duration of attacks should be noted.
Other joint symptoms
MORNING STIFFNESS. This is characteristic of inflammatory arthropathies. The duration of stiffness gives some guide to the activity of the inflammatory process.
JOINT SWELLING. This always indicates local disease.
PATTERN OF JOINT INVOLVEMENT. For example, recurrent attacks in the big toe are suggestive of gout.
CLICKING AND CREAKING OF THE JOINT. These are not important and can be felt in normal joints. DISABILITY. This is a very individual problem, depending on joints affected and the demands made upon them. It is however important in determining the right approach to treatment.
Associated non-articular symptoms
Nodules or a pleural effusion may be a clue to the diagnosis of rheumatoid arthritis. The cause of a particular arthritis may also lie in disease of other systems such as psoriasis or ulcerative colitis.
Past medical history
A history of trauma or of some other disease like psoriasis may be helpful.
Some conditions run in families, e.g. osteoarthritis, ankylosing spondylitis and gout. Patients with psoriatic arthritis do not necessarily have psoriatic skin lesions but may give a family history of psoriasis.
The occupation of the patient may have a bearing on the arthritis. In addition, the development of a chronic arthritis has a major influence on the life-style of both patient and family.
A record of the previous treatments tried and their success is important for the future management.
EXAMINATION OF JOINTS
There are three stages in the examination of an individual joint:
1 Look at it
2 Feel it
3 Move it
Inspection will reveal swelling, deformities, changes in the overlying skin (e.g. erythema) and abnormalities of the surrounding structures, e.g. wasting of muscle or swelling of bursae.
Palpation will reveal the nature of any observed swelling as well as the presence or absence of warmth and tenderness, which are cardinal signs of inflammation. There are three types of joint swelling:
1 A hard or bony swelling
2 An effusion
3 Synovial thickening
The presence of an effusion can be demonstrated by fluctuation or by a patellar tap in the knee joint. A firm nonfluctuant swelling is characteristic of synovial thickening. Movement of a joint may produce pain or crepitusa sensation of grating that is characteristic of osteoarthritis. The range of movement should be noted. Excessive
abnormal movement is called instability. Posture and gait should also be assessed.
Movement of joints is described in terms of flexion, extension, abduction, adduction and rotation. Deformities are described as valgus (like knock knees) or varus (like bow legs). A system of examination should be followed so that no joint is missed.