dr f pato may 2011. 01-03-2011 69yr african female painful and swollen right ankle 2yrs ...
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Dr F PatoMay 2011
01-03-2011 69yr African female painful and swollen right
ankle 2yrs Associated with swelling
of feet at times. Difficulty in sleep Occasional paraesthesia Tiredness Radiates to the hip joint.
Walks with aid (easy mobilization and balance)
limping gait Weight transferred to
the left side of the body.
She has been seen with this complaint by GP.
Patient is also having bilateral flank pain.
Prev medical history: hypertension, rheumatoid arthritis, dermatitis
Prev surgical history: sterilisation
Medication: antihypertensive
Allergies: Unknown Family history:
Hypertension Social: Pensioner, non-
smoking, non-alcohol user, lives with grandchildren en looks after them.
On Examination Overweight Oedema of the ankles and knees Cardiovascular: intact Respiratory: intact Abdomen: central obesity Skin: Dermatitis
Ankle joint: Range of movement decreased in all
directions. Passive and active
Pain with inversion of right ankle Rest of movement not painful, active en
passive. No notable deformities from rheumatoid
arthritis.
3point assessment: Subjective: Pain hinders with the level of
daily function, that is: playing with the children and taking care of the house and yard. She wants pain relief
Objective: Rheumatoid arthritis of ankle and knee joints, osteoarthritis
Contextual: osteoarthritis secondary to rheumatoid arthritis and obesity.
Assessment: rheumatoid arthritis, osteoarthritis, obesity, urinary tract infection.
Plan: urine dipstix, x-ray X-ray: decreased joint space and
osteophyte formation at the margin plus bone cysts. No signs of previous injury.
Advise exercise and weight reduction to relieve pressure applied to the joints
Exercises prescribed: walking, squats, dorsiflexion, eversion and inversion, heel raisers. Help with strengthening of the muscles around the joints and maintainance of movement.
Range of movement better. Pain improving. Swelling less. On examination: Swelling subsided. Still walking with aid Less antalgic. Range of movement improved. Patient to continue with exercise at
home. Review in 1 month.
Definition Rheumatological condition Synovial inflammatory
response Imbalance in joint tissue
breakdown and repair 3 Subchondral bone sclerosis Erosion of articular cartilage Deposition of osteophytes Structural and functional
failure of synovial joints3
Epidemiology6% above 30yrs (2006), 13% >60
(1998)Depends on method used to classifyRadiographs or self report
Risk factorsAge, gender, diet, family history,
obesity, joint injury, endocrine, occupational
BonesTibiaFibulaTalus
Ligamnets Lateral
Ant talofibular Post talofibular Calcaneofibula
r Medial
Ant tibiotalar Tibionavicular Tibiocalcaneal Post tibial part
Weight reduction not costly reduces joint load
Compliance with dietNot guaranteed to help
Exercise increases mobility Symptomatic relief only
Simple analgesiaSafe, cheap, relieve mechanical pain Often incomplete control of symptoms
NSAIDSReduce pain and
inflammation
Side effects ? chondrodestructive
OsteotomyRelieves painful movementIncreases joint mobility
Limited success rate
Intra articular steroidsTemporary decrease in stiffnessand inflammantion
May cause joint degradation side effects
ArthroplastyRelieves painful movementIncreases joint mobility
CostProsthesis lifespan and failure
Exercise prescription3 Weight loss Joint range of motion preserved Functional performance improvement Strength improvement Symptom reduction
Start with isometric then move to isotonic resistance as tolerated
Promotion of low-impact exercise Encourages exercise benefits Avoids potential damaging effects of high-
impact activities
Favourable dGEMRIC index (Delayed Gadolinium Enhanced MRI of cartilage) Compared sedentary vs exercise intervention Increased proteoglycan Cross sectional study (2004)
OA risk increased by activity of high impact and high stress to the joint, increased by the presence of previous injury to the specific joint
Overexercise leads to glycosaminoglycan depletion
Lack of mechanical stimulation leads to cratilage atrophy
? cartilage transplants
Human cartilage recovers within 90 min after loading
Appeared to deform a little in the 1st few minutes under high loads
Very little deformation shown Increased loading not associated with
articular thickening Deformation is dependent on biochemical
composition of tissue Aid in designing of artificial cartilage
Deformation difficult to assess during loading Age results in linear decrease in cartilage
thickness with or without OA Cartilage thickness is genetically determined Different genes responsible for different joints
Study comparing siblings and twins
Prevention of further degradation and maintaining functionality of joint is important
1. Clinical sports medicine revised third edition, P Brukner, K Khan
2. Clinically orientated anatomy fourth edition. K I Moore and A F Dalley
3. David J. Hunter. Felix Eckstein. Exercise and osteoarthritis, Journal of Anatomy2009.214(2):197-207
4. Lecture notes, D Whitelaw, osteoarthritis lecture notes, 2005
5. F. Eckstein, M. Huldelmaier, R. Putz. Effects of exercise on human articular cartilage, Journal of Anatomy2006.208:491-512