Arthritis is a swelling of one or more joints. The initial history and physical examination is critical to allow the physician to determine whether the patient is suffering from arthritis or any other medical conditions that will cause pain around a joint, for example, peripheral neuritis or peripheral vascular disease. Mosby's Medical and Nursing Dictionary 1983 defines arthritis as any inflammatory condition of the joints, characterized by pain and swelling. Arthralgia is defined as pain that affects a joint.

Arthritis and other rheumatic conditions are chronic, very often disabling, and affect an estimated 40 million Americans. Nearly 50 percent of persons greater than 65 years of age have arthritis. Younger people have a lower risk of having arthritis but still comprise half of all people affected. Arthritis limits the activity of over seven million people and is second only to heart disease as a cause of work disability. Recent estimates place the direct medical cost of arthritis at $15.2 billion per year, with total costs of medical care and lost wages exceeding $64 billion.

Despite recent scientific evidence that regular physical activity has significant physical and mental health benefits (such as outlined in the 1996 Surgeon General's Report on Physical Activity and Health), millions of Americans remain physically inactive. The Surgeon General's Report on Physical Activity and Health found for persons with osteoarthritis (a degenerative joint disease) that "regular physical activity is necessary for maintaining normal muscle strength, joint structure, and joint function and was not associated with joint damage or development of osteoarthritis and may beneficial for many people with arthritis." Other studies have found that persons with arthritis have experienced improvement in muscle function and other important health benefits from exercise training. This was true even for older adults with arthritis.

The impact of arthritis is expected to increase dramatically as the baby boomers age. By 2020 an estimated 60 million Americans, or almost 20 percent of the population, will be affected by arthritis, and more than 11 million will be disabled.

There are approximately 2.9 million incidences of rheumatoid arthritis (RA) in the United States. Two to three times more women are affected than men. RA typically occurs between the ages of 25- 50. Juvenile arthritis affects 71,000 young Americans that are aged 18 and under. Juvenile arthritis affects six times as many girls as boys.

RA and juvenile rheumatoid are types of inflammatory arthritis. They are considered to be autoimmune disorders where the patient's immune system improperly identifies the synovial membranes that secrete the lubricating fluid in the joints as foreign. As a result, inflammation occurs and the cartilage and tissues in and around the joints are damaged or destroyed. This type of arthritis results in patient stiffness, swelling, fatigue, anemia, weight loss, fever, and often times crippling pain. The common symptoms include joint stiffness that occurs upon awakening that lasts an hour or longer, swelling in a specific finger or wrist joints, swelling in the soft tissues that are around the joints, and finally swelling on both sides of the joint.

Rheumatoid arthritis is a chronic, multi-system disease of unknown etiology. The characteristic feature of rheumatoid arthritis is persistent inflammatory synovitis. The peripheral joints are involved in a symmetric distribution. Vasculitis is an inflammatory condition of the blood vessels that is characteristic of certain systemic diseases. Rheumatoid vasculitis can affect any organ system seen in patients with severe manifestations of rheumatoid arthritis. In its most aggressive form rheumatoid vasculitis can cause polyneuropathy, cutaneous ulceration, dermal necrosis and digital gangrene. Large ischemic ulcerations may develop in the lower extremity. The pathogenesis of these types of ulcers is not well understood. These particular ulcers may take a long time to heal. Felty syndrome characteristically comprises rheumatoid arthritis, leukopenia, and splenomegaly. About a quarter of these patients are affected by large refractory skin ulcerations.

Vasculitic ulcers are often associated with infiltration and inflammation of small vessels in the skin. These ulcers are most often found associated with patients with inflammatory conditions such as rheumatoid arthritis, scleroderma, and systemic lupus erythematosus.

Characteristically these ulcers are painful, may be multiple and confluent. A biopsy may be necessary for confirmation of the diagnosis. Small vessel vasculitis accounts for about 10-20 percent of lower leg ulcerations in rheumatoid arthritis. Prednisone in combination with methotrexate has been proven successful in the management of rheumatoid vasculitis.

Juvenile rheumatoid arthritis (Still's Disease) is a polyarticular joint disease associated with splenic and lymph node enlargement occurring in infants and children. It is often accompanied by profuse sweating, mild intermittent fever, and anemia. This type of arthritis usually begins before the age of 16. It typically affects girls more often than boys. Hepatosplenomegaly, lymphadenopathy, pleuritis, pericarditis, myocarditis, and iridocyclitis all may occur in patients with juvenile rheumatoid arthritis.

Osteoarthritis affects individual joints while rheumatoid arthritis affects all of the body's synovial joints. The joints that are affected with rheumatoid arthritis have a tendency to make a sound like crinkling cellophane, whereas osteoarthritic joints make a popping, clicking noise. Osteoarthritis is a chronic degenerative disease e that is a deterioration of the cartilage that covers the ends of the bones. There are approximately 15.8 million incidences of osteoarthritis in the United States, and afflicts three times as many women as men. The symptoms associated with osteoarthritis include stiffness and pain with joint motion, and usually occurs gradually over a period of years. Typically inflammation is not present initially, however in later stages inflammation, muscle contractures and enlargement of the joint become evident.

Ankylosing Spondylitis (AS) is an autoimmune disease that affects collagen structures. It is a chronic progressive sero- negative spondyloarthropathy characterized by involvement of sacroiliac and spinal apophyseal joints, plus the paravertebral soft tissues. A genetic marker or tissue type (HLA-B27) is found more often in patients with AS than the rest of the population. 80 percent of patients with this genetic marker never go on to develop this type of arthritis. It specifically affects the joints between the vertebrae of the spine. The onset is usually of lower back and sacroiliac pain with morning stiffness is often present. In many cases the etiology is unknown. More than 400,000 Americans suffer from this type of arthritis and it is most often seen in young men between 16 and 35 years of age. Additionally, it also affects 1 in 1000 people under the age of 40. Three times as many males are diagnosed with this type of arthritis than females.

Psoriatic Arthritis is a specific type of arthritis that occurs in about 10 percent of the population in patients who have psoriasis. The diagnosis of psoriatic arthritis is made based on the patient's medical history, physical examination, blood studies, and radiographs of the joints that are symptomatic. This type of arthritis may develop at any age, but it typically occurs between the ages of 30 and 50.

Sjogren's syndrome is a chronic illness that sometimes can accompany rheumatic diseases such as rheumatoid arthritis and lupus. This syndrome is characterized by changes in the patient's immune system that result in the destruction of the moisture- producing glands. This lack of moisture affects many body parts including the eyes, joints, mouth, lungs and the kidneys. The symptoms of Sjogrens syndrome include, dry mouth, skin, throat, fatigue, hair loss, weakens, and coughing.

Kawasaki syndrome is an infectious disease that causes symptoms of arthritis in children. The etiology is unknown. This syndrome usually affects children under five years of age. Many children recover, but some patients it can cause permanent heart damage. It is usually accompanied by conjunctivitis, fever, rash, swollen red tongue, and swelling of the palms of the hands and soles of the feet.

Reiter's syndrome is a sero-negative arthropathy characterized by urethritis, arthritis, conjunctivitis, circinate balanitis, ulcerations of the buccal mucosa and keratodermia. The etiology is unknown. Young adult males are mainly affected. These patients usually present with an asymmetric arthritis involving multiple large joints like the knees, ankles and metatarsalphangeal joints. These patients typically will present with heel tenderness that is due to periostitis on the plantar aspect of the calcaneus. The disease is self-limiting and may subside in weeks to months, however recurrences are common.

Gout- Primary gout occurs in post-pubertal men (90-95 percent) with a peak onset in the fourth and fifth decades. The remaining 5-10 percent are women who are mostly postmenopausal. Secondary gout is usually a complication of other diseases or it may be the result of drug therapy. For example, low doses of salicylates or thiazide diuretics.

Gout is a condition in which crystals of uric acid, that are normal within the body, rise above normal levels and deposit in the joints giving rise to inflammation of those joints.

Gout has been recognized since antiquity. It was described by Hippocrates, amongst others, and was known as the "king of diseases" and the "disease of kings" as it occurred among the royal family. It can be caused by dietary factors, some drugs and toxins. For example, low doses of salicylates or thiazide diuretics.

Gout occurs most commonly in those countries with a high standard of living. It was previously uncommon in Chinese, some Polynesians and Filipinos, but these same races when living in locations other than their native land have higher incidence of gout also. This suggests that environmental factors (diet in particular) play a major role.

Its prevalence in males is 5-28/1,000 and in females 1- 6/1,000. It is found worldwide, but shows some regional differences, which may reflect environmental factors as well as racial predisposition.

The acute nature of the attack and the joints involved may often be the key to diagnosis. Blood tests will usually reveal an abnormally high level of uric acid. It should be noted, however, that having an elevated level of uric acid in the blood does not mean you have gout. Fewer than one in five people with elevated levels of uric acid will develop gout. Unless the uric acid level is very high, in which case it can lead to kidney complications, it does not require treatment.

A typical patient will go to bed and sleep in good health. During the night, the patient is awakened by acute pain in the big toe, more rarely in the heel, ankle or instep. This pain is intense and feels as though somebody has poured a bucket of cold water over the affected body part. The pain increases to become a violent stretching, tearing sensation. There is also a pressure and tightness around the affected body part. The pain and sensation are so acute that the individual cannot tolerate even the weight of blankets or the sheet on the toe.

In over half of the initial attacks, the joint at the base of the big toe is the first joint affected and, in time, this joint is involved in 75 percent of people with gout. Almost any joint can be affected, but it commonly affects the joints of the lower limb more than the upper limb. While mainly affecting the joints, gout can also affect bursa and tendons giving rise to large soft tissue swelling such as at the back of the heel or under the elbow joint.

The soft tissues overlying the joint can become acutely red, hot and swollen which does not occur in most other forms of arthritis. The swelling, in addition to being in the joint itself, can become more diffuse involving the whole foot and ankle for example. Wearing of a regular shoe becomes impossible over the inflamed toe and health professionals are not unfamiliar with seeing the approach of a patient with a shoe on one foot and a slipper with a hole cut in the toe on the other.

Acute gout may be triggered by events such as surgery, heart attacks, trauma, alcohol use or some drugs such as diuretics (water pills). This type of gout usually involves a single joint or just a few joints. Attacks frequently begin at night. Affected joints are usually red, swollen and exquisitely tender. Early attacks usually subside after three to 10 days with some skin sloughing off over the affected joint. An individual who is untreated may have an attack that lasts longer.

Over 50% of individuals who have had an acute gouty attack will have a recurrence within the year. Over time the attacks may become more frequent, longer lasting and often involve more joints.

In some individuals the attacks do not abate but linger on, and the course of the disease becomes chronic with persisting inflammation in the involved joints. The crystals of uric acid deposit inside the joint and in the soft tissues around the joint leading to destructive changes in the joint.

Uric acid crystals can be deposited in soft tissues forming what are known as "tophi." They cause local irritation of the soft tissues leading to redness. They may appear as whitish or yellowish deposits under the skin. Sometimes the chalky material can ulcerate through the skin. Tophi may occur at any site but commonly occur in the digits of the hands and feet, or at the back of the elbow, or behind the heel. Another site at which they occur is around the outer edge of the ear where they may appear as small chalky lumps under the skin.

Elevated levels of uric acid can be from either overproduction of uric acid or from under excretion of uric acid through the kidneys. Overproduction can be associated with nutritional factors. The following beverages/food should be avoided:

tea
coffee
cocoa
chocolate.

Certain animal proteins must be avoided and include:

seafood
liver
kidney
heart
gizzard
sweetbreads
meat extracts
gravy.

Some vegetables may also present a problem. They are:

peas
beans
spinach
lentils.

Alcohol in any form - beer, wine etc.- is a known risk factor for triggering a gouty attack.

There are a number of medications that alter the excretion of uric acid through the kidneys. Commonly implicated drugs include the thiazide drugs given to aid fluid excretion. Aspirin (ASA) may also be a problem.

The goal of treatment for our patient's is to safely provide relief of acute attacks, prevent further attacks, prevent damage to the joints, and prevent the formation of "tophi" or kidney stones.

It is important to remember that the acute attack of gout though painful, is self-limiting. If left untreated, the acute attack will usually resolve in seven to 10 days. Treatment such as rest, ice and analgesics are acceptable but the main therapy is medication.

Treatment for the acute attack is non-steroidal anti-inflammatory medication (NSAID), cortisone, or colchicine. NSAIDs usually form the first line of treatment in the acute attack. One of the most commonly used of the NSAID medications is Indocid (indomethacin sodium trihydrate). Other medications often used in this group include Naprosyn (naproxen), Orudis (ketoprofen), Voltaren (diclofenac sodium) and Tolectin (tolmet in sodium).

After the acute attack has settled down the decision whether to treat the underlying problem has to be made. Individuals with recurrent attacks of gout, or who develop the soft tissue lumps (tophi), or those who have kidney disease will usually require ongoing treatment.

We must advise our patients of the many procedures for the management of Gout. For example, weight control, controlling blood pressure, following dietary advice, and avoiding certain foods known to precipitate attacks (see above).

Here are a few of the many medications used to treat the symptoms of arthritis:

Aspirin (a non-steroidal anti-inflammatory drug) in low doses can suppress pain, but high doses are needed to fight inflammation. The side effects of high-dose aspirin therapy include stomach bleeding, ulcers, and ringing in the ears.

Other non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen, can be effective but may cause side effects such as nausea, diarrhea, stomach ulcers, and intestinal bleeding.

Corticosteroids can reduce inflammation and suppress the activity of the immune system. With long-term use, they can cause weight gain, diabetes, osteoporosis, and eye problems.

Disease-modifying antirheumatic drugs (including oral and injectable gold) may be effective for people with RA. They can offer short-term relief but have significant side effects.

Anticancer drugs, such as methotrexate, may be helpful for people with RA but may also dangerously suppress the immune system.

Moderate daily exercise can keep joints flexible and protect them from further stress. We must advise our patients that they should not exercise too long or hard and to get adequate amounts of rest. Applying cold (in the form of ice packs or wet towels) or heat (warm baths or heating pads) can ease most pain. Additionally we must encourage our patients to maintain healthy body weight because this will decrease any extra burden on sore joints.

The drugs, Celebrex (celecoxib) and Vioxx (rofecoxib) are anti-inflammatory drugs that work like many of the existing drugs, called NSAID's, which stands for non-steroidal anti- inflammatory drugs. However, there is one very significant difference with Celebrex and Vioxx: the incidence of gastrointestinal ulcerations is not far from that of placebo, about 2-3 percent, as opposed to other NSAID's in which ulceration occurs at about a 16 percent rate.

Although the FDA has placed a warning that Celebrex and Vioxx are still associated with ulcers, the clinical data thus far show a rate that is far lower than other NSAIDs. For example, in one study, in comparison to placebo and Naprosyn 500mg twice daily, the following percent incidence of ulcerations occurred: Placebo- 2.3 and 2 percent, Celebrex- 3.4 and 3.1 percent, and Naprosyn- 16.2 and 17.6 percent. As you can see, there is a very low incidence of ulcerations in both the placebo group and the Celebrex group. There is other data available with similar findings.

Celebrex can be used in osteoarthritis for pain relief at doses of 100mg twice daily or 200mg once daily with no further benefit of doses over 200mg daily. Celebrex can be taken without regard to meals. Common side effects are stomach upset, nausea, diarrhea, and flatulence. Celebrex is effective in managing pain and inflammation in those with rheumatoid arthritis. The effective daily dose may need to be higher than in those with osteoarthritis, up to 400mg daily as divided doses. E.g. 200mg twice daily. For the treatment of osteoarthritis, 12.5-25 mg of Vioxx taken once daily is recommended. Side effects may include: dizziness, heartburn, tinnitus, among others.

A complete and comprehensive medical history is essential in obtaining a diagnosis of arthritis in the lower extremity. The patient's function, structural deformities, and ability to ambulate will guide the practitioner in selecting the most appropriate treatment program for their patient.

The various forms of arthritis affect more than 15 percent of the U.S. population- over 43 million persons and more than 20 percent of the adult population, making arthritis one of the most common conditions in the United States. The significant public health impact of arthritis is reflected in a variety of measures. First, arthritis is the leading cause of disability. Arthritis limits the major activities of nearly 30 percent of the entire U.S. population 97 million persons), including nearly 1 out of every 5 persons with arthritis. The goal of the Healthy People 2010 report when addressing arthritis, osteoporosis and chronic back conditions is to prevent illness and disability related to arthritis and other rheumatic conditions, osteoporosis and chronic back conditions.

What is the Healthy People 2010 report? It is a report that provides our nation with the wide range of public health opportunities that exist in the first decade of the 21st century. The report outlines a comprehensive nationwide health promotion and disease prevention agenda. It is designed to serve as a road map for improving the health of all people in the United States during the first decade of the 21st century. Healthy People 2010 is designed to achieve two overarching goals. First is to increase quality and years of healthy life. Secondly, to eliminate health disparities. To receive more information about the Healthy People 2010 initiative, you can visit the website at http://www.health.gov/healthypeople or call 1-800-367-4725.

Glossary:

Cartilage: The end of each bone is covered with cartilage, a tough material that cushions and protects the ends of the bone.

Synovial membrane: Around each joint is the synovial sac, which protects the joint and also secretes the synovial fluid, which oils the joint.

Tendon: Are fibrous cords that attach the muscles to the bones.

Ligaments: Are shorter fibrous cords that attach bone to bone and make up the joint capsules.

REFERENCES

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2. Harrison's Principles of Internal Medicine- 12 Edition, Jean D. Wilson, M.D., Eugene Braunwald, A.B., M.D., Kurt J. Isselbacher, A.B., M.D., McGraw-Hill, Inc., 1991.

3. CDC- Prevalence of disability and associated health conditions- United States, 1991-1992. MMWR 1994:431401:730-731, 737-739.

4. Healthy People 2010 report, Volume 1 and Volume 2- U.S. Department of Health and Human Services, Washington, DC: January 2000.

5.Yale's Podiatric Medicine- Jeffrey F. Yale- Third Edition- Williams and Wilkins- 1987