Degenerative arthritis

Overview

Arthritis is described as either acute or persistent joint inflammation. Arthritis can cause a wide range of symptoms such as pain, stiffness, limited range of motion, and joint abnormalities. There are various varieties of arthritis, and each requires a unique approach to treatment. The history and physical examination are critical in determining the kind of arthritis, but further laboratory and imaging tests may be required to confirm the diagnosis in some cases.

Arthritis definition

The name "arthritis" is derived from the Greek term "joint illness." It is described as acute or chronic joint inflammation that is frequently accompanied by pain and structural damage. Arthritis is not the same as arthralgia, which is pain that is confined to a joint, independent of the source of the pain, which may or may not be attributable to joint inflammation. Arthritis afflicted both Neanderthals and ancient Egyptians, although the name "osteoarthritis" was not created until 1886 by Dr. John K. Spencer.

There are about 100 distinct varieties of arthritis, with the most prevalent being osteoarthritis or degenerative arthritis, which is a non-inflammatory arthritis. Inflammatory arthritis can occur in a variety of settings, and it can be caused by autoimmune processes (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and so on), crystal deposition-induced inflammation (gout, pseudogout, basic calcium phosphate disease), or infections (septic arthritis, Lyme's arthritis).

Other autoimmune connective tissue illnesses, such as systemic lupus erythematosus, Sjogren syndrome, scleroderma, myositis, inflammatory bowel disease, celiac disease, and others, can be accompanied with inflammatory arthritis.

What is degenerative arthritis?

Degenerative arthritis is characterized by the continuous degradation of cartilage in the joints, resulting in severe joint inflammation. Facet joint osteoarthritis, also known as degenerative arthritis or spinal arthritis, is a condition that causes cartilage degradation between the facet joints in the rear of the spine.

When the joints articulate, a lack of cartilage produces discomfort and inhibits movement. Adults over the age of 60 are more likely to develop the illness.

Epidemiology

On imaging, more than one-third of the American population has arthritis, and this figure is expected to rise as the average population ages. Osteoarthritis is the most common kind of arthritide. Knee osteoarthritis affects between 19% and 30% of persons over the age of 45, whereas hand osteoarthritis affects 27% of adults and hip osteoarthritis affects 27% of adults. It is anticipated that 40% of men and 47% of women will get osteoarthritis in their lifetime, with the incidence increasing to 60% if their BMI is more than 30.

Gout is the most prevalent inflammatory arthritis in the United States, affecting more than 8 million people with a frequency of 3.9 percent, with a prevalence of more than 9 percent among those over 60. Gout affects more than 45 people out of every 100,000. Notably, the incidence and prevalence of gout are increasing, with a more than twofold increase in the last few decades. The frequency of pseudogout in the adult population is between 4% and 7%, with more than half of individuals suffering from knee arthritis.

Rheumatoid arthritis affects about 1% of Caucasians, with females being afflicted more commonly than males (lifetime risk of 3.6 percent in women vs. 1.7 percent in men). The disease often manifests itself in early adulthood, with a disease frequency of 5% in women over the age of 65.

Causes of degenerative arthritis

The etiology of arthritis differs depending on the kind of arthritis. The key contributing variables in osteoarthritis include growing age, female sex, joint trauma, and obesity. Some genetic variables, such as mutations in genes encoding collagen types II, IV, V, and VI, have been identified.

In contrast, rheumatoid arthritis (RA) is an autoimmune systemic inflammatory condition. In RA, an interaction between multiple genetic variables and environmental factors (smoking) leads to immune system activation and malfunction, resulting in inflammation.

In Gout, persistent hyperuricemia leads to uric acid buildup in joints, which eventually leads to joint inflammation. There are various genetic variants that can induce hyperuricemia, however they account for fewer than 10% of gout cases. The majority of gout patients are under-excretors, meaning they are unable to eliminate all of the uric acid created in their bodies as a result of endogenous or exogenous purine metabolism. Male genitalia, increasing age, chronic renal disease, drunkenness, and certain medicines, such as diuretics, are all risk factors for hyperuricemia and gout.

Septic arthritis is an acute form of arthritis that is uncommon in the general population; however, individuals with pre-existing risk factors such as immunodeficiency, advanced age, diabetes mellitus, artificial joints, rheumatoid arthritis, and intravenous drug misuse are at a higher risk.

Arthritis is a common clinical sign in people with different autoimmune disorders and is one of the most prevalent clinical features in systemic lupus erythematosus patients (SLE). Inflammatory bowel disease, psoriasis, celiac disease, Sjogren syndrome, systemic sclerosis, dermatomyositis, mixed connective tissue disease (MCTD), and other disorders are commonly linked with arthritis.

Pathophysiology

Osteoarthritis is characterized by a gradual degenerative cascade of cartilage loss that leads to bone deterioration. Subchondral cysts, osteophytes, and subchondral plate thickening are common observations. Interleukin-6, monokines, interferon-induced protein-10, and macrophage chemotactic protein all activate proteolytic enzymes that degrade joint collage, including matrix metalloproteinases, serine proteases, and cysteine proteinases.

Calcification of the surrounding articular cartilage lowers the thickness of the cartilaginous matrix and finally destroys it. Age is also related with a decline in chondrocyte function, which increases vulnerability to osteoarthritic degeneration.

Rheumatoid arthritis symptoms are often more severe than osteoarthritis symptoms. Rheumatoid arthritis is a systemic and chronic inflammatory condition produced by an autoimmune reaction to a stimulus in the environment. Endothelial cell activation and synovial cell hyperplasia precede cartilage and, finally, bone deterioration. Pathology develops as a result of abnormal inflammatory mediator production.

Gout monosodium urate salts crystallize as needle-shaped crystals. This crystallization is more likely to occur in colder areas of the body and under acidic environments. The destabilization of these deposited intraarticular uric acid crystals causes an inflammatory response mediated by IL-1, resulting in the characteristic acute gouty arthritis flare. In pseudogout, the inorganic pyrophosphate from chondrocytes interacts with calcium to generate calcium pyrophosphate dihydrate.

This crystal is found in joint areas that are prone to osteoarthritic alterations. Pseudogout crystal damage causes bone and cartilage fragmentation, as well as the production of osteophytes and subchondral cysts. Hemochromatosis, hyperparathyroidism, and hypomagnesemia are all metabolic diseases that enhance the chance of calcium pyrophosphate accumulation.

Clinical presentation of degenerative arthritis

The history and physical examination are critical in evaluating arthritis, defining the kind of arthritis, and distinguishing symptoms from non-articular etiologies. The first step in a patient's physical examination with musculoskeletal problems should be determining and verifying whether the pain is articular or not.

Non-articular pain can occur as a result of a variety of diseases, including fibromyalgia, in which patients report soreness in both articular and extra-articular locations but no effusion, edema, warmth, or erythema limited to the joints. Tendinitis can also induce periarticular discomfort; in these situations, a physical exam will often demonstrate soreness throughout the tendon course or insertion without any specific tenderness or loss of joint range of motion.

Pain, swelling, loss of function, stiffness, deformity, weakness, and instability are common arthritis symptoms. They may also be accompanied by weariness, sleep disruption, emotional vulnerability, and symptoms of the underlying systemic disease. Arthritis pain is typically exacerbated by activities and at the end of the day. Inflammatory arthritis also causes discomfort in the morning and during rest, which may ease initially with exercise but then worsens with continued usage and movement.

Patients with fibromyalgia and myofascial pain syndrome typically experience widespread discomfort. Paraesthesias in the nerve distribution can accompany neuropathic pain. Morning stiffness lasting more than 45 minutes is usually linked with inflammatory arthritis, however this is not always the case, since individuals with osteoarthritis or non-articular disorders such as fibromyalgia can also have prolonged morning stiffness.

The most significant technique in evaluating arthritis and arthralgias is a physical examination. Tenderness, swelling, effusion, erythema, and warmth are all symptoms of inflammatory arthritis. These characteristics are more noticeable in acute inflammatory arthritic processes but may be less prominent in chronic inflammatory arthritides.

Tenderness, swelling, and effusion are also symptoms of osteoarthritis, albeit erythema and warmth are frequently absent. Arthritis can also cause a reduction in range of motion and visible joint deformities.

The next step will be to evaluate the beginning of arthritis, the number of joints involved, symmetry, distribution, and pattern.

1. Onset.

Septic arthritis, crystalline arthropathies, and reactive arthritis all have acute onset arthritis. Osteoarthritis, on the other hand, nearly always has a gradual beginning. Rheumatoid arthritis and psoriatic arthritis usually have an insidious beginning, however, they can sometimes have an abrupt onset. Arthritis caused by underlying autoimmune illnesses generally has a slow start.

2. Number of involved joints.

Arthritis can be monoarticular (single joint), oligoarticular (2-4 joints) or polyarticular (many joints) (several joints). Bacterial, Lyme's disease, mycobacterial, and Neisseria infections all cause acute monoarthritis. Patients with gout (particularly early in the illness), pseudogout, hydroxyapatite disease, and trauma are also at risk for monoarthritis. Psoriatic arthritis can occasionally appear as monoarthritis, which can progress to oligo or polyarthritis.

Untreated infections (Bacterial, Lyme's, mycobacterial, and fungal), gout, pseudogout, osteoarthritis, Pigmented villonodular synovitis, hemarthrosis, tumors, osteonecrosis, early oligoarticular juvenile idiopathic arthritis (JIA), and rheumatoid or psoriatic arthritis can all cause chronic monoarthritis.

In general, illnesses that affect one or more joints might manifest as oligoarthritis. However, oligoarthritis of the lower extremity joints (knees or ankles) is a feature of HLA-B27-related seronegative spondyloarthritides. A subset of psoriatic arthritis patients have oligoarticular involvement of tiny hand joints such as the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP).

Polyarthritis can be caused by a variety of inflammatory and non-inflammatory arthritides. Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, reactive arthritis, IBD-associated arthritis, juvenile idiopathic arthritis, undifferentiated spondyloarthritis, gout, pseudogout, and arthritis associated with underlying autoimmune diseases such as SLE and MCTD are all causes of inflammatory polyarthritis. Non-inflammatory polyarthritis can be found in osteoarthritis, specifically erosive osteoarthritis, nodal osteoarthritis, and primary generalized osteoarthritis.

Symmetry

The hallmark of RA is polyarticular symmetrical inflammatory arthritis affecting the tiny joints of the hands and feet. JIA, psoriatic arthritis, pseudogout (pseudo-RA type), Adult-onset Still disease, arthritis associated with underlying autoimmune diseases such as SLE and MCTD, and osteoarthritis, particularly erosive osteoarthritis, nodal osteoarthritis, and primary generalized osteoarthritis, are other causes of symmetrical polyarthritis.

RA is distinguished by polyarticular symmetrical inflammatory arthritis including the tiny joints of the hands and feet. Other causes of symmetrical polyarthritis include JIA, psoriatic arthritis, pseudogout (pseudo-RA type), Adult-onset Still disease, arthritis associated with underlying autoimmune diseases such as SLE and MCTD, and osteoarthritis, particularly erosive osteoarthritis, nodal osteoarthritis, and primary generalized osteoarthritis.

Distribution

Osteoarthritis frequently involves the axis or spine. Another cause of non-inflammatory axial arthritis is diffuse idiopathic skeletal hyperostosis (DISH). Ankylosing spondylitis, reactive arthritis, IBD-related arthritis, psoriatic arthritis, undifferentiated seronegative spondyloarthritis, and non-radiographic axial spondyloarthritis are the most common inflammatory arthritides with axial involvement. JIA and SAPHO syndrome are two other causes of axial inflammatory arthritides. In RA, there is no axial involvement.

Several patterns of peripheral involvement can help in determining the diagnosis. RA is commonly accompanied with polyarticular symmetrical inflammatory arthritis of the hands (MCP, PIP) and foot (MTP). Wrist, ankle, and knee involvement is also prevalent. However, with RA, the DIP joints of the hands are frequently spared. Osteoarthritis, psoriatic arthritis, and gout can all cause DIP joint involvement.

The most typically affected joints in pseudogout are the knee, wrist, and the 2nd and 3rd MCP joints. Polymyalgia rheumatica is distinguished by pain, stiffness, and reduced range of motion in bilateral shoulders and hips caused by underlying inflammatory arthritis and periarthritis; nevertheless, RA can have a similar appearance in rare cases.

Pattern

In RA, psoriatic arthritis, and polyarticular osteoarthritis, a progressive additive pattern with the continued involvement of additional joints can be recognized. Whipple illness, neisserial arthritis, and rheumatic fever all exhibit a migratory pattern in which arthritis spreads from one joint to another with full remission in the previously afflicted joint.

Palindromic rheumatism, gout, pseudogout, familial Mediterranean fever, adult-onset Still disease, and Muckle-Wells syndrome all exhibit an intermittent pattern. This is characterized by full remission of symptoms in previously affected joints, with the asymptomatic phase lasting a variable amount of time until arthritis recurs in the same or other joints.

Other clinical factors that might help restrict the differential diagnosis include family history and age of onset, with osteoarthritis being more frequent in older people and inflammatory arthritides being more common in younger individuals. It is also critical to thoroughly examine the adjacent joints to rule out transferred pain. The inspection of the skin is critical and can substantially aid in diagnosis.

Degenerative arthritis in the spine

The most prevalent kind of spine arthritis is osteoarthritis (noninflammatory or degenerative arthritis). It mainly affects the lower back and develops as a result of normal wear and tear. As the cartilage between the joints deteriorates, irritation and discomfort result.

Diagnosis

There is no one test that can be used to confirm a diagnosis of degenerative arthritis. Instead, doctors will ask a series of questions regarding the patient's medical history, such as when the pain started and whether they have had any traumas to the afflicted joint or joints. They may also want to know when the pain arises and what, if anything, aggravates it.

In addition, the doctor can utilize X-rays to examine for bone spurs or other forms of bone injury. They may also collect joint fluid samples to rule out infection or gout, as well as do blood tests to rule out other probable reasons.

Management

Degenerative arthritis can be treated in a variety of ways by healthcare providers. Some patients with the illness may benefit from a combination of medications.

The main aims of treatment include:

• reducing symptoms
• improving joint function
• preventing the condition from progressing further
• maintaining or improving the person’s quality of life

Medications

Medication is prescribed by doctors to alleviate the pain and inflammation associated with degenerative arthritis.

Medications may include:

• Oral pain relievers, such as acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
• Oral anti-inflammatory medications
• Corticosteroid injections to relieve inflammation and pain
• Topical products, such as creams, sprays, or rubs, to soothe sore joints

Physical therapy

Physical therapy combined with improved activity levels can help a person manage the symptoms of degenerative arthritis. People should limit their participation in high-impact activities to avoid additional joint injury.

Maintaining an active lifestyle may help by:

• reducing pain
• improving function
• increasing muscle and bone strength
• improving mood
• increasing quality of life
• preventing falls by improving balance

It can also assist a person in maintaining a healthy weight, which specialists encourage persons with OA to strive for.

Surgery

If various therapies are ineffective or the joint damage is significant, some patients may require surgery. This operation might be an osteotomy, in which a surgeon removes or reshapes a section of the injured bone. A person may also undergo a partial or whole joint replacement, which entails a surgeon removing the joint and replacing it with a synthetic one.

Nonmedical options 

Maintaining a healthy weight may alleviate the additional stress that extra body weight can place on the joints. This may be accomplished by eating a nutritious, well-balanced diet and engaging in frequent, low-impact physical activity.

Hot and cold therapy may also help to reduce joint pain and stiffness. People should alternate between applying heat and cold compresses to the afflicted joints. However, an ice pack should always be wrapped in a towel before being applied directly to the skin.

Can people prevent degenerative arthritis? 

There is no way to totally avoid osteoarthritis. People can reduce their chance of acquiring OA or stop it from advancing if they already have it by addressing modifiable risk factors. Other strategies to reduce the likelihood of having the illness include:

• Warming up before exercise
• Having a varied exercise schedule
• Resting after intense physical activity

Prognosis

Osteoarthritis is a degenerative disease with no known treatment. The prognosis is determined on the number of joints involved and the severity of the illness. In elderly patients, obese persons, those with varus deformity, and those with numerous joint involvements, rapid development is expected. The results of joint replacement are favorable, but no prosthesis is permanent; hence, revision may be required after 10-15 years.

The prognosis of rheumatoid arthritis has improved dramatically as a result of recent advances in medication, yet morbidity and death in rheumatoid arthritis remain significantly greater than in the general population, owing mostly to extra-articular symptoms.

Conclusion 

By 2040, more than a quarter of the adult population in the United States will have been diagnosed with some type of arthritis. Degenerative arthritis, often known as osteoarthritis, is the most frequent kind of arthritis in the United States. Although there is no treatment for OA, persons with the illness can manage it and improve their quality of life by combining medical therapy with lifestyle adjustments.

Arthritis is a joint disease, but it also has systemic consequences. There is no treatment for osteoarthritis, which can significantly reduce one's quality of life and contribute to depression. Other organs may be impacted depending on the kind of arthritis. An interprofessional team including a nurse, nutritionist, rheumatologist, physical therapist, orthopedic surgeon, pain expert, pharmacist, and internist is excellent for arthritis care.