Arthritis Rematoid, Polimialgia

Reumatik, Osteomielitis,
Oesteoporosis, Gout Arthritis

Prof. dr. Hermansyah, SpPD-KR

Untuk Koass Penyakit Dalam

I. Arthritis
A. Karena inflamasi sendi, akibat inflamasi
outoimun, proses degeneratif, maupun kelainan
metabolik (asam urat)
- Rhematoid Arthritis  autoimun
- Osteroarthritis  proses degeneratif
- Gout Arthritis  asam urat

B. Infeksi
- Septik Arthritis
Arthritis symptoms
l pain
l swelling
l stiffness
l deformity
l instability
l loss of function
II. Kelainan Regional
Jaringan Ikat Sendi
(Penyakit Reumatik Ekstra
Artikular)
- Biceps Tendinitis
- Tenis Elbow/ Golf Elbow
- Tendinitis pergelangan tangan
- Trigger Finger
- Tendinitis Achilles
- Plantar fascitis
III. Kelainan Metabolik
Tulang degeneratif
(Osteoporosis)
Rhematoid Arthritis

• Synovial joints: Normal Anatomy

1. Bone:
2. Cartilage:
3. Synovium
1. Cartilage
2. Bone
3. Synovium
Rhematoid Arthritis
• Etiology: autoimmune (complex)

• Prevalence: 1 to 2% of population

• Onset: age 30 to 50

• 3:1 female to male ratio

Synovial joints:
Normal physiology

1. Relatively friction free movement

of cartilage on cartilage

2. Lubricated by synovial fluid

3. Maintained by synovial membrane

RA: pathophysiology
1. Synovitis secondary to
deposition of immune
complexes
RA: pathophysiology
2. Proliferation of invasive
granulation tissue: pannus
formation
RA: pathophysiology
3. Enzymatic destruction of
cartilage and bone …
spreading to capsule and
ligaments with loss of range
of motion
Rhematoid Arthritis
Manifestation of RA
 Rheumatoid arthritis: diagnosis
(four or more for diagnosis of RA)

• Morning stiffness (>1 HR)

• 3 or more joint areas affected
• Hand joint arthritis
• Symmetric arthritis
• Rheumatoid nodules
• Serum rheumatoid factor (auto Ab 85%)
• Radiographic changes
RA: managment
• Goals:

• decrease inflammation and swelling

• decrease pain and stiffness
• increase or maintain normal function

• Education / rest / exercise and physical

therapy
 RA: management

• NSAIDs: ASA, etc.

• Steroids: prednisone
• Immunosuppressive therapy:
methotrexate, cyclophosphamide
• TNF alpha inhibitors: etanercept and
infliximab
Osteoarthritis
• Osteoarthritis is an idiopathic disease
• Characterized by degeneration of
articular cartilage
• Leads to fibrillation, fissures, gross
ulceration and finally disappearance
of the full thickness of articular
cartilage
 Normal Cartilage
• Avascular, alymphatic and aneural
tissue
• Smooth and resilient
• Allows shearing and compressive
forces to be dissipated uniformly
across the joint
 What causes it?
• Degeneration of the cartilage that
lines the joints
• Formation of bony outgrowths called
osteophytes, leading to pain,
stiffness, and reduced joint function
 Signs and Symptoms
• Pain and swelling of the joint
• Creaking and stiffness of one or more
joints
• Muscle atrophy surrounding the
problem joints is common if the
condition restricts activity levels
Factors responsible
• Ageing
• Genetics
• Hormones
• Mechanics
Pathologic lesions
• Primary lesion appears to occur in
cartilage
• Leads to inflammation in synovium
• Changes in subchondral bone,
ligaments, capsule, synovial
membrane and periarticular muscles
 Prevention and Treatments
• There is no complete cure; focus is on reducing
pain tolerance and increasing flexibility to
maintain lifestyle and activity, and to prevent
muscle degeneration which may result in further
complications
• For osteoarthritis of the elbows and wrists,
protective range of motion activities
• Joint strengthening exercises
• Wax bath therapy
• Activity modification
• Ice and heat therapy
• Modalities such as interferential current (IFC)
 Gout Arthritis
• Gout can also occur
as a result of
overproduction of uric
acid
• Gout is an attack of
uric acid deposits in
joints
• Usually found in joints
of feet and legs
 What is Gout Arthritis
• Purines are not
properly processed in
our body
• Excreted through
kidneys and urine
• Hyperuricemia- build-
up of uric acid in body
and joint fluid
The Four Stages of Gout
• Asymptomatic
• Acute
• Intercritical
• Chronic
ASYMPTOMATIC
• A- meaning without
indicates that there
are no symptoms
associated
• Patient will be
unaware of what is
happening
• Gout can only be
determined with the
help of a physician
ACUTE
• Sever and sudden
onset
• Involve one or a
few joints
• Frequently starts
nocturnally
• Joint is warm, red,
and tender
 INTERCRITICAL
• More concentration
of uric acid crystals
• Typically no need for
drug intervention at
the time.
CHRONIC
• Continuous or
persistent over a long
period of time
• Treatment required
• Not easily or quickly
resolved
SYMPTOMS

• Joint pain
– Affects one or more joints : hip, knee, ankle,
foot, shoulder, elbow,wrist, hand, or other
joints
– Great toe, ankle and knee are most common
• Swelling of Joint
– Stiffness
– Warm and red
– Possible fever
• Skin lump which may drain chalky
material
Diagnosing Gout
• X-rays
• Arthrocentesis-
extraction of joint fluid
• Examination of joint
• Patient medical
history
 TREATMENT
• Colchicine- reduces pain, swelling, and
inflammation; pain subsides within 12 hrs and
relief occurs after 48 hrs
• Allopurinol- decreases the production of uric
acid
• Probenecid and sulfinpurazone- prevent
absorption of uric acid in the tubules of kidney
• Reduce alcohol intake
• Increase water intake
• Watch diet for food rich in purines
 PENYAKIT REUMATIK
EKSTRA ARTIKULAR DAN
PENYAKIT KELAINAN
METABOLIK TULANG
(OSTEOPOROSIS)
RHEUMATIK EXTRA-ARTICULAR
(EXTRA-ARTICULAR RHEUMATISM)
1. BICEPS TENDINITIS
• Mechanism
– Irritation of biceps tendon in the groove
– Rotator cuff dysfunction
– Repeated microtrauma
– Overuse
– Degenerative changes
– impingement
 What causes it?
• Repetitive over-arm movements
• Sudden increase in activity
• Damage to rotator cuff caused by
impingement syndrome, which
predisposes the tendon to irritation.
• Structural deformity of the bicep
groove in which it is rough or too
shallow
 Signs and symptoms
– Pain on P/A/RROM
– Loss of function
– Overuse activity
– Tenderness
– Errythema
– Swelling
– Inflammation
– Crepitus
• Special Tests
– A/P/RROM
– RC muscle test
• Diagnostic Procedure
– Physician if symptoms persist
 Prevention and Treatments
• Modalities such as ultrasound and
laser therapy
• Ice
• Rest
• Transverse frictions
• Progressive strengthening
2. TENNIS ELBOW/ GOLF ELBOW

 What is it?
• Inflammation of the tendon that
attaches the extensor muscles
responsible for straightening the
fingers and wrist to the humerus
bone at the elbow
 What causes it?
• Constant tugging of the tendon at the
point where it attaches to the
humerus, resulting in irritation and
inflammation
• Activities such as tennis or golf when
a faulty grip is used
• Overuse, especially after prolonged
gardening
 Signs and Symptoms
• Pain and tenderness on the outside
of the elbow, especially when
performing gripping tasks such as
lifting a milk container from the
refrigerator
• If untreated, the problem can become
chronic and extremely debilitating
 Prevention and Treatments
• Athletic therapy if the injury is sports
induced, including technique modification,
education, equipment evaluation and
changes, and a rehabilitation program
• Bracing
• Activity modification
• Rest
• Stretching and strengthening exercises
• Ice and heat
• Transverse frictions
• Modalities such as ultrasound
 3. TENDINITIS PERGELANGAN
TANGAN (wrist tendinitis/
dequarvain)

WHAT IS IT?
Inflammation of the abductor and
extensor tendons that run across the
wrist and into the thumbs
 WHAT CAUSES IT?
• Wrist tendinitis is caused by overuse,
repetitive, forceful or unaccustomed
movements of the wrist and hand.
Repeated use of weakened, stiff
muscles can result in injury.
• Activities that entail repeated
snapping of the wrist such as
throwing, hammering, or in racket
sports
Signs and Symptoms
• Gradual onset of symptoms
• Dull ache on the thumb side of the
wrist
• Localized swelling and tenderness on
the thumb side of the wrist
• Pain when trying to extend the thumb
completely
 WHAT MAY I EXPECT?
• Your wrist and forearm may feel
much better after a period of rest, but
the problem will most likely return if
you do not take steps to protect
muscles from further injury. In most
cases, this condition takes several
weeks to months to fully heal.
 WHAT CAN I DO TO HELP MYSELF?
• Modify Your Activities to be pain-free. Do not
continue to stress the muscle.
• Apply Ice for 10-15 minutes 3-6 times per day.
• Use Neutral Wrist Position (see back) minimizing
wrist bending activities.
• Stretch 3 times per day to start, gradually
increasing to once an hour.
• Circulation can be improved by decreasing
consumption of caffeine, nicotine and alcohol and
increasing light aerobic exercise such as walking.
• Use a Wrist Splint if the pain is disabling. Wear
the brace as little as possible toprevent muscle
weakness.
4. TRIGGER FINGER

 What is it?
• Locking in a bent position of one or
more fingers at the joint closest to the
hand
 What causes it?
• Swelling of the fibrous sheath that
encloses the tendon and localized
swelling of the tendon; when the
finger is bent, the tendon is forced
out of the sheath and is unable to re-
enter it, causing the finger to remain
bent
 Signs and Symptoms
• Permanent bending of the finger at
the joint closest to the hand
• Audible clicking sound when the bent
finger is forced straight
 Prevention and Treatments
• Modalities such as ultrasound
• Friction massage
• Activity and technique modification
5. ACHILLES TENDINITIS

 What is it?
• Inflammation of the large tendon at the
back of the leg that inserts into the heel
• Often made worse by activities that stress
the tendon such as running, prolonged
walking, high-impact sports, and even
standing for extended periods of time
• Should be treated to prevent weakening of
the tendon or rupture
 What causes it?
• High impact activities that put
repeated strain on the tendon
• Over pronation caused by flat feet.
The arch collapses during impact
activities such as walking, running, or
standing and puts stress on the
achilles tendon
 Signs and Symptoms
• Shooting, burning, or sharp pain in
the ankle and back of heel
 Prevention and Treatments
• Prescription custom orthotics from
your Chiropodist to alleviate over-
pronation, provide arch support, and
reduce impact and stress on the
tendon
• Heel cup or heel lift to help reduce
impact and stress on the tendon
• Stretching, strengthening, and
balance exercises
• Rest / decrease activity level; athletes
reluctant to stop training should switch
to low-impact exercise such as
swimming
• Ice and heat therapy
• Ultrasound from your Physiotherapist or
Chiropodist
• Taping and bracing
• Transverse friction massage
• Modalities such as interferential current
(IFC), ultrasound, and laser therapy
6. PLANTAR FASCITIS

 What is it?
Inflammation of the fibrous band that
maintains the arch of the foot called
the plantar fascia
 What causes it?
• Structural problems in the feet such as flat feet or
high arches often result in arch pain
• Inflammation results as the plantar fascia is pulled
away from where it attaches to the bones of your
feet, particularly in the heel; this can eventually
lead to a heel spur as your body inserts bone into
the area in an attempt to repair itself where the
plantar fascia is pulling away
• Inflammation is made worse by activity, including
walking. This is why it is important to seek
treatment early to prevent the condition from
becoming chronic
 Signs and Symptoms
• May begin as a dull pain in the heel
and sometimes in the mid or fore-foot
• Pain may get sharper, more intense,
and more persistent over time
• Pain is usually worst after getting out
of bed in the morning or following a
prolonged period of rest
• Visible swelling may be present in
severe cases
 Prevention and Treatments
• Icing for ten minutes three times per day and/or
anti-inflammatory drugs to reduce inflammation
• Low dye strapping (taping) to help relieve stress
on the plantar fascia
• Off-the-shelf arch supports for simple, non-severe
problems
• Prescription custom orthotics to help correct
structural foot problems causing the pain and
inflammation and provide cushioning
• Footwear that is properly suited to your foot type.
For an illustration of what to look for in footwear at
your local shoe store for your type foot, click here.
Your Chiropodist can provide further footwear
advice
• Possibly prescription custom footwear
from your Chiropodist, depending on the
severity of the structural foot problem.
• Stretching exercises for your plantar
fascia. For examples of the kinds of
exercises your Physiotherapist or
Chiropodist may recommend.
• Persistent problems may benefit from a
cortisone injection.
• Physiotherapy and ultrasound.
• As a last resort for rare, extreme
cases, a soft-tissue surgical
procedure called a plantar fasciotomy
may be performed in which a small
notch is made in the plantar fascia to
relieve stress
 OSTEOPOROSIS

 What is it?
• Loss of protein in the bone, causing it
to become brittle and easily fractured
 What causes it?
• Reduced bone mass is a natural part of
aging; menopause accelerates the
process in women
• Hormonal disorders
• Prolonged treatment with corticosteroid
drugs
• More pronounced in smokers and
drinkers
• Inactivity and poor muscular fitness
resulting in accelerated loss of bone
mass
 Signs and Symptoms
• Fractures caused by falls that should
normally not result in bone damage
• Compression or wedge fractures
• Progressive loss of height attributable
to crumbling of the vertebrae, also
causing pain due to pressure on the
nerves
• Prevention and Treatments
• Resistance exercise to build muscle
and bone mass and a diet rich in
calcium are preventative measures
that should begin young in life
• Balance exercises
• Fall prevention, postural, and
osteoporosis management education
• Back extension strengthening
• Ice and heat