Medical Care: Most patients who present with a new musculoskeletal complaint have a problem restricted to one anatomic region or joint. Examples include back or shoulder pain. These problems are usually recognized as self-limited and not of the type to pose a major hazard to the health of the patient. Such patients are treated symptomatically and advised about the optimal balance of activity and rest, the benign nature of the problem, and the expectation of healing in 2-6 weeks. Extensive testing is inappropriate because abnormalities may be revealed that are irrelevant, and these results may prompt further, often unnecessary, investigations.
Clinical situations in which acute musculoskeletal symptoms must be evaluated promptly and thoroughly include (1) a severe condition involving one joint or, at most, a few joints; (2) a patient who is febrile, is systemically ill, or is showing signs of multiple organ involvement; (3) a problem associated with significant trauma, and (4) a condition in which an associated neurologic problem exists, such as carpal tunnel syndrome, sciatica, or cervical radicular symptoms.
In patients with arthritis, the goals of treatment include relief of pain, restoration or maintenance of joint function, and prevention of joint damage. These goals are achieved with both pharmacologic and nonpharmacologic therapeutic modalities. While some modalities are common to the treatment of all forms of arthritis, others are specific to certain forms of arthritis. Thus, proper treatment begins with an accurate diagnosis. One of the challenges in treating arthritis is determining the expected prognosis and instituting appropriate therapy in a timely fashion, thereby avoiding the development of irreversible joint dysfunction.
The initial assessment of the patient should allow classification of the joint problem into one of the categories detailed below:
" Acute monoarthritis
o Principles of management
" Hospitalize any patient with possible septic arthritis.
" Aspiration of joint fluid is a critical step in diagnosis.
" The finding of noninflammatory joint fluid in an acutely inflamed joint should prompt consideration of juxta-articular osseous pathology (eg, stress fracture, osteomyelitis, avascular necrosis), acute inflammation of periarticular structures (eg, gouty inflammation of tendon sheaths or bursae, septic bursitis), subcutaneous inflammation (eg, arthritis of ankles in erythema nodosum, pancreatic fat necrosis), or cellulitis.
o Initial treatment of possible septic arthritis
" Begin intravenous antibiotic therapy based on the clinical situation and the results of a Gram stain of centrifuged synovial fluid.
" Provide for adequate drainage of the joint. Repeated percutaneous aspiration of the joint with a large-bore needle is indicated. Arthroscopic drainage of knees, shoulders, ankles, and elbows is an acceptable alternative, provided the risk of anesthesia is not excessive. Use surgical drainage for hips and for other joints that cannot be adequately drained with needle aspiration or that do not improve after 3-5 days of repeated percutaneous aspiration.
o Initial treatment of acute crystalline synovitis
" NSAIDs should initially be given at their maximum recommended dosage until symptoms improve. Then, they should be tapered gradually over several days. Indomethacin is very effective, but adverse effects in some patients limit its utility. Other NSAIDs with short half-lives (eg, ibuprofen, diclofenac) can also be used.
" Colchicine has a narrow therapeutic window, which limits its effectiveness. It must be used cautiously in the setting of renal insufficiency. Thus, its use to treat acute gouty arthritis (as opposed to low doses to prevent attacks) has been largely supplanted by other therapies.
" Corticosteroids are an effective alternative to NSAIDs and colchicine for patients in whom these drugs may be contraindicated or hazardous (eg, patients with advanced age, renal insufficiency, congestive heart failure, inability to take oral medications). Regimens include (1) an intramuscular injection of a long-acting crystalline preparation (eg, triamcinolone acetonide at 60-80 mg), with an option to repeat once after 24-48 hours; (2) prednisone at 20-30 mg/d with a progressive taper over 7-10 days; and (3) intra-articular corticosteroid therapy.
" Acute polyarthritis
o Principles of management
" Hospitalize the patient in the presence of (1) significant, concomitant internal organ involvement; signs of bacteremia, including vesiculopustular skin lesions, Roth spots, shaking chills, or splinter hemorrhages; (3) systemic vasculitis; (4) severe pain; (5) severe constitutional symptoms; (6) purulent (group III) synovial fluid in one or more joints; or (7) immunosuppression.
" An infectious etiology should receive first consideration. Obtain appropriate cultures (eg, blood, joint, cervix, urethra, pharynx). Begin empiric antibiotic therapy if bacteremia or sepsis cannot be readily excluded.
" Extra-articular manifestations, such as a rash, hematologic abnormalities, or heart murmur, should be sought as important indicators of the diagnosis.
" Repeated examinations of the patient are required to detect diagnostic physical findings that may be absent at presentation.
o Initial treatment modalities for patients with acute polyarthritis
" Antibiotic therapy is indicated for septic polyarthritis or bacteremia with joint involvement (eg, disseminated gonococcemia). Systemic antibiotics are used after appropriate cultures are taken. Prolonged treatment with lymecycline (a form of tetracycline) or ciprofloxacin may decrease the duration of Chlamydia-induced reactive arthritis. Benefit has not been shown for reactive arthritis induced by enteric infections.
" Analgesics without anti-inflammatory properties may be appropriate as the initial treatment in patients with milder forms of acute rheumatic fever, viral arthritis (eg, parvovirus arthritis), or acute leukocytoclastic vasculitis. They also may be appropriate for those with polyarticular crystalline synovitis in whom significant concomitant medical problems preclude the use of NSAID or corticosteroid therapy. This therapy allows for the complete expression of the clinical manifestations of the disease, thereby aiding in diagnosis.
" NSAID therapy can be instituted with high-dose aspirin therapy, which can be used for acute rheumatic fever, with the goal of achieving a salicylate level of 20-30 mg/dL. High-dose NSAID (nonsalicylate) therapy is used to treat crystalline synovitis, acute viral arthritis, and polyarthritis related to RA, SLE, or other connective-tissue disorders.
" Corticosteroids are used in persons with polyarthritis alone in whom high-dose NSAID therapy has failed or who cannot be treated safely with NSAIDs because of renal insufficiency, active GI bleeding, or other conditions. Prednisone at 15-20 mg/d (or equivalent) is usually sufficient for acute polyarticular flares of RA. High doses of prednisone (0.5-1 mg/kg/d) are used in the setting of severe constitutional symptoms, concomitant major organ involvement, or signs of systemic vasculitis. Examples include acute SLE, Still disease, or acute rheumatic fever that fails to respond to NSAID therapy.
" Chronic (inflammatory) monoarthritis
o Principles of management
" Diagnoses other than osteoarthritis should be considered if the patient has a synovial fluid WBC count of greater than 1000/ L, hemorrhagic synovial fluid, no significant radiographic changes associated with osteoarthritis, synovial proliferation, significant pain, or constitutional symptoms.
" The initial diagnostic focus in a patient with a chronic inflammatory monoarthritis is always on a potential infectious etiology. (Lyme arthritis can manifest as a subacute or chronic inflammatory monoarthritis; its diagnosis is based on the results of serologic testing and/or detecting Borrelia DNA in the synovial fluid using polymerase chain reaction. Antibiotic treatment is indicated.)
" Perform a synovial biopsy and culture if the initial evaluation (including synovial fluid cultures) fails to establish a specific diagnosis.
" Consider aseptic necrosis in a joint with noninflammatory joint fluid.
o Treatment modalities for patients with chronic (inflammatory) monoarthritis
" Chronic gout therapy requires allopurinol (the preferred drug) to correct hyperuricemia. Suppress chronic inflammation with NSAIDs, colchicine (eg, 0.6 mg bid), or both. Intra-articular corticosteroid therapy may also be appropriate.
" Other crystalline arthropathies (calcium pyrophosphate, hydroxyapatite) are treated by suppressing chronic inflammation with NSAIDs, colchicine, or both. Intra-articular corticosteroid therapy may also be appropriate.
" Monoarticular presentation of a systemic rheumatic disease is treated with systemic therapies appropriate to the rheumatic disease, particularly if intra-articular corticosteroids are contraindicated or ineffective for long-term suppression of the monoarticular disease.
" Chronic (inflammatory) polyarthritis
o Principles of management
" Treatment with NSAIDs is often initiated before a firm diagnosis is established.
" Certain diagnoses should be sought during the initial patient evaluation because specific (and potentially curative) therapies are needed. These include chronic polyarticular gout, subacute bacterial endocarditis, and hepatitis C-related syndromes (eg, cryoglobulinemia, arthritis).
" Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, leflunomide, and tumor necrosis factor-alpha antagonists should be started relatively early in the course of rheumatoid or psoriatic arthritis in order to prevent joint damage. Consultation with a rheumatologist is prudent in order to confirm these diagnoses and to initiate appropriate DMARD therapy.
" Corticosteroids in low doses (<10 mg) may serve as a valuable adjunct to the treatment of chronic inflammatory arthritides, although attention must be paid to the adverse effects of long-term steroid use (eg, osteoporosis).
o Treatment modalities
" NSAID choice is guided by the patient's comorbidities and past response to these drugs. It is also guided by the cost and dosing frequency of the drugs. Maximal doses of NSAIDs are generally required for effective management of chronic polyarthritides. However, lower doses may be used if the disease is being adequately suppressed with DMARDs.
" DMARDs are used to suppress synovitis and thereby prevent or at least retard the development of joint damage and/or deformity. The choice of DMARD regimen depends on a number of factors, including the underlying disease, comorbidities, and prior treatment responses, among others.).
" Osteoarthritis
o Principles of management
" Management is most effective when it includes physical measures to reduce joint loading, an appropriate exercise regimen, medications, and, occasionally, surgery.
" The natural history of osteoarthritis is punctuated by episodes of more intense joint pain, followed by long periods of relative quiescence. More persistent, chronic pain is a feature of advanced disease. Dosing of anti-inflammatory and analgesic medications should be calibrated to the severity of the joint pain. Acute episodes may require enforced joint rest for relief; use of crutches, a cane, splints, or other orthotic devices; and strict avoidance of certain activities.
" Prevention of symptomatic flares is key to proper management. Patients should be educated to maintain or achieve ideal body weight, exercise to strengthen muscles that support diseased joints, and avoid specific activities that aggravate joint pain (eg, stair climbing, strenuous exercise, throwing, kneeling).
o Nonpharmacologic management
" Instruct the patient to attempt to achieve and/or maintain ideal body weight.
" Teach the patient joint preservation techniques.
" Recommend a physical therapy regimen that includes range-of-motion and flexibility, conditioning, and aerobic cardiovascular exercises.
" Prescribe orthotic devices (eg, cane, walker, splint, wedged insoles) to rest or unload a joint.
" Recommend the use of devices to assist activities of daily living (eg, tub seat, elevated toilet, dressing sticks, long-handled shoe horns).
o Pharmacologic management
" Mild disease can be treated with acetaminophen (up to 1 g qid); propoxyphene/acetaminophen (up to 4 caps/d); tramadol (50-100 mg qid); over-the-counter NSAIDs (eg, naproxen, ibuprofen) in analgesic doses, glucosamine (500 mg tid); or topical analgesics containing capsaicin, methylsalicylate, or an NSAID.
" Moderate disease is treated with NSAIDs. Persistent symptoms not relieved by mild therapy often require NSAID administration for prolonged periods in anti-inflammatory doses. In this setting, give careful consideration to potential NSAID toxicities. Avoid long-term use of indomethacin, piroxicam, and mefenamic acid. COX-2 inhibitors (eg, celecoxib) are associated with a lower frequency of serious GI complications but have potential cardiovascular toxicity. COX-2 inhibitors are an option for patients with a history of peptic ulcer disease or previous upper GI bleeding and for those taking anticoagulants or oral corticosteroids. They should be avoided in patients with significant cardiovascular disease or risk factors. The risk of NSAID gastropathy can be reduced by coadministering a proton pump inhibitor.
" Intra-articular hyaluronan may provide relief of symptomatic knee osteoarthritis for periods up to 1 year. It requires a series of 3-5 weekly injections. Intra-articular corticosteroids are beneficial for patients with symptomatic effusions. Use is limited to 1 injection per joint every 3 months.
" Severe disease is the presence of intractable pain and/or significant incapacity, and this is an indication for surgical intervention. Opiate analgesics may be used for intractable pain, but first thoroughly consider the risks associated with their long-term use.
" Soft tissue rheumatic pain disorder
o Principles of management of regional musculoskeletal pain syndromes (eg, tendonitis, bursitis, acute soft tissue injuries, and regional myofascial pain syndromes)
" Allow the soft tissue injury to heal with a short period of enforced rest. This can be achieved with immobilization or avoidance of activities that require the use of the involved part.
" Provide pain relief using both nonpharmacologic (eg, local heat or cold, electrical stimulation, massage) and pharmacologic (eg, oral analgesics, NSAIDs, muscle relaxants, corticosteroid injections, topical agents) modalities.
" Prescribe an exercise program to be performed at home or under the guidance of a physical therapist. The goals should include stretching, muscle strengthening, and education about proper body mechanics.
" Identify and eliminate factors that have aggravated or precipitated soft tissue pain (eg, posture, repetitive trauma, poor body mechanics).
o Principles of management of generalized noninflammatory soft tissue rheumatic pain syndromes (eg, fibromyalgia, hypermobility syndrome)
" Screen for coexistent depression, and treat it if present.
" Screen for a sleep disorder, and treat it if present.
" Emphasize the primary role of low-level aerobic exercise in treatment.
" Treat pain using agents that are acceptable for prolonged use and do not promote physical dependence.
Surgical Care: Indications for surgical management of arthritis include the following:
" Uncertain diagnosis: Perform a synovial or bone biopsy.
" Acute septic arthritis
o Drain hip and shoulder joints.
o Surgically drain joints that are not responding to repeated percutaneous needle drainage.
o Remove hardware or exchange polyethylene components in an infected prosthesis.
" Rheumatoid arthritis
o Perform total arthroplasty on large joints, such as hips, knees, and shoulders. The primary indication is relief of pain that has failed to improve with medical therapy. Improvement of function and motion are secondary goals that are not always attainable.
o Perform wrist synovectomy and dorsal hand tenosynovectomy for persistent synovitis of the dorsum of the wrist and hand that threatens tendon integrity.
o Correct atlantoaxial or subaxial subluxation in the cervical spine.
o Perform reconstructive surgery of the hands and feet.
" Osteoarthritis
o Use arthroscopic surgery for mild-to-moderate osteoarthritis of the knee to correct internal derangements (eg, meniscal tears) and remove loose bodies, among other repairs.
o Perform an osteotomy to distribute weight in the compartment of a joint with relatively preserved cartilage.
o Total arthroplasty is indicated to relieve the pain of advanced joint disease; improvement of function and motion are secondary goals.
o Joint fusion is indicated on joints such as the ankle (eg, triple arthrodesis) or carpometacarpal joints in order to relieve pain and instability.