MODULE 1Joint Ache Scenario 1 “A woman 58 years old, a housewife, complains about the ache on her knees that she has suffered for 3 months, especially when she walks. She has difficulty to stand up from the squad position. She feels stiffness in the morning continuously for about 10 – 15 minutes. The knees are swollen, but there are no sign of redness. She also feels ache on the fingers, asymmetrically. The patient also suffers from diabetes and has a regular treatment in endocrine clinic. Her weight is 65 kg and 162 cm tall” Keywords: 1. A 58 years old woman 2. Pain during walking in the knees for almost 3 months 3. Feeling stiff about 10-15 minutes in the morning 4. Having difficulty to stand up from squatting 5. No redness in swollen legs 6. Diabetes patien and receive regular treatment 7. Her weight is 65 kg and 162 cm tall 8. Asymmetrical pain in the fingers Clarification of words: 1. squat position = frog position 2. asymmetric ache = non-symmetrical pain 3. stiffness = inflexibility . Humid and cold weather increases the pain in many patients. Occasionally. any joint in the body can be affected. causing loss of ability and often stiffness. although in theory. and patients may experience muscle spasm and contractions in the tendons. called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints). the more they are used throughout the day. and the large weight bearing joints. are stiff and painful.Differential diagnosis: 1.when the affected joint is moved or touched. rendering them red or swollen. thus distinguishing it from rheumatoid arthritis. osteoarthritis 2. or a burning sensation in the associated muscles and tendons. and though they are not necessarily painful. As OA progresses. the joints may also be filled with fluid. Rheumatoid arthritis 3. Gout arthritis SIGN AND SYMPTOMS: OA can cause a crackling noise (called "crepitus") In smaller joints. may form. and usually feel worse. OA at the toes leads to the formation of bunions. "Pain" is generally described as a sharp ache. hard bony enlargements. feet.The main symptom is acute pain. such as the hips and knees. spine. they do limit the movement of the fingers significantly. OA commonly affects the hands. such as at the fingers. the affected joints appear larger. non-arthritic person. Not everyone with arthritis feels stiff in the morning. may find it difficult to walk immediately after they wake up. They may experience pain when they keep their feet on the floor. The duration of symptoms in the morning is an important clue as to what type of arthritis you may have. In severe diseases.QUESTION 1) 2) 3) 4) 5) 6) What is the cause of morning stiffness in this disease? What is the relation between DM and the disease? Why doesn’t the pain symetrical ? What is the correlance between obesity and jont pain? What is the relation between sex.and age in joint pain Why does the patient having the difficulties to stand up from squat position? ANSWERS 1. some complain they hurt more in the morning or describe discomfort without pain. the muscles of the legs are often held in contracted positions for longer periods of time and so it can lead to stiffness in legs. stiff. Due to sedentary lifestyle. stiffness in legs due to bone problems occurs mostly in older people. After getting up. Based on medical investigations. who experience stiffness in legs after sleeping. the small facet joints are a common source of arthritis and back pain. the . On the other hand. In the spine. the joints "loosen up" as they move around and are used. doctors have agreed that there is no specific cause of stiffness in legs and they have come to the conclusion that they usually increase with the aging process. the person may feel stiffness in legs but that may be due to weaknesses in the legs. rheumatoid arthritis or lupus patients often complain of prolonged morning stiffness or pain which may last 45 minutes or longer. Instead of stiffness. osteoarthritis patients symptoms typically improve within 30 minutes but may be aggravated during the day with use of the affected joints. Some people. For example. and painful after sleep or after resting them for a while. In a young. In osteoarthritis. For majority of the people. This gives the feeling of muscle cramps and stiffness in legs that can be at times painful. Stiffness in legs usually gives the people an impression that it may be due to some potential health risk of the bones like arthritis or osteoarthiritis. joints are commonly sore. However. The facet joints work as hinge joints similar to the hinges on a door. stiffness in legs is due to under oxygenation of the leg muscles thereby leading to the build up of lactic acid. joints glide smoothly over one another. The cartilage which degenerates will turns into fragments and tiny pieces and will accumulate in the synovial fluid. Due to the degeneration of cartilage. However. The cartilage will slowly degenerate. the more the joint fluid coats and lubricates the inner joint. non-inflammatory type. Diabetes mellitus is a metabolic disease in which there is an excess amount of glucose in the body. as you swing the door open and closed. a condition in which cells fail to use insulin properly. Several studies conducted in patients with Diabetes Mellitus. and this will results in the over growth of bone called osteophytes. Gestational diabetes is a type of diabetes which only occurs to pregnant women. shows that most of them mainly suffer from the degenerative. inflammation. When the joint is used. Gestational diabetes is a condition in which pregnant women. Type 2 diabetes and gestational diabetes. It is a similar phenomenon with the rest of the joints. Type 2 diabetes results from insulin resistance. or degeneration and many more causes. Osteoarthritis is a “wear and tear arthritis” which means that the cartilage at the joint will degenerate faster if it is repeatedly used beyond its capabilities to withstand the pressure. the joint fluid is soaked up by the cartilage within the joint similar to how a sponge soaks up water. Type I diabetes results from the body's failure to produce insulin. and slowly exposing the bone to the synovial fluid. It may precede development of type 2 DM. open and closed. and presently requires the person to inject insulin. have a high blood glucose level during pregnancy. Joint pain which happen because of metabolism is called osteoarthritis. Basically. who have never had diabetes before. However. infection. 2. Diabetes mellitus is associated with a variety of musculoskeletal disorders. the growth of bone is slightly becoming abnormal as there is no bone-shaper which is cartilage. there are three types of diabetes mellitus widely known as Type I diabetes. as the joints become arthritic. the door becomes looser and glides more smoothly. This might happen due to the decrease production of insulin or due to the cells in the body does not respond well to the insulin produced. Arthritis is a musculoskeletal disorder in which it affects the joints of the body whether due to metabolism. the cartilage is "squeezed" and the joint fluid bathes the joint. Pain in knee joint is closely related to arthritis. With rest. making the bone to be in contact with it. they function more as a rusty hinge joint on a door that squeaks when you first try to move it. sometimes combined with an absolute insulin deficiency. The more the joint is used. Musculoskeletal disorders are a common . the diagnosis of which depends on the radiographic recognition of a minimum of two bridges connecting three consecutive vertebrae in diabetics usually complaining of backache. certain activity such as repeated knee bending. stiff hand syndrome. accumulation of abnormally glycosylated by-products.finding among patients with type 2 diabetes. Asymmetrical is (not "matching") swelling in individual joints that are not part of a pair. as . Several musculoskeletal disorders have been described in these patients which can be divided into three categories. pyomyositis and the diffuse idiopathic skeletal hyperostosis (DISH) syndrome. such as osteoarthritis and the carpal tunnel syndrome. disorders which represent intrinsic complications of diabetes. and collagen accumulation in skin and periarticular structures have been proposed as potential pathogenesis mediators of these connective tissue abnormalities. Therefore. Obesity. obesity is a risk factor for both conditions. 3. flexor tenosynovitis. It is a condition associated with wear and tear of that particular joint. OA of the weight-bearing joints in the affected type 2 diabetic patients may be related to their obesity and not to the diabetes itself. neuropathic arthropathy. proximal motor neuropathy. microvascular abnormalities with damage to blood vessels and nerves. Both large and small joint OA have been reported to be increased in type 2 diabetes. but also with other joints. and diabetic muscular infarction. osteopenia (in type 1 DM). Diabetes mellitus (DM) affects connective tissues in many ways and causes different alterations in periarticular and skeletal systems. disorders for which a possible association with diabetes has been proposed but not proven yet. which are first. shoulder capsulitis. such as limited joint mobility or diabetic cheiroarthropathy. such as hands orsternoklavikula. Diabetes is not clearly a risk factor for osteoarthritis (OA). It is not yet known whether diabetes is a risk factor for OA independent of obesity. However. In everyday life. and finally c. However. disorders with an increased incidence among diabetics. septic arthritis. acute proximal neuropathy. glycosylation of proteins. 4. heavy lifting and carrying involve repeated heavy use of particular joints over long period of time. Several studies have reported an association of early OA and diabetes. Obesity appears to not only associated with pain in joints that bear the burden. second. One knee and an elbow instead of both knees. Obesity or excessive weight gain associated with increased risk for theemergence of good joint pain in women nor in men. such as Dupuytrens disease. however. The smaller joint surfaces in women might explain sex differences in knee OA because of higher articular pressures with smaller surface area. after adjustment for height and weight . Since men and women vary in body size. Using healthy men and women. Women had a higher annual rate of cartilage volume loss than men in all knee compartments. Therefore. cartilage thickness. suggesting that smaller joint surfaces in women were not a likely explanation for sex differences in knee OA . one might assume that men have greater cartilage volume. In a study of nine healthy German men and nine women in their early 20 s without a history of athletic or heavy physical activity. Men had larger femoral and patellar cartilage volumes than women. independently of age. using the metric of body weight/joint surface area. 5. Importantly. and offspring/control status in cartilage volume in any plates. there were no significant sex differences in the crude annual percentage change or in the annual percentage change adjusted for age. These sex differences first appeared at age 40 and increased with age . thus causing the cartilage to be less resilient. where differences were less pronounced and not statistically significant. Without the protective effects of the proteoglycans. were equivalent in men and women. the authors confirmed that men have greater knee subchondral bone area. BMI. These authors found that total subchondral bone area and cartilage volume were strongly associated in young healthy men and women. leading the authors to suggest the possibility that different factors are responsible for bone and cartilage growth in men and women . their associations with height in men were weak and inconsistent.well as mechanical factors that play a role. height. the water content of the cartilage decreases due to a reduced proteoglycan content. and cartilage volume compared with women. As a person ages. Estimated tibial or patellar pressures. the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. confirmed lower cartilage volumes in women than men and showed that this sex difference was related primarily to differences in joint surface area or bone size rather than cartilage thickness. there is another factor that is suspected to play a role in the incidence of metabolic connection. However. although only tibial cartilage loss was statistically significantly different by sex. while cartilage volume and bone area were strongly related to height in women. Sex differences in patellar cartilage volume were magnified with increasing age . it can be concluded that patients with obesity over the range of affected joints ache. . weight. and bone volume. An increase in body weight has been associated with osteoarthritis of the knee in women but not statistically significant in men. Osteoarthritis results from wear and tear and rip at the knee. when you over 50 years of age. suggesting a high risk for the development of cartilage loss and presumably. Women were also three times more likely than men to have increases in tibial cartilage defects over time. The composition of this convenience sample was intriguing. when the job involves a lot of knee joint as many squats. hips and spine. because the knee joint is one of the main bearer of weight and many suffer wear and tear and stretch in each of the activity level is. for the development of knee OA . Postmenopausal estrogen replacement therapy may have a moderately protective effect on the incidence and progression of radiographic osteoarthritis of the knee in elderly women.sex differences were evident only after further adjustment for baseline cartilage volume and bone size. can cause symptoms of knee pain. the sample consisted of offspring of people who had undergone knee arthroplasty for knee OA and the rest were from the general population. Almost all elderly people have experienced knee pain. especially when it comes to stand and walk after sitting for long time. 6. Reduced quadriceps muscle strength relative to body weight may be a risk factor for osteoarthritis of the knee in women. Interestingly. But the risk the greater the wear and wounded. Therefore knee pain in older people need to watch out the occurrence of osteoarthritis. later. Osteoarthritis is caused by cartilage or bone network is broken up dipersendian pain arises. Quadriceps strength was found to be about 15% to 18% less among women with radiographic evidence of osteoarthritis of the knee compared with normal subjects. Regular contact with the elderly. So that the bones and joints stay strong and healthy. This relationship did not hold true for men. like knees. as a key element is the joint fluid for lubricating and nutrition proteoglycan as water storage and collagen molecules as guardian of . Gender is another critical factor for osteoarthritis of the knee. and this could have inflated the difference. Osteoarthritis causes pain and stiffness felt movement at the joints. When coupled with obesity can lead to the elderly can not do aktivitasnya daily. Function of cartilage / cartilage that is dipersendian as bearings to withstand the motion. usually the rest of the body joints. Osteoarthritis of the knee raised to attack pain and stiffness in the joints. the magnitude of cartilage loss was higher in off spring than the general population. Estrogen deficiency may also play a role in the development of osteoarthritis in women. as doctors could detect the abnormalities of bones or affected joints. it is not always correlated to certain disease we might think off. decreased of range of motion in joints. An x-rays also could be among the steps to diagnosed the disease. resulting in bone and joint stiffness. and it is normal procedure for joints pain patients. such as joint swelling. the doctors – in this case. Thus. The condition is depends on the lifestyle of the patients. WE – need to do a physical examination. visible joint damage. and images of infected joints. laboratory test should also be made. Some patients might become worse. crepitus and pattern of affected joints. In this examination. to determine the cause or pathomechanisme of the disease. In diagnosing disease. Secondly. the doctors could use America College of Rheumatology (ACR) criteria that has been established for diagnosing rheumatology problem. some might maintain and some patient might have a healthy improvement. we observe any signs or symptoms associated. Fixed at the time get older. Eventhough x-rays revealed the apperance of joints. and sclerosis. PROGNOSIS The disease was diagnosed by considering the patient’s medical history. to differentiate types of joints pain and arthritis. physical examination. the production of proteoglycan and collagen in the body to be reduced. consequently the joint protection layer becomes thin. First. The diagnosis focused on two major goals. typically. joints space narrowing. Accurate diagnosis should is necessary so that an appropriate treatment can be considered. Besides that. as we could detect the disease approximately. TREATMENT Every patients has a different survival towards the disease. . X-rays can reveal osteophyte at the joints margin. joint tenderness.the stability of proteoglycan molecules. OA patients because so many elderly have to be careful in giving this type of drug. So pick a cure for the minimal and modest attire. patients come to the doctor. then the weight loss should be sought.Non-Pharmacological Therapy Education and Information Purpose of education and information so that patients know some specifics about the illness. especially in the case megurangi and relieve pain Analgesic topical Topical analgesic we can easily obtain also in consumption of pain patients to meredahkan Medication non-steroidal antiinflammatory When the analgesic medicines that were given would not work in general. this drug effect analgetik other member is also member-inflammatory effects. Therefore weight should always be on guard so as not greater. how to secure it so that the disease is not increased severe and permanent joints can be used Physical Therapy and Rehabilitation These therapies are used to train patients to fixed joints can be used and to train patients to protect joints Weight Loss Excessive body weight has been a factor that will aggravate OA disease. Chondroprotective Agent . Pharmacological Therapy Oral Analgesics Non-opiate In general. when greater. patients have tried to treat his own illness. ii. Education and Information Physical Therapy and Rehabilitation Weight Loss Pharmacological Therapy i. Malaligment. v. Non-pharmacological therapy i. Surgical therapy This therapy is given when pharmacological therapy failed to reduce pain and also to make correction in the event of joint deformities that interfere with daily activities.ncbi. iii. Some researchers classify these drugs in slow acting anti Osteoarthritis Drugs (SAAODs) or Disease Modifying Osteoarthritis Drugs Anti.Does the Agent is chondroprotective drugs that can protect and stimulate repair (repair) joint cartilage in OA patients. Varus Arthroscopic debridement and joint lavage Osteotomi total joint Artroplasti REFERENCES Merck’s manual Harrison’s Manual http://www. iii. iv. iv. ii. valgus knee deformity. ii. iii.nlm.gov/pmc/articles/PMC2552988/ .nih. Analgesics non-opiate oral Topical Analgesic Medication non-steroidal anti-inflammatory Chondroprotective steroids intra-artikuler Surgical Therapy i. full .diabetesjournals.http://clinical.org/content/19/3/132.