Ioannis Vosinakis
Orthopaedic
Scientific Head of the Orthopedic Department of ANASSA General Clinic
Pains in the joints (arthralgias) are common in everyday life. Barring obvious injuries, most patients are concerned about arthritis in a painful joint. Sometimes, often even by doctors, the term “periarthritis” is misused as a diagnosis.
The first step in diagnosis is to distinguish whether it is periarthritis, arthritis, or simple arthralgia.
PERIARTHRITIS
This term is purely descriptive, it is not a diagnosis and only means that there is some problem around the joint that is responsible for the pain. The structures that make up and surround a joint are varied. Each of them can suffer and cause pain in the joint:
Skin and subcutaneous tissue: cysts, inflammations, neuromas from old injuries
- Muscles: contusion, myositis
- Tendons: tendinitis, enthesitis (trochanteritis)
- Ligaments: bruises, calcifications (Pellegrini-Stieda on the medial side of the knee)
- Menisci: chronic tears, degeneration
- Cartilage: osteochondral fractures, chondrocalcification
- Bones: stress fractures, bone pain (Hyperparathyroidism, Hyperhypothyroidism, Musculoskeletal tumors, Metastatic disease, Multiple myeloma, Osteonecrosis, Bone infarcts. A particular feature of bone lesions is that the pain does not subside with bed rest.
A “periarthritis” can therefore hide many and potentially dangerous conditions and the differential diagnosis is particularly important. The first reason for the diagnosis is always the detailed clinical examination to identify the cause of the pain. X-rays, CT and MRI help to make an accurate diagnosis. The treatment of periarthritis is individualized depending on the underlying condition.
SIMPLE ARTHRALISM
It is the joint pain that is not accompanied by objective findings during the clinical examination of the joint and surrounding structures. It can be due to remote, or systemic causes such as endocrinopathies, fibromyalgia, viral infections of other systems, be referred pain (genalgia due to sciatica or hip problem) or reactive bursitis (as in rheumatic fever). The treatment of the root cause is also the treatment of arthralgia with simple painkillers having an auxiliary role until the underlying condition is definitively treated.
ARTHRITIS
Arthritis is the deterioration and destruction of the articular cartilage accompanied by pain, stiffness or even stiffness of the joint, swelling, hydroarthrosis (collection of fluid in the joint), heat (in acute arthritis) and eventually deformity and permanent impairment of function.
Arthritis is divided according to the time of onset into acute and chronic and according to the etiology into inflammatory and non-inflammatory. Inflammatory ones are characterized by intense signs of local inflammation (swelling, heat), pain and stiffness in the morning hours and after prolonged immobility. Symptoms show little improvement with movement. Non-inflammatory ones present with pain during movement and at the end of the day and absence of local signs of inflammation.
INFLAMMATORY ARTHRITIS
They are divided into septic (of microbial etiology) and aseptic (rheumatic diseases, connective tissue diseases, autoimmune, crystallogenic).
Septic arthritis
It is caused by the establishment of germs in the joint. It has intense, acute symptomatology and rapid progression, with the production of pus in the joint. Without appropriate and timely treatment, the destruction of the articular cartilage occurs quickly and is extensive, leading to permanent destruction of the joint.
Infection can occur blood-borne (from other foci of germs in the body: urinary tract infections, teeth, distant infected wounds), after injuries or surgical operations on the joint (infection), or even be an advanced stage of tuberculosis.
Diagnosis is made with blood tests (indicators of inflammation) and a puncture of the joint to obtain fluid for culture. Treatment involves immediate surgical debridement and removal of infected tissue and intravenous administration of the appropriate antibiotic for a long period of time, followed by continued oral antibiotics until markers of inflammation fully return to normal.
Aseptic inflammatory arthritis
They are distinguished in rheumatism (collagenosis, autoimmune) and crystallogenic.
Rheumatic diseases include many different diseases and syndromes with manifestations from many systems with rheumatoid arthritis being the best known. Relapsing rheumatism, Reiter’s syndrome, Still’s disease, Scleroderma, Psoriatic arthritis, Sarcoidosis, Systemic lupus erythematosus, Inflammatory enteropathies (Ulcerative colitis, Crohn’s disease), Ankylosing spondylitis are some of the most common. They appear at any age, often with an initial acute phase.
Rheumatic diseases are characterized by the involvement of several joints simultaneously or successively. Affected joints show swelling, pain and stiffness. In axial rheumatic arthropathies, such as ankylosing spondylitis, the spine is also affected, while from the joints of the limbs, the large joints are mainly affected and the attack is asymmetrical. In the rest, such as rheumatoid arthritis, the joint involvement is symmetrical and includes the small joints as well. Basic laboratory testing includes x-rays of the affected joints, markers of inflammation (TKE, CRP), antibodies (ANA, antiCCP), rheumatoid factor and many other specialized tests. Early diagnosis is important to reduce morbidity and prevent permanent deformities. Treatment is individualized and includes corticoids, immunosuppressants and biological agents.
Crystalgenic arthritis, such as gout and pseudogout, often have a severe clinical picture and, without treatment, can lead to catastrophic deformity. The diagnosis is made by detecting the specific crystals in the synovial fluid and the treatment of the acute phase includes anti-inflammatory drugs.
NON-INFLAMMATORY ARTHRITIS – OSTEOARTHRITIS
Osteoarthritis causes degradation of articular cartilage, disruption of the smooth rolling surface and reduction of the joint’s ability to absorb shocks and loads. It usually appears in middle age but, depending on its etiology, it can also appear in much younger patients. It is divided into primary, which has a hereditary burden, and secondary, which can be due to a multitude of underlying causes – ailments – conditions.
Congenital causes include dysplastic hip and congenital hip dislocation.
Developmental causes are conditions that in childhood or adolescence disturb the anatomy of the joint and lead to osteoarthritis in adulthood. Such conditions are Perthes osteochondritis, multiple epiphyseal dysplasia, and epiphyseal slip.
Anatomical anomalies of the axial skeleton, such as vlaisogonia, rheogonia, etc. disrupt the distribution of loads and lead to early joint wear.
Post-traumatic arthritis due to fractures (intra-articular or fractured in an incorrect position with a change in the axis of the leg), instability from ruptures of ligaments or tendons (such as arthritis from a rupture of the rotator cuff of the shoulder), tears of menisci are also common. It can be prevented by timely and correct treatment of the above situations.
Untreated osteonecrosis leads to osteochondral fracture, articular cartilage subsidence and eventually osteoarthritis. The treatment of osteoarthritis includes, in addition to analgesics and anti-inflammatories, modification and limitation of activities, weight loss, maintaining mobility, deloading (bacteria, guardians), mild aerobic exercise, range of motion exercises, strengthening exercises, rest, frequent joint position change .
Physiotherapy has a role (Thermo-cryotherapy, hydrotherapy, TENS, placement of orthotics). The administration of glucosamine and chondroitin can have a protective effect on cartilage. Intra-articular injections of hyaluronic acid and/or PRP (platelet-rich plasma) can help for months. Arthroscopic debridement of the affected joint also has transient satisfactory results. However, the definitive treatment of advanced arthritis is surgery. Arthrodesis is indicated mainly in small joints. For the older ones, replacing the joint with an artificial prosthesis, arthroplasty, achieves a painless and stable joint with good mobility for several years.