Arthritic and inflammatory joint conditions

Osteoarthritis (OA) or degenerative joint disease (DJD)

• Chronic degenerative joint disease that causes the breakdown of cartilage, the protective tissue that cushions the ends of bones in joints

  • Characterized by articular cartilage with hypertrophy of subchondral bone and joint capsule of weight-bearing joints
  • Most common form of arthritis
  • Most common joints are cervical spine, lumbar spine, hips, knees, and great toe (weight-bearing joints)

• Symptoms

  • Slow, progressive with pain, initial episode, and only presents when triggered by specific activity
    • Progressing to chronic with pain present with weight-bearing activities (including ambulation, standing, stair climbing)
  • Swelling in joints
  • Loss of range of motion of joints
  • Bony deformities can occur

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroids
  • Intra-articular injections into the joint space

• Physical therapy management

  • Joint mobility
  • Joint strengthening
  • Aquatic therapy
  • Aerobic/conditioning activities

Rheumatoid conditions

Rheumatoid arthritis (RA)

• Chronic autoimmune disease that causes inflammation and damage to the joints due to the overproduction of antibodies

  • Etiology is unknown, but it is thought to have genetic links

• Disease is characterized by times of exacerbation and remission

• Most common areas are hands, feet, cervical spine

• Symptoms (bilateral, symmetrical)

  • Joint pain, especially in the hands, feet, wrists, and knees
  • Swelling and stiffness in the joints
  • Fatigue
  • Fever
  • Deformities in the joints

• Diagnosis

  • Clinical presentation
  • X-ray imaging
  • Lab values
    • White blood cell count (WBC), erythrocyte sedimentation rate, rheumatoid factor

• Medical management

  • Antirheumatic medications/Immunosuppressive agents (disease-modifying antirheumatic drugs, DMARDs), e.g., synthetic methotrexate and biologic adalimumab (Humira)
  • Corticosteroid medications

• Physical therapy management

  • Management of pain and inflammation (during exacerbation phase)
  • Improve joint mobility and mechanics (during remission phase)
  • Resistance training (only during remission phase; contraindicated in exacerbation phase)

OA vs. RA at a glance

Feature	Osteoarthritis	Rheumatoid arthritis
Onset pattern	Slow, progressive, mechanical (worse with use)	Autoimmune; marked by exacerbation and remission
Joint symmetry	Often asymmetrical	Bilateral, symmetrical
Common joints	Weight-bearing joints (hips, knees, spine, great toe)	Hands, feet, wrists, cervical spine
Systemic features	None (localized to joint)	Fatigue, fever, systemic inflammation
PT management	Progressive strengthening throughout	Resistance training only during remission; contraindicated during exacerbation

PTA insight: During an RA exacerbation, the PTA’s role is to collect data on the patient’s response (increased pain, swelling, fatigue), recognize it as an adverse reaction, and communicate those findings to the supervising PT rather than independently modifying the plan of care.

Psoriatic arthritis

• Chronic, inflammatory arthritis that often, but not always, occurs in people with the skin condition psoriasis

  • Autoimmune disorder

• Typically occurring in the axial skeleton and joints of the digits

• Symptoms

  • Joint pain
  • Swelling
  • Stiffness
  • Fatigue
  • Skin psoriasis
  • Changes in fingernails and toenails (discoloration)
  • Inflammation where tendons and ligaments attach to bone

• Diagnosis

  • Clinical presentation
  • Lab tests only to rule out rheumatoid arthritis

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Antirheumatic medications
  • Biological response modifier medications

• Physical therapy management

  • Improve joint mobility and mechanics
  • Joint protection strategies
  • Aquatic therapy
  • Aerobic/conditioning activities

Ankylosing spondylitis

• An autoimmune disease that causes inflammation and stiffness, primarily in the spine, and is notably more common in men. Men typically develop AS in early adulthood. It causes inflammation of the joints (vertebrae) and ligaments in the spine, leading to stiffness, pain, eventual fusion of the bones, and development of osteoporosis

• Symptoms

  • Mid and low back pain
  • Morning stiffness of the spine
  • Increased thoracic kyphosis with loss or reversal of cervical lordosis
  • Flattening (decreased lordosis) of the lumbar spine
  • Degeneration of peripheral and costovertebral joints

• Diagnosis

  • Clinical presentation
  • Lab tests and bone scans show increased uptake in the anterior vertebrae
    • HLA-B27 antigen

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroid medications
  • Cytotoxic drugs

• Physical therapy management

  • Improve joint mobility and mechanics
  • Emphasis on spinal extension
  • Joint protection strategies
  • Freestyle swimming
  • Aerobic/conditioning activities
  • Activities to maintain respiratory function
  • Avoidance of high-impact sports, resistance activities, and repetitive bending

Gout

• Primary gout is a male genetic disorder in which uric acid changes into crystals and deposits in the peripheral joints

• Secondary gout affects all ages and genders with elevated uric acid in the blood secondary to other disease processes, primarily of the kidneys.

  • Characterized by elevated serum uric acid due to a disorder of purine metabolism

• Typically occurring in the knees and great toes

• Symptoms

  • Sudden onset of severe, intense pain in one or more joints, typically the big toe.
    • Pain may feel like burning, throbbing, or crushing
  • Significant swelling and redness in the affected joint
  • The joint may feel hot to the touch and tender to the slightest touch

• Diagnosis

  • Clinical presentation
  • Lab tests
    • Identify uric acid levels

• Medical management

  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Colchicine medications
  • Corticosteroid medications
  • Allopurinol medications
  • COX-2 inhibitor medications

• Physical therapy management

  • Prescription of an assistive device as appropriate
  • Education on diet restrictions limiting consumption of red and organ meats, shellfish, alcohol (especially beer), and fructose-sweetened drinks, and medication adherence

Tendonosis/tendopathy

• Tendon dysfunction caused by overuse or repetitive motions that put excessive stress on the tendon

  • Can also be caused by sudden trauma or age-related degeneration

• Symptoms

  • Pain is typically located over the affected tendon, often worse with activity.
  • Swelling present around the tendon.
  • Stiffness at the affected joint.
  • Weakness in the joint

• Diagnosis

  • Clinical presentation
    • Special tests specific to the joint
  • MRI

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroid medications

• Physical therapy management

  • Flexibility; joint mobilization
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Bursitis

• Inflammation of bursae due to overuse, trauma, gout, or infection

• Symptoms

  • Pain at rest
  • PROM and AROM presenting an empty end feel limited by pain (no capsular pattern)
  • Swelling of the joint area
  • Redness over the inflamed bursa
  • Warmth to the affected area may feel hot to the touch
  • Tenderness over the affected area when pressed

• Diagnosis

  • Clinical presentation

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)

• Physical therapy management

  • Same conservative approach as tendonosis/tendopathy above: flexibility and joint mobilization, soft tissue techniques, progressive resistance training, modalities for pain and inflammation, and functional mobility training.