Arthralgia

Arthralgia is a syndrome accompanied by pain and dysfunction of a joint or group of joints.

Arthralgia is observed not only in diseases of the articular apparatus (arthritis, arthrosis, diseases of periarticular tissues), but also in other pathological processes: infectious-allergic processes, diseases of the blood, nervous and endocrine systems, etc. Arthralgia can be caused by organic (inflammatory, dystrophic, degenerative) changes in the joint and surrounding soft tissues or functional neurovascular disorders.

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Arthralgia in exudative arthritis

In exudative inflammatory processes in the joints, defined by the general term "arthritis", "synovitis", arthralgia is associated with a violation of tissue metabolism and the accumulation of products in the synovial membrane and periarticular tissues that irritate nerve endings. There are many reasons for their development, mainly repeated injuries, transient inflammations from adjacent tissues, but they can be caused by diseases of other organs and systems, in this case we are talking about reactive synovitis, for example, endocrine and metabolic disorders. A special place is occupied by scapulohumeral periarthritis.

Arthralgia is constant. The pain is aching, depending on the type of inflammation, and can be sharp, especially in dry arthritis. The shape of the joint changes due to effusion and swelling of the surrounding tissues, the skin fold is thickened (Alexandrov's symptom). With effusion in the knee, the symptom of ballotturation of the patella is noted - when pressed, it springs and seems to float; Baker's symptom - protrusion (one or more) of the joint capsule into soft tissues, palpation resembles a cyst, which can be found in the popliteal fossa above or below the popliteal fold, more often between the two heads of the gastrocnemius muscle. The skin temperature above them is elevated due to irritation of the nerve endings. Movements are limited due to pain contracture. Exudate in arthritis can be serous, serous-fibrinous, serous-hemorrhagic, purulent, putrefactive. The nature of the exudate is determined by joint puncture and laboratory examination of the puncture.

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Arthralgia in purulent arthritis

Purulent arthritis is accompanied by the same clinical picture, but its severity is significant. Formation of purulent arthritis occurs against the background of developing intoxication syndrome. Arthralgia is constant. Pains are sharp, twitching. The joint is in a forced, semi-bent state to increase the range of motion. The patient spares it from the load, pressing it to the body or another limb (adduction symptom), or supports it with his hands. It is sharply increased in volume due to both effusion and edema of the surrounding tissues. The skin above it is hot to the touch, hyperemic. Palpation and attempts to move are sharply painful. With a large accumulation of exudate, the fluctuation symptom is revealed, and with gonarthritis, the symptom of balloting of the patella is determined. During joint puncture, either obvious pus or neutrophilic transudate is obtained. In the presence of purulent exudate, it is necessary to be wary of osteomyelitis of the bones that make up the joint, especially in the presence of intoxication syndrome, since exogenous invasion of purulent microflora can only occur with penetrating wounds or in the presence of an abscess revealed during examination.

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Arthralgia in allergic arthritis

A special place is occupied by infectious-allergic polyarthritis (these processes are almost never encountered as monoarthritis). They can be caused by a non-specific infection, often in association with viruses, with the formation of rheumatism, chronic sexually transmitted infection (gonorrhea, chlamydia, trichomoniasis) with the development of Reiter's disease, tuberculosis, syphilis, etc., in which immune-dependent autoantigens are formed.

The involvement of joints in the process is explained by the fact that it is in the synovial membranes that the maximum number of immunocompetent lymphoid cells is formed, forming pathological immune complexes antigen-antibody, which is characteristic of autoallergic reactions. Provoking factors for the formation or exacerbation of polyarthritis are exacerbation in the main focus of a chronic infection of any localization, more often ENT organs, or activation (provocation) of the reaction during a viral infection, hypothermia and colds, etc.

The pathogenesis of these polyarthritises has not yet been fully studied, as it is complex and diverse. The synovial membrane is the most active of all serous layers in terms of function, both in terms of exudation and resorption. It is richly vascularized and innervated, which causes a rapid response to various direct and indirect effects, vascularization is provided not so much by blood vessels as by lymphatic vessels, and the synovial fluid has a lymphoid character. Innervation is represented to a greater extent by the vegetative part, which is clinically manifested by the symmetry of joint damage, impaired trophism of muscles, bones, cartilaginous plates, increased sweating, etc.

In systemic infectious-allergic polyarthritis, arthralgia is constant, spontaneous, of varying intensity, sharply increasing with weather changes, with prolonged rest, especially at night and in the morning, causing stiffness, while the patient is forced to change position, move more to reduce pain. Arthralgia is often combined with myalgia and neuralgia. In addition to damage to the synovial membrane and cartilage, ligaments can be involved in the process, causing their reactive inflammation - ligamentitis, more often on the hand, accompanied by arthralgia. "Dry" Sjogren's syndrome may be observed: polyarthritis, polymyositis, dry mucous membranes and skin, up to seborrheic dermatitis; Felty's syndrome: a combination of rheumatoid polyarthritis with neutropenia and splenomegaly, which also belong to rheumatoid diseases and can be combined with each other in 50% of cases. Buyo's disease is accompanied by the development of recurrent volatile exudative rheumatoid polyarthritis and rheumatic carditis with high temperature, arthralgia develops or worsens after streptococcal tonsillitis, the lungs, kidneys, and meninges may be affected.

In chronic arthritis and polyarthritis, periarthritis develops in 26% of cases, when tendons and serous bags are involved in the process, and periodic arthralgia occurs without an inflammatory reaction.

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Functional arthralgia

It is observed in vegetative-vascular dystonia, "psychogenic rheumatism", neurasthenia, etc., and is characterized by pain caused by transient vascular disorders of the joint blood supply and increased excitability of receptors. They are distinguished by polymorphism of pain sensations, absence of local changes, ineffectiveness from taking analgesics, but high effect from sedatives.

Arthralgia in degenerative diseases

In dystrophic and degenerative diseases, defined by the general term "arthrosis", arthralgia is caused by mechanical irritation of the synovial membrane by osteophytes, their fragments, fragments of necrotic cartilage and cartilaginous hernias. Arthralgia is moderate, mainly under static and mechanical load, significantly reduced at rest. They develop very slowly, without significant impairment of function, only in advanced cases. Deformation due to growths and thickening of bone tissue (marginal, osteophytes) is most pronounced in the area of the interphalangeal joints of the hands (Hibernian nodes) and hip joints (the state of flexion, adduction and external rotation of the hip). During movements and palpation, it is most pronounced in the knee, a characteristic rough crunch is determined due to calcareous deposits, fibrosis of the capsule. The muscles around are usually hypotrophic or atrophic. Most often, 1-2 symmetrical joints suffer, mainly large ones, with a painful functional load. If an effusion forms against their background during an exacerbation, the process is defined as arthrosis, and if there is damage to bone tissue - as osteoarthritis.

Structural changes in tissues are detected radiologically (preferably using electroradiography, densitometry, pneumoarthrography) or using magnetic resonance imaging. In this case, characteristic signs are detected - epiphyseal osteoporosis, narrowing of the joint space, erosion of bone surfaces, ankylosis and fibrosis. In arthrosis - deformation of the epiphyses and cartilaginous plates, the presence of a joint hernia or joint mouse, thickening, calcification and sclerosis of the synovial membrane.

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How is arthralgia diagnosed?

Laboratory blood parameters relatively indicate the development of inflammation by the presence of leukocytosis, increased ESR, neutrophilia, and in case of allergies - eosinophilia. Changes are more pronounced in purulent arthritis. Serological reactions and studies, which are combined into a group of so-called rheumatic tests, provide more information: DFA reaction, seromucoid, growth of globulins, C-reactive protein, latex test, Valera-Rose Borde-Zhangou reactions, etc. In the presence of infectious-allergic polyarthritis in men, it is necessary to examine the prostate juice to detect chronic gonorrhea (preferably after provocation) or chlamydia (an antigen reaction is also carried out for it). Laboratory examination of exudate reveals the presence of an inflammatory reaction by the formed elements of the blood and the presence of crystals. Suppuration is characterized by a high content of neutrophils, tuberculosis - lymphocytes, allergies - eosinophils. Changes in laboratory parameters are not typical for arthrosis.

If blood is detected during a puncture, it is hemarthrosis. Hemarthrosis is bleeding into a cavity, which develops mainly during injuries. Knees that bear the maximum physical load and have increased vascularization are most often affected. Others rarely develop hemarthrosis and do not have such clinical symptoms.

Arthralgia of the knees, especially in young men, should cause special alertness, since they contain vascularized fat bodies of Hoffa, which can be injured and sclerosed with the development of hemarthitis (Hoffa's disease) or hemarthrosis. In acute knee trauma, menisci are often damaged, the clinical picture of their ruptures is covered by hemarthrosis, and subsequently revealed by meniscitis or persistent synovitis.

The examination should be carried out in comparison with the opposite joint. In cases of hemarthrosis, an increase in volume is noted; on palpation it is painful, hot to the touch due to irritation of the parapatellar nerve; the patella is mobile and springy (patella ballottosis symptom); fluctuation can be determined with large volumes. Blood is obtained during puncture.

To confirm the diagnosis of arthralgia, X-rays are taken to exclude or confirm bone damage; puncture is performed to determine the nature of the effusion, remove blood, and wash the joint with a 2% solution of novocaine. Arthroscopy is performed very rarely, and only in specialized departments.

In addition to the main synovial bag that forms the joint cavity, there is a bag isolated from the cavity in the surrounding tissues - bursa, its inflammation is called "bursitis". Bursitis most often develops in the elbow, knee, ankle area. The main reasons for their development are repeated injuries, but there may also be reactive inflammation. Suppuration is rare, in most cases there is serous and serous-fibrinous effusion. It can be acute and chronic. When bursitis is formed, an elastic, soft fluctuating formation of oval, round or oblong shape is revealed under the skin. Arthralgia, edema and hyperemia are observed only with suppuration. In other cases, the skin is thinned and degeneratively changed. In the chronic form, specific fibrinous bodies - "rice grains" are palpated in the cavity of the bag.