– [Voiceover] In talking about the different symptoms between osteoarthritis and rheumatoid arthritis, I think my obsession with color coding will really pay off so we’ll have red for rheumatoid arthritis and green for osteoarthritis. We’ll talk about all the different symptoms but I want to make this a logical discussion so thinking back to the cause of these two diseases and why it is that they are different in symptoms. In rheumatoid arthritis, it’s always going to be autoimmune so the body’s attacking itself, it’s a whole body kind of process whereas in osteoarthritis, we’re dealing with overuse. Usually in elderly people or people carrying extra weight weighing down their joints. Okay, first, before the differences, let’s just quickly go over the commonalities and why it’s important to distinguish them because people will come in complaining of the same things.
Pain, number one, their joints hurt. Both of these can be painful, they can also involve stiffness. The quality and timing with it will be different but they’ll both tell you that their joints feel stiff and they can’t use them well. So with that, they might avoid using their limbs, might lead to muscular weakness. Weakness, loss of function, and this weakness and loss of function and inability to do the things they like to do might actually have indirect effects on their mood, for example, depression is common because both of these are chronic diseases so depression, risk for heart disease and other things from a sedentary lifestyle are all things to consider. So the point of this is when patients come in and tell you, “my joints hurt,” make sure to not leave it at that and keep asking the questions to distinguish the two.
The first question you might ask is, “Where does it hurt, “which joints?” And here a very important feature that distinguishes the two is gonna be the fact that in rheumatoid arthritis, we have symmetry between the left side and the right side of the body. For example, when a person with RA comes in and tells you, “my shoulders hurt,” it’s going to be shoulders, left and right. They tell you, “my knees hurt,” it’s going to be, likely, left and right knee. When you just think of location, there can be overlap. For example, both of these can lead to painful knees but in rheumatoid arthritis, it’s more likely to be both sides. Again, wrists, elbows, both sides whereas here on this side have we have, often, asymmetry because OA comes from wear and tear on the joints and sometimes the use is going to be not even between the left, right side of the body and also the cartilage that we start out with might not be the same.
For these people, they can have one shoulder, the other knee, maybe the same ankle and the other wrist. The pattern of it is gonna look more like this. So symmetry, very important clue. Also, the specific locations is really important to know. In our hands we have different knuckles, right, and the very last knuckle, rove knuckles, closest to the tips of the fingers are called the distal interphalangeal joints. DIP, D for distal. So if we keep going towards the wrists, the next set is going to be called the proximal interphalangeal joints, or PIP as in proximal or closer to the center of the body.
In RA it’s very important to know that the DIP joints are spared, meaning they’re usually not affected, gonna write “spared.” So the very last knuckles there are usually not going to be affected. When RA affects the joints in our hands, it’s going to affect the PIP, the proximal kind of, in the middle of the fingers. And, of course, it’s symmetrical so it’s gonna be both sides and, as you guessed, for osteoarthritis, the DIP is not spared, so the very last joints here can be affected but, again, it’s not symmetrical so we might have these fingers on one hand and different fingers on the other hand. DIP, PIP, very important to know for physical exams and also for testing. Next, let’s talk about the time of day. When is RA going to be the worst? So autoimmune diseases, this is not caused by overuse of the joints. So for patients with RA, their symptoms are going to be worst in the morning. I’m going to draw a clock here of, let’s make it 8am. We’re not lazy, we got up at 8am and for this patient, that’s going to be the worst.
As they get up and move around during the day, the stiffness gets better throughout the day so as they use it more, the symptoms are actually lessened for rheumatoid arthritis. Since we know that OA is from overuse, you can guess that this particular feature is going to be opposite on this side. So our patients with osteoarthritis, when they first wake up, they’ve rested overnight so the pain and stiffness is actually a lot better but as they use it, it gets worse, so I’m gonna draw a clock for, let’s make it 3pm.
They’ve had an active day so by 3pm, or whatever other time depending on their activity level, this is going to be the worst for them and mornings are going to be better. Next well talk about when we do the physical exam and we’re looking at the joint and we’re feeling it, what it might feel like. In rheumatoid arthritis, this is inflammation coming from the immune system attacking itself, there’s going to be a warmth in the erythema, which is redness in the joints that are affected.
So as you look at it, it’s gonna look pinkish, different from the rest of the skin and when you put your hand to it, it should feel warm. I’m not going to draw that around all the affected sites but just remember that, temperature, warmth and color and on the OA side, we’re going to have some enlargements, maybe the shape of the fingers change and you can see the big, painful torturous knuckles but it’s usually not going to be warm to the touch so this side is going to be cooler. Speaking of shape, RA definitely changes the shape of the joints, dramatically so. So on this side, it’s gonna be more of a twisting different shape of the joint and in OA it’s going to be more of an enlargement just going down the sensory organs.
On the OA side, if the patient is using the joint and you’re next to them, you might hear something and we call it crepitus, which is a sound, crep-i-tus, which is a sound that their joints make when it’s bone grinding on bone, so it’s a sound of friction and grinding, it doesn’t sound good coming from a joint but it’s something that’s more specific to osteoarthritis than rheumatoid. Next, we’ll talk about the time of onset. So this is overuse, we should be born with plenty of cartilage and it wears down over time so the onset of osteoarthritis should be slow, it should take years to develop and the symptom, the severity should look like this, worse over time. Then over here, for rheumatoid arthritis, I don’t know if fast is a good word because it’s a chronic disease but I think a better word for describing the timing for RA might be random or just cyclical. They might have flare ups, better one second, worse the next, so it might look like this. As the flares go up and down, this systemic disease affects the whole body so might have some fever, might have some malaise, like this person is just ill overall, it’s not just a joint problem.
We’d have vasculitis because the immune system is attacking everything and in the joints affected, we might develop cysts, which are fluid-filled sacs as the body’s reaction to the inflammation, the chronic inflammation, that comes from within. And on this side, we shouldn’t have any fever or any bodily symptoms but, again, keep in mind that not being able to use your body is frustrating, it limits the quality of life so depression can happen which can sometimes lead to malaise but it should be different from this whole global picture that we get with RA. So these are some of the main symptoms that are different in RA and OA and as you can see, they should all make sense thinking back to why it’s there in the first place, thinking back to the cause of each disease. So really, history alone, asking these questions, alone, should give you a good idea of which one it is. There are more specific ways to diagnose each but just from these symptoms right here, I think you should be able to tell rheumatoid arthritis apart from osteoarthritis.
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