REVIEW OF RHEUMATOLOGY AND

HOMOEOPATHIC MANAGEMENT
(PART-1 : GENERAL PRINCIPLES)

Prof. (Dr.) V. K. Chauhan, MD (Hom)

Ex-Principal / Professor
Dr B R Sur Homoeopathic Medical College, Hospital & Research Centre,
Nanak Pura, Moti Bagh, New Delhi

Dr. Meeta Gupta, MD (Hom)

Chief Medical Officer (NFSG)
Dr B R Sur Homoeopathic Medical College, Hospital & Research Centre,
Nanak Pura, Moti Bagh, New Delhi

PRELOGUE
The term ‘rheumatism’ is derived from the Late Latin ‘rheumatismus’, ultimately from
Greek meaning ‘to suffer from a flux’, with the term ‘rheum’ meaning ‘bodily fluids’. Before
17th century, it was always referred to as ‘gout’ (commonly called ‘Gathiya Baye’ in India)
instead of the present day specific terms. ‘The meaning of a disease of the joints is first
recorded in 1688, because rheumatism was thought to be caused by an excessive flow of
rheum into a joint thereby stretching ligaments’ (H.W. Wilson Co. 1988 Quote, Barnhart Dictionary of Etymology).
Rheumatism is a term applied to a wide variety of diseases, which include muscle ache,
pain, stiffness and joint swelling occurring in the extremities and vertebral column. The
discomfort encountered can range from mild, poorly defined and vaguely localised
discomfort to pain of such an intensity that severly affects the patient’s general condition.
These joint symptoms may be varying from minor swellings or stiffness to severe destruction
and deformity , which prevent the affected joint or joints from functioning normally.
The understanding of the joint diseases has undergone a sea change with the advancement
in the medical science. It is insufficient to establish that a patient is suffering from
rheumatism, but needs further clarification. The modern physician is an alert clinician who
anticipates the problems beforehand and institutes intervention planning on sound clinical
footings, incorporating latest developments in the medical science. The emphasis is on
prompt institution of appropriate therapy (along with all available secondary care measures)
before irreversible joint damage has occurred.
The aim of this series is to adapt to this transition in the field of rheumatology so as to
abridge the gap in a meaningful manner. The amalgam of prevalent medical applications,
when incorporated in the light of homoeopathic principles, brings about an uniformity in the
treatment planning of each individual case. This facilitates the smooth interaction among
medical professionals on a rational and scientific basis, with uniformity in expression. At the
same time it maintains our great tradition of healing art in the purest form, and provides an
ample room and flexibility for every homoeopathic physician in his individual professional
judgement in every individual case in question.
The scope of rheumatology has increased to such an extent that it is becoming increasingly
difficult to mainatain a fundamental grasp on concepts. Moreover, the ever increasing
demands of time of a busy practioner add to these constraints. Therefore, we have adhered to
common conditions that a physician encounters at a primary care level providing relevant
information for day-to-day practice. This review series is not intended as an alternative to
other texts on rheumatology and homoeopathy as detailed descriptions are outside the scope
of this series. This represents a concise clinically oriented pattern specifically focussing on:
 Review of joint anatomy, physiology, pathology, genesis of symptoms and signs, and
investigations with their significance and utility. It also includes a short case-taking
plan which emphasises the symptomatic as well as diagnostic approach, with a bedside
ready reference to important drugs.
 Review of important arthritic conditions and each disease is dealt in terms of aetiology,
clinical features, investigations, prognosis and then adapting to homoeopathic
conceptual disease diagnosis. Treatment planning includes general management and
suggestions for important ready references to a few drugs, which should not to be taken
as a complete therapeutic index for that particular disease.
We have taken deliberate liberty to put certain chronic diseases in distinct clinical stages
while describing their classical presentation to fit in the conceptual homoeopathic progression
of the disease. It represents the core of the basic underlying concept and deals with an
orientation in adapting and processing joint complaints according to the guidelines of
homeopathic philosophy and miasmatic ideology which is the basis for the assessment,
prognosis and intervention planning for each individual case in question.
Small catalogue of few commonly used drugs has been added as a ready reckoner, with
therapeutic hints on constitutional, miasmatic, clinical, keynote and palliative prescribing.
However some of the drugs discussed are not very well proved and needs to be further
clinically verified.

JOINT ANATOMY
Joint is an articulation between two or more bones or cartilages. These are functionally
classified as immovable, slightly movable and freely movable joints:

Immovable Joints Slightly Movable Joints Freely Movable Joints

(Skull Type) (Vertebral Type) (Limb type)
These are mostly found These are mostly found in the The bony ends of such a joint
in the vault of skull. midline of the body, i.e. between are covered by an articular
These are known as the bodies of the vertebrae, cartilage and are connected
‘Fibrous Joints’. manubrium sterni and sternum, and by a fibrous capsule which is
between the pubic bones. continuous with the
The articular surfaces are coated periosteum of the bone. The
with hyaline cartilage, and are inner surface of the capsule
united by an intervening disc of and all the intra-articular
fibrocartilage surrounded by a ring structures, which are not
of strong fibrous tissue. which is covered with the articular
continuous with the periosteum of cartilage, are covered by a
the two bones. Twisting of the disc synovial membrane, which
and yielding at different points secrets an oily fluid callled
under pressure allow limited the synovial fluid. These are
movements. These are known as known as ‘Synovial Joints’.
‘Cartilagenous Joints’.
These gradually ossify These joints persist throughout the The structural complexity of
with the advancing age, life. Vertebral joints, which are these joints make them more
therefore, do not situated in the mobile part of the vulnerable to multiple joint
present whatsoever vertebral column, i.e. cervical and affections.
joint complaint. lumbar regions, are prone to be
affected by the wear and tear, as
commonly seen in chronic
degenerative arthrosis.
Inflammatory arthritis affects all
the vertebral joints, as seen in
ankylosing spondylitis

SYNOVIAL JOINT

These joints have the following components:

Bony Articulation
 Articular bony ends are covered by hyaline cartilage. Articular cartilage is devoid of
vascular, nerve, and lymphatic supply. It receives nutrition from the synovial fluid. It is
not covered with the synovial membrane.
 Articular cartilage has a wear resistant, low frictional, compressible, elastic, lubricated
surface ideally suited for easy movement over a similar surface and absorption of large
forces of compression and shear generated by gravity and muscular power.
 Ageing results in thinner, less cellular, firmer and more brittle cartilage, as commonly
seen in degenerative arthrosis.

Fibrous Capsule:
 It is attached to the articular ends of the bones. It is made-up of white connective tissue. It
is pierced by the blood vessels and nerves. It may form localised thickening, forming
ligaments and separate accessory ligaments.
 It is tough but flexible. It checks excessive or abnormal movements. It is protected from
excessive tension by the reflex contraction of the appropriate muscles. Continued and
excessive strain results in the loss of resilience of the capsule.

Synovial Membrane:
 It lines the inner surface of the fibrous capsule.
 It secrets a fluid ‘synovia’ which lubricates and provides nourishment to the articular
cartilage.

Blood Supply:
 Periarticular plexus: Arteries near the joint give articular and epiphyseal branches, and
supplies the capsule, synovial membrane and epiphyseal union.

Nerve Supply:
 Capsule and ligaments have rich nerve supply, and are sensitive to pain. Synovial
membrane has least nerve supply, and is mildly sensitive to pain. Articular cartilage has
no nerve endings, and is insensitive to pain.
 Nerve which supplies the joint also supplies the group of muscles acting on the joint and
the skin covering the joint. Therefore, in joint diseases, muscles reflexly contract and fix
the joint in a comfortable position, and also there may be referred pain in the skin
overlying the joint.

VERTEBRAL JOINT
 The two vertebrae are joined by the intervertebral discs. These discs are semi-elastic in
nature and act as shock absorbers when the load on the vertebral column is increased.
Intervertebral disc consists of two parts:

Annulus Fibrosus (Peripheral Part):

 It is a concentric band of fibrocartilage attached to the anterior and posterior longitudinal
ligaments of the vertebral column. The posterior ligament is weaker and narrower than
the anterior ligament.

Nucleus Pulposus (Central Part):

 It is a gelatinous mass of water and collagen fibres situated nearer to the posterior margin
of the disc. Its semi-fluid nature allows it to change its shape and permits one vertebra to
move forwards or backwards on the other.

JOINT PATHOLOGY
SYNOVIAL JOINT

The synovial joint pathology can be grouped in reference to the involvement of the joint
structure (along with the most suitable organopathic clue to few drugs) which may be
grouped as under:

1. ARTICULAR COMPONENT
It comprises of the bony ends along with the articular cartilage, synovial membrane and joint
capsule. Disorders affecting the articular joint components are of two main varieties:
Degenerative Arthrosis Inflammatory Arthritis
Features It is characterised by focal cartilage It is dominated with the inflammation of
loss, subchondral bone retraction, the synovial membrane, followed by loss
with simultaneous proliferation of of articular cartilage and subchondral
new bone and cartilage, remodelling bone damage.
of joint contour and mild synovitis.
Clinical -Pain in joint. -Pain in joint.
Features -Limitation of joint function. -Limitation of joint function.
-Bony swelling, with local tender -Soft tissue swelling, with marked
spots. tenderness.
-Morning stiffness of less than 1 -Morning stiffness of more than 1 hour
hour duration. duration.
-Stiffness after rest of less than 5 -Stiffness after rest of more than 5
minutes duration. minutes.
-Stiffness increases with use and -Stiffness improves with activity.
weight bearing. -Signs of inflammation, warmth, effusion
-Crepitus present but signs of and joint crepitations are present.
inflammation are lacking. -Laboratory evidence of inflammation,
-Laboratory evidence of e.g. elevated ESR, elevated CRP,
inflammation, e.g. ESR, CRP, etc. hypoalbuminaemia, normochromic
may be normal. normocytic anaemia, thrombocytosis.
Common Osteoarthrosis, spondylosis, Immune mediated (SLE, RA), Reactive
Examples traumatic conditions (reactive arthritis), Infectious (gonococcal
 arthritis, pyogenic arthritis), crystal
induced (gout, pseudogout).
Common Angustura vera, Baryta muriaticum, Actaea spicata, Alfalfa, Apis, Belladona,
Drugs Calcarea fluorica, Conium, Bryonia, Chininum sulphuricum, Formic
Gettysburg water, Kali hydroidicum, acid, Formica rufa, Gaultheria, Rhus
Lycopodium, Mercurius, toxicodendron.
Phosphorus, Phytolacca, Radium
bromide, Selenium, Syphilinum,
Thuja, X-Ray.
2. PERI-ARTICULAR COMPONENT
It comprises of structures surrounding articular components. Disorders affecting the peri-
articular joint components are of two main varieties:
Synovial Insertional
Features Synovial lining of the bursae and the It includes affection at the point of
tendon sheaths are involved. The insertion of the ligaments and tendons into
common pathology involving these the bone. The common pathology
structures is inflammatory synovial involving these is tendinitis which occurs
disease (e.g. rheumatoid arthrotis) at the site of tendon insertion, or within
and repetitive trauma. the tendon sheath along the tendon’s
course. Common cause is repetitive strain.
Clinical -Tenderness over the bursa which -Affected tendon is tender to pressure.
Features can be pointed by a finger tip. -Pain aggravates when the affected part is
-If the bursa is superficial it may actively used against resistance. Pain is
appear as superficial and local comparatively less on the passive
swelling. movement.
-Pain is aggravated on moving the -Joint movements are not restricted.
ligament or soft tissue covering the -Commonly involved sites are:
bursa. Usually the pain is absent if supraspinatus, biceps, triceps, tendo-
the nearby joint is moved passively. achilles.
Common Subacromial bursitis, olecranon Golfer’s elbow (common flexors at medial
Examples bursitis, trochanteric bursitis, pre- epicondyle), Tennis elbow (common
patellar bursitis (housemaid’s knee), extensors at lateral epicondyle), Achilles
retrocalcaneal bursitis, infra-patellar tendinitis (insertion of tendo-achilles on
bursitis (clergyman’s bursitis). calcaneum).
Common Apis, Arnica, Benzoicum acidum, Arnica, Causticum, Cereus bonplandii,
Drugs Bryonia, Formic acidum, Ledum palustre, Phytolacca, Ruta.
Phytolacca, Rhus toxicodendron,
Ruta, Sticta.
3. NEUROGENIC COMPONENT
Nerve Root Affection Peripheral Nerve Entrapment
Features Compression is the common cause The common pathology involved is the
of irritation to the nerve roots at the compression to nerves subsequent in their
intervertebral foramen or subsequent course.
in their course.
Clinical -Location and character: Local pain -Location and sensation: Shooting pain or
Features and stiffness in the spine. paraesthesia distal to the nerve
Asymmetrical paraspinal muscle entrapment.
spasm causes compensatory -Radiation: Distally.
scoliosis. -Aggravation: At night.
-Radiation: Characteristic -On examination: Sensory loss usual,
 dermatomal distribution. occasionally hyperaesthesia; does not
-Sensory-motor changes: Sharp correspond to the nerve root distribution.
pain, hyperaesthesia, anaesthesia,
paraesthesia. Motor weakness in the
innervated muscles.
-Deep tendon reflexes: Diminished
or lost.
-Aggravation: On turning the neck
or lumbar spine. Straight leg raising
test increases the symptoms in the
nerve root distribution.
Common Prolapse intervertebral disc, cervical Carpal tunnel syndrome (median nerve
Examples and lumbar spondyloses. compression at wrist), ulnar nerve
entrapment at elbow.
Common Arnica, Causticum, Gnaphalium, Calcarea fluorica, Causticum, Cereus
Drugs Hypericum, Rhus toxicodendron. bonplandii, Gnaphalium, Hypericum,
Phytolacca.

VERTEBRAL JOINT

The vertebral joints or the intervertebral discs most commonly affected are those where a
mobile part of the vertebral column joins a relatively immobile part, i.e. cervico-thoracic
junction and lumbo-sacral junction.

Ageing Prolapse Intervertebral Disc

With advancing age the water Increased compression load on the vertebral column
content of nucleus pulposus causes the semi-fluid nucleus pulposus to become
diminishes and is replaced by flattened. The outward thrust is accommodated by the
fibrocartilage. As a result the discs resilience of the surrounding annulus fibrosus. When
become thin and inelastic, and the the thrust is too great, the annulus fibrosus ruptures,
intervertebral spaces diminish. allowing the nucleus pulposus to herniate.
These result in structural instability This results in:
and subsequent development of -Narrowing of the intervertebral space.
degenerative arthrosis. -Slackening of posterior longitudinal ligaments
resulting in abnormal mobility of vertebral bodies
producing local pain.
-Lateral herniation causes pressure on the spinal nerve
roots. This causes muscle spasm especially on the side
of herniation. As a consequence, the vertebral column
shows a compensatory scoliosis with its concavity on
the side of the lesion. Pain is distributed along the
distribution of the compressed nerve root.
-Large herniation directly backwards in the lumbar
region causes compression of the whole cauda equina,
resulting in paraplegia.
-Central protrusion in the cervical and thoracic regions
causes compression of the spinal cord and anterior
spinal artery, with the involvement of the pyramidal
tracts.
Common Drugs: Baryta Common Drugs: Arnica, Bryonia, Causticum, Conium,
muriaticum, Conium, Selenium, X- Gnaphalium, Hypericum, Kali hydroidicum,
Ray. Phosphorus, Plumbum metallicum, Rhus
toxicodendron, Ruta, Thallium.

EVALUATION OF PATIENT WITH JOINT DISEASE

AGE
Group Common Examples Common Drugs
Upto 5 years Juvenile rheumatoid arthritis Abrotanum, Calcarea carbonica, Chamomilla,
Tuberculinum
5-15 years Rheumatic fever Apis, Bryonia, Kalmia, Ledum palustre, Rhus
toxicodendron
20-30 years Gonococcal arthritis Jacaranda, Medorrhinum, Mercurius, Natrum
sulphuricum, Thuja
Rheumatoid arthritis Actaea spicata, Bryonia, Causticum, Rhus
toxicodendron
40 and above Degenerative arthrosis Calcarea fluorica, Conium, Radium bromide,
Selenium
Gout Benzoicum acidum, Colchicum, Ledum
palustre, Lycopodium, Urtica urens
Any age Traumatic arthritis Arnica, Bellis perennis, Phytolacca, Rhus
toxicodendron, Ruta, Symphytum
Iatrogenic arthritis Nux vomica

GENDER
Category Common Examples Common Drugs
Females Rheumatoid arthritis Caulophyllum, Pulsatilla, Sepia
predominate Rheumatic fever Apis, Belladona
Males Ankylosing Spondylitis Lycopodium, Mercurius, Thuja
predominate Gout Lycopodium
Boys only Haemophilic arthritis Phosphorus
Males = Females Degenerative arthrosis Calcarea carbonica, Lycopodium, Sulphur

ONSET
Type Common Examples Common Drugs
Acute Rheumatic fever Aconite, Apis, Belladona, Eupatorium perfoliatum
Gout Formic acid, Ledum palustre, Urtica urens
Sub-acute Rheumatoid arthritis Actaea spicata, Causticum
Ankylosing spondylitis Bryonia, Rhus toxicodendron
Psoriatic arthropathy Antimonium crudum, Natrum arsenicosum
Insidious Degenerative arthrosis Calcarea carbonica, Lycopodium, Sulphur, Thuja
Neuropathic arthritis Syphilinum

PRECIPITATING CAUSES
Cause Common Examples Common Drugs
Trauma; Rheumatoid arthritis Caulophyllum: after abortion or child birth
mental or Pyogenic arthritis Arnica
physical Haemophilic arthritis Arnica
 Psychogenic Rheumatism Ignatia, Natrum muriaticum
Sore throat Rheumatic fever Streptococcin
Lowered Tubercular arthritis Iodium, Phosphorus, Tuberculinum
vitality Rheumatic fever Sulphur, Tuberculinum
Altered Rheumatoid arthritis, SLE, Thuja
immunity connective tissue disorders
Hormonal Rheumatoid arthritis Pulsatilla: at the time of puberty or
disturbance menopause; Sepia: at the time of menopause
Exposure to Soft tissue rheumatism Dulcamara, Natrum sulphuricum
cold, humid
conditions

RHEUMATOLOGICAL SYMPTOMS

PAIN:

 Pain is the most common symptom in rheumatology and most vague and subjective both
in description and severity.
 The estimation of severity is required in assessing the progress of the disease or the
response to treatment.
 The patient is asked to mark the severity on an analogue scale of 1–10, with 1 being mild
and easily ignored and 10 being totally unbearable. However, patients are not able to
differentiate between 1, 2, 3 or 8, 9, 10.
 A simpler gradation is as follows:

Grade Intensity Description

Grade I Mild Pain that can easily be ignored
Grade II Moderate Pain that cannot be ignored, interferes with function and
needs attention or treatment from time to time
Grade III Severe Pain that is present most of the time, demanding constant
attention or treatment
Grade IV Excruciating Totally incapacitating pain

Location Common Examples Common Drugs

Big joints, fleeting Rheumatic fever Apis, Kalmia, Ledum palustre
arthritis
Big joints, Gonococcal arthritis Jacaranda
monoarticular Pyogenic arthritis Armica, Belladona
Small joints, bilateral Rheumatoid arthritis Actaea spicata
Great toe Gout Arnica, Belladona,Colchicum, Ledum
palustre
After trauma (sprain, Traumatised joint Arnica, Bellis perennis, Phytolacca,
strain, injury) Rhus toxicodendron, Ruta, Symphytum

Sensation Common Examples Common Drugs

Painless Neuropathic arthritis Syphilinum, Thallium
(Charcot’s joint)
Painful Majority of Arnica, Bellis perennis,
(Aching/Boring/Burning/Cutting/ rheumatological Bryonia alba, Phytolacca,
 Drawing/Pressing/Sore, bruised, conditions Rhus toxicodendron, Ruta
sprained /Stitching, tearing/
Neuralgic/Stiffness)

Aggravation Common Drugs

Night as in tuberculous Arsenicum album, Iodium, Mercurius, Silicea
arthritis
2-3 a.m. onset as in Gout Benzoicum acidum
Moving about Bryonia, Kalmia, Ledum palustre, Mercurius, Phytolacca
Cold Calcarea carb, Dulcamara, Guaiacum, Mercurius,
Phytolacca, Rhus toxicodendron, Silicea

Amelioration Common Drugs

Moving about Bellis perennis, Iodium, Rhus toxicodendron, Ruta, Pulsatilla
Rest Bryonia, Mercurius, Phytolacca, Rhododendron
Warmth Bellis perennis, Causticum, Colchicum, Dulcamara, Phytolacca, Ruta,
Silicea
Cold Apis, Bryonia, Iodium, Ledum palustre

SWELLING:

Spindle shaped Rheumatoid arthritis

Sausage shaped Gout
Marked swelling Gonococcal arthritis, Haemophilic arthritis, Pyogenic arthritis
Slight swelling Rheumatic fever

DEFORMITY

Gross Late rheumatoid arthritis

Moderate Osteoarthrosis
Gross and painless Neuropathic arthritis (Charcot’s joint)

WEAKNESS:

 Generalized weakness is a feature of all chronic illness, and any prolonged joint
dysfunction will inevitably lead to weakness of the associated muscles.
 Gradation of muscle power:

Grade Description
0 No contraction or muscle movement
1 Visible muscle contraction, but no movement at the joint
2 Movement at the joint, but not against gravity
3 Movement against gravity, but not against added resistance
4 Movement against external resistance, but with less strength than usual
5 Normal strength

DISABILITY:
Gradation of disability at the time of examination:
Class-I Active
 Class-II Restricted yet self care possible
Class-III Marked restriction, self care impossible
Class-IV Confined to bed

GAIT:

Hobbling Bilateral metatarso-phalangeal joints’ arthritis

Waddling Bilateral hip dislocation
Limping Unilateral pain; knee, ankle, foot
Hopping Acute immobility of ankle (Gout)

OTHERS:
 Fever, lymphadenopathy, lassitude, malaise, vasomotor disturbances, numbness, weight
loss or weight gain, general debility (common associated symptoms with inflammatory
and menopausal arthritic affections)

PAST HISTORY

History of Common Examples Common Drugs

Sore throat, Chorea Rheumatic fever Silicea, Streptococcin,
Sulphur, Tuberculinum
Psoriasis Psoriatic arthropathy Lycopodium, Mercurius,
Thuja
Non-specific urethritis Reiter’s syndrome Thuja
Gonococcal urethritis Gonococcal arthritis Medorrhinum
Syphilis Neuropathic arthritis (Charcot’s joint) Syphilinum
Pulmonary tuberculosis Tuberculous arthritis, Pott’s Spine Tuberculinum
Trauma to joint Secondary degenerative arthrosis Arnica
Bleeding tendency Haemophilic arthritis Lachesis, Phosphorus
Psycho-neurosis Psychogenic rheumatism Ignatia

RHEUMATOLOGICAL SIGNS

Signs which are frequently encountered in the joint diseases are as:

SWELLING:

Type of Swelling Description Common Drugs

Bony Swelling It is due to the osteophytes and other Calcarea carbonica,
manifestations of new bone formation, Calcarea fluorica, Hekla
commonly seen in osteoarthrosis. Examples lava, Thiosinaminum,
Heberden’s nodes and Bouchard’s nodes Thuja
(involvement of distal interphalangeal joints
and proximal interphalangeal joints
respectively)
Synovitis The inflamed, oedematous synovium Actaea spicata,
produces a ‘boggy swelling’ which is often Chininum sulphuricum,
tender. Common causes of this type of Formic acid, Formica
swelling are rheumatoid arthritis, psoriatic rufa, Mercurius
 arthropathy, reiter’s syndrome and infective
arthritis
Effusion An excessive fluid in the synovial cavity may Apis, Belladona,
occur in arthropathies. It can be demonstrated Bryonia, Gaultheria,
by cross fluctuation Guaicum, Ichthyolum,
Rhus toxicodendron
Rheumatoid These are fleshy and varying in character, Bryonia, Formic acid,
Nodules more in size than the bony swellings of Formica rufa, Guaicum,
osteoarthrosis. These tend to occur over the Ledum palustre,
joints and the extensor surfaces of the Rhododendron, Rhus
extremities. These are seen in rheumatoid toxicodendron
arthritis and rheumatic fever
Tophi Deposits of crystalline uric acid and other Ammonium benzoicum,
substances at the surface of joints or in skin or Antimonium crudum,
cartilage, typically seen as a feature of gout Benzoicum acidum,
Ledum palustre, Lithium
carbonica, Lycopodium,
Natrum sulphuricum,
Rhododendron, Urtica
urens
Other localized As in cases of bursitis, e.g. olecranon bursitis, Apis, Arnica,
swellings infrapatellar bursitis Benzoicum acidum,
Formic acid, Phytolacca,
Rhus toxicodendron,
Ruta, Sticta

MUSCLE WASTING:

 Painful joint affection is associated with the atrophy of the adjacent muscles, and occur as
a result of disease or reflex phenomenon.

DEFORMITY:

 Abnormal shape or size of a structure; may result from bony hypertrophy, malalignment
of articulating structures, or damage to periarticular supportive structures.
 It is applicable to central as well as appendicular skeleton.
 Common Drugs: Calcarea fluorica, Causticum, Radium bromide, Syphilinum, Thuja, X-
Ray.

Type of Deformity Description

Flexion Deformity Of the knee or elbow, with inability to extend the limb
Instability of Joint It is due to the mal-alignment of the articulating bones
without any change in the relationship between the
articulating surfaces, e.g. ulnar deviation of wrist, fingers;
valgus or varus deformity
Subluxation Deformity It occurs due to the mal-alignment of the articulating bones
associated with an altered relationship between their
articulating surfaces. However, some contact between the
joint surfaces is preserved
Dislocation Deformity It occurs due to the complete loss of contact between the
 articulating surfaces of the joint

CREPITUS:

 It is an important sign and points to the nature of the underlying joint disease:

Type of Crepitus Description Common Drugs

Soft Fine Crepitus It is often a feature of Bryonia, Causticum, Ledum
rheumatoid arthritis, indicating palustre, Mandragora
that the articulation is no longer officinarum, Rhus
a smooth cartilage Toxicodendron
Coarse Crepitus It is usually encountered in Angustura vera, Calcarea
cartilaginous and degenerative fluorica, Causticum, Cocculus,
changes Lycopodium, Thuja
Gross Grinding It indicates a badly destroyed Mercurius, Radium bromide,
Crepitus joint in advanced degeneration Syphilinum, X-Ray

STABILITY:

 Diseased joints can be moved into abnormal positions, due either to the joint surface
damage or laxity of the periarticular ligaments.

MOVEMENTS:

 Measurement of the range of movement is essential, keeping in view two possibilities:

 Assessment of the progress of the disease.
 Assessment of the response to the treatment.

TENDERNESS:

 Discomfort may be produced by pressing on a joint in addition to the background

discomfort.
 Following are the four grades of tenderness:

Grade Description Common Drugs

Grade I Pain only Actaea spicata, Bellis perennis, Calcarea carbonica,
Causticum, Eupatorium perfoliatum, Iodium,
Lycopodium, Tuberculinum
Grade II Pain and Gaultheria, Ichthyolum, Ledum palustre, Mercurius,
winching Phosphorus, Phytolacca, Rhododendron, Ruta
Grade III Winching and Aconite, Apis, Belladona, Bryonia, Formic acid,
withdrawing Guaicum, Rhus toxicodendron, Silicea
Grade IV Palpation not Arnica, Chamomilla, Colchicum, Hepar sulphuricum,
tolerated Lachesis

REDNESS:

 Redness, which occurs as a diffuse erythema overlying the joint, is a feature of acute
synovitis, associated with the crystal deposit synovitis, e.g. gout, pseudogout.
 Common Drugs: Apis, Belladona, Bryonia, Formic acid, Guaicum, Ichthyolum,
 Mercurius, Phosphorus, Rhododendron, Rhus toxicodendron, Silicea.

LOCAL HEAT:

 Increased warmth at the joint is a sensitive index of inflammatory joint disease.

 Common Drugs: Apis, Belladona, Bryonia, Formic acid, Guaicum, Ichthyolum,
Mercurius, Phosphorus, Rhododendron, Rhus toxicodendron, Silicea.

RASH:

Description Common drugs

Psoriatic plaques may be seen over the Antimonium crudum, Aranea ixobola,
joint or some other areas, especially along Lycopodium, Natrum arsenicosum,
with the psoriatic arthropathy Stellaria media, Thyroidinum, X-Ray
Butterfly rash on the face is characteristic Sepia
of SLE
Erythema marginatum, mainly on the Apis, Arsenicum album, Belladona, Rhus
trunk, is seen in rheumatic fever toxicodendron

SYSTEMIC REVIEW

Parts Features Clinical Conditions

Skin and Nails Pallor Anaemia of infection or chronic
disease
Erythema marginatum Juvenile rheumatoid arthritis,
Rheumatic fever
Erythema chronicum migrans Lyme disease
Psoriatic plaques Psoriatic arthropathy
Photosensitivity SLE
Palmar erythema Rheumatoid arthritis
Nail dystrophy Psoriatic arthropathy
Subcutaneous nodules Rheumatic fever, Rheumatoid
arthritis
Heberden’s nodes Osteoarthrosis
Bouchard’s nodes Osteoarthrosis
Butterfly rash on nose and cheeks SLE
Head Alopecia SLE
Eyes Scleritis Rheumatoid arthritis
Uveitis Rheumatoid arthritis, Ankylosing
spondylitis, SLE
Conjunctivitis sicca Sjogren’s syndrome
Ears Tophi Gout
Mouth and Dry mouth Sjogren’s syndrome
Throat Bleeding gums Haemophilia
Oral ulceration Reiter’s syndrome, SLE
Septic focus in tonsils Rheumatic fever, Pyogenic
arthritis
Neck and Back Spasm of cervical muscles Juvenile rheumatoid arthritis,
Cervical spondylosis
 Fixed neck Ankylosing spondylitis
Loss of lumbar lordosis Postural backache, Ligament
strain
Scoliosis Intervertebral disc prolapse,
congenital
Respiratory Pleurisy / Pleural effusion Rheumatoid arthritis, SLE
Fixed chest (diminished chest Ankylosing spondylitis
movements)
Interstitial fibrosis Rheumatoid arthritis, SLE
Cardiac Valvular heart disease Ankylosing spondylitis,
Rheumatic fever
Pericarditis Rheumatoid arthritis, Rheumatic
fever, SLE
Gastro-Intestinal Ulcerative colitis Auto-immune disorders
Splenic enlargement Felty’s syndrome (Rheumatoid
arthritis with splenomegaly and
neutropenia)
Bowel infarction (due to Rheumatoid arthritis, SLE
vasculitis)
Urino-Genital Nephropathy Gout, SLE
Non-specific urethritis Reiter’s syndrome
Purulent discharge per urethra Gonorrhoea
Balanitis Reiter’s syndrome
Ulceration Syphilis
Peripheral Raynaud’s phenomenon SLE
Vascular Vasculitis, leg ulcers Rheumatoid arthritis, SLE
Central Nervous Chorea Rheumatic fever
System Vertigo, fainting Cervical spondylosis, with
vertebro-basilar insufficiency
Psychosis, convulsions SLE
Peripheral Weakness, paralysis, numbness, Polyneuropathy (sensory-motor)
Nervous System tingling
Entrapment neuropathy Carpal tunnel syndrome

INVESTIGATIONS IN RHEUMATOLOGY
DISEASE ACTIVITY MARKERS

These help in the assessment of the acute phase of the disease and to determine the
response to the treatment. These include:

Activity Marker Description Significance Limitation

Erythrocyte -ESR is the rate of It monitors the -It is a non-specific
Sedimentation erythrocytes settling in activity of marker of tissue
Rate (ESR) anticoagulated blood. inflammatory inflammation.
-The presence of conditions (e.g. -It varies with age,
asymmetric macromolecules rheumatoid gender, food,
produced by the liver during arthritis) and anaemia, etc.
 inflammation promotes connective tissue
erythrocyte aggregation and disorders (e.g. SLE)
increases the ESR.
C-Reactive -CRP is a beta globulin -It is a sensitive -Raised CRP in the
Protein (CRP) normally present in the marker of the elderly may
serum in trace amounts. inflammation. indicate age-related
-CRP is a component of the -It is an useful disorders whose
innate immune response, the indicator of the pathogenesis may
major function is to extent and activity involve low-grade
recognize foreign pathogens in such disorders inflammation.
and damaged cells by as SLE and
binding to phosphocholine. rheumatoid
-CRP is the most responsive arthritis.
of the acute phase proteins, -It is also useful in
with increased levels differentiating
usually appearing 4-6 hours bacterial from viral
after injury or infection. infections, being
-Levels <0.2 mg/dL are raised only in the
normal and >1 mg/dL are former.
consistent with active
inflammation.

AUTOANTIBODIES

Autoantibody Description Significance Limitation

Anti-Nuclear ANA are -Antibodies against -Higher titers carry
Antibodies immunoglobulins that specific nuclear increased clinical
(ANA) are produced in antigens can be significance but do not
response to the nuclear detected. correlate with disease
DNA component of the -ANAs are useful in activity. AS such,
leucocytes. the diagnosis of many there is no need to
autoimmune diseases repeat the ANA once
including SLE and the diagnosis is clearly
other connective tissue established.
diseases. -False negative tests
have been reported in
tissue damage such as
is observed in SLE.
Rheumatoid -RF is a polyclonal -RF may be elevated -Antibodies are often
Factor (RF) antibody directed in chronic absent in early disease
against the Fc portion inflammatory and and it is common to
of immunoglobulin. infectious disorders, have low titres of a
-RF initiates immune e.g. rheumatoid variety of
complexes in the arthritis, Sjogren’s autoantibodies which
synovium, which syndrome, hepatitis C includes RF. Therefore
activate, complement infection, multiple only higher titres are
and release myeloma, interstitial significant.
chemoattractants that lung disease, -A simple positive test
recruit immune cells. cryoglobulinaemic is of little value. At
vasculitis, sarcoidosis, times a false positive
 leprosy, leukaemia. is common, therefore,
-Persistent high it is wise not to rest the
antibodies titres are diagnosis entirely on
associated with more the antibody test.
severe disease.
Anti-Cyclic -Anti-CCP are -Anti-CCP antibodies They do not correlate
Citrullinated autoantibodies directed can be detected in with extra-articular
Peptide against amino acids patients with disease.
Antibodies formed by the post- rheumatoid arthritis up
(Anti-CCPA) translational to 10 years prior to the
modification of onset of disease.
arginine. -Anti-CCP antibodies
-They are specific for are used to evclude
rheumatoid arthritis. rheumatoid arthritis in
-Higher titers correlate patients with other
with more erosive connective tissue
disease. diseases, hepatitis C
-Positive anti-CCP infection or other
combined with positive conditions that are
RF IgM correlates associated with RF
strongly with positivity.
radiographic
progression.
Anti- This is a serological -It confirms a recent or
Streptolysin O test that measures the ongoing infection with
relative serum - haemolytic
concentration of the streptococci.
antibody to -It also aids in the
Streptolysin O. diagnosis of rheumatic
fever and post-
streptococcal
glomerulo-nephritis in
the presence of clinical
symptoms.

OTHER BLOOD TESTS

Test Description Significance Limitation

HLA–B-27 -It refers to a certain It aids in the diagnosis Although it is
Antigen Test antigen group. of ankylosing associated with a
-A number of disease spondylitis, reiter’s wide range of
processes are positively syndrome and some pathology, specially
associated with HLA-B- cases of psoriatic ankylosing
27 antigen. arthropathy. spondylitis, it does
-It is positive in not appear to be the
ankylosing spondylitis sole mediator in
(90%), reiter’s syndrome development of
(85%), psoriatic disease.
arthropathy (35%).
Serum Uric -Uric acid is the end -The serum uric acid is -Interfering factors
Acid product of the purine high in cases of gout. include drugs causing
metabolism. -5% of the population increased levels, e.g.
-Whenever it is more has raised serum uric thiazide diuretics,
than 7mg% the treatment acid levels, and very which impair uric
is to be continued to few of them suffer acid clearance by the
bring the level below from gout, therefore, kidneys.
4mg%. every subject suffering -Excessive stress and
-However, one very from joint pain with fasting cause
rarely encounters a uric high uric acid levels elevation in the uric
acid level significantly may not be actually acid levels.
below the normal ranges. suffering from gout.

DIAGNOSTIC IMAGING

The availability and imaging technology has advanced tremendously in recent years. It
aids in diagnosis and objective assessment of disease severity and progression. It provides
historical record of anatomical changes, which are often disease specific.
The modalities used include conventional radiography, computed tomography, magnetic
resonance imaging, ultrasonography, arthrography, angiography, radionuclide imaging, and
bone densitometry.

CONVENTIONAL RADIOGRAPHY:

Conventional radiography is the initial imaging choice for most rheumatic conditions,
especially at the primary care level. It demonstrates fine bone details but lacks sensitivity to
distinguish soft tissue structures.

Following are the important features seen on the plane radiograph of the joint:

Feature Clinical Condition

Soft tissue swelling Non-specific feature of inflammatory arthritis
Juxta-articular osteoporosis Seen in early rheumatoid arthritis
Joint space narrowing Can occur both in degenerative and inflammatory
arthritis
Periarticular erosion Often seen in rheumatoid arthritis but not specific
Subchondral cyst Commonly seen in osteoarthrosis
Can also occur in other arthritis with secondary
osteoarthritic changes
Osteophytes Common feature of degenerative arthrosis
Subchondral sclerosis Feature of osteoarthrosis
Ankylosis Seen in ankylosing spondylitis
Rarely seen in rheumatoid arthritis
Osteolytic whittling and cupping Encountered in psoriatic arthropathy
Punched out erosions Typical feature of gout
Chondrocalcinosis Common in pseudogout.
(Linear calcification between and Calcification can occur in hyaline as well as
parallel to the articular surfaces) fibrocartilage.
Loose bodies Encountered in osteoarthrosis
Deformity Can be due to simple angulation, subluxation, or
 dislocation

MAGNETIC RESONANCE IMAGING (MRI):

MRI is now the modality of choice for evaluating potential internal joint derangements. It
has specific utility in the:
 Assessment of the integrity of peri-articular components.
 Detection of the extent of injury to the synovium, joint cartilages, ligaments, tendons,
muscles, bone marrow and other soft tissues.
 Detection of joint effusions, popliteal cysts, ganglion cysts, meniscal cysts, and bursitis.
 Evaluation of the extent of the intervertebral disc herniation and spinal cord compression.
 Patients who continue to have symptoms following surgery for back pain. Post-operative
scarring can be accurately distinguished from the disc herniation by obtaining the contrast
enhanced images following intravenous administration of gadolinium.
 Diagnosis of microfractures due to trauma or stress, often referred to as ‘bone bruises’.
 Early detection of osteomyelitis due to alterations in marrow signals.

COMPUTERISED TOMOGRAPHY:

 CT is useful for evaluating structures in areas of complex anatomy where overlying

structures obscure the view on conventional radiographs.
 It is useful in the diagnosis of low back pain syndromes (e.g. spinal stenosis vs. herniated
disk), sacroiliitis, osteoid osteoma, and stress fractures.
 It aids in evaluation of suspected or established interstitial lung disease that occurs with a
variety of rheumatic conditions (systemic sclerosis, rheumatoid arthritis, inflammatory
myopathy, microscopic polyangiitis)

ARTHROSCOPY:

 It is of great value in the examination of the interior of a joint, performed by inserting a

specially designed endoscope through a small incision.
 It also aids in the investigation of monoarthritis of uncertain aetiology.
 This technique also permits biopsy of the cartilage or synovium; or removal of loose
bodies in the joint space.

ULTRASONOGRAPHY:

 It can be used in detection of rotator cuff tears, Achilles tendon and patellar tendon tears.
 It is also used for assessing fluid collections, such as joint effusions, popliteal cysts, and
ganglion cysts, and is used to guide aspiration of fluid.

BONE DENSITOMETRY:

Bone densitometry is used primarily for evaluating osteoporosis. Two precise, accurate,
and widely available techniques are and.

Technique Description Significance Limitation

Dual-energy -Amount of radiation absorbed by -Relatively -Cannot predict
X-ray the bone can be calculated since inexpensive. who will
Absorptiometry the absorption characteristics of -Radiation dose experience a
(DXA) bone and soft tissue vary at fairly low. fracture but can
different x-ray energies. -Any part of the provide
-As such the amount of bone in the body can be indications of
path of the x-ray beam at any point studied. relative risk.
along the scan is determined. -Standard values -Not helpful in
Quantitative -It scans several lumbar vertebrae. are available for following
Computed -Simultaneously scans a phantom lumbar spine response to
Tomography containing different concentrations and proximal treatment.
(QCT) of bone equivalent material. femur, which -Limited use in
-Standard curve is constructed are most widely people with
from the concentration values studied. spinal deformity
versus CT attenuation. or those who
-Bone density at any location have had
scanned is determined from the previous spinal
standard curve. surgery.

SYNOVIAL FLUID EXAMINATION

SYNOVIAL FLUID ANALYSIS:

Normal synovial fluid is an ultrafiltrate of plasma that contains small amounts of high
molecular weight proteins (fibrinogen, complement, globulin), acting as a lubricant and shock
absorber for the joint. It identifies the cause of the joint effusion and aids in the differential
diagnosis of arthritis. Classes of Synovial Fluid are:

Feature Class I Class II Class III Class IV

Type Normal Non- Inflammatory Septic Haemorrhagic
inflammatory
Colour Straw Clear/Yellow Yellow/White Yellow/White Red
Clarity Transparent Transparent Translucent/ Opaque Opaque
Opaque
Viscosity Egg-white like High Variable Low NA
consistency
Mucin Clot Compact Firm Variable Friable NA
WBC Count <200/cu.mm <2,000/cu.mm 2,000-100,000/ >100,000/ NA
cu.mm cu.mm
Polymorphonuc <25% <25% >50% >95% NA
lear Leukocytes
Culture Negative Negative Negative Positive Variable
Crystals Nil Cholesterol and Monosodium NA NA
hydroxyapatite in urate in Gout;
Osteoarthrosis CPPD in
pseudogout;
Cholesterol in
rheumatoid
arthritis

SYNOVIAL BIOPSY:

Synovial biopsy should be done only if the diagnosis cannot be made using traditional,
less invasive procedures. The synovial biopsy is useful in differentiating inflammatory
arthritis. Typical changes are seen as:
 Clinical Condition Features
Rheumatoid arthritis Multilayered synovium, infiltration of subsynovial layer with
plasma cells and lymphocytes
SLE Massive superficial fibrin loss of synovial lining cells,
infiltration with lymphocytes and plasma cells
Tuberculous arthritis Caseating granuloma in superficial synovium, scattered chronic
inflammatory cell infiltration, and acid-fast stain or culture
evidence of Mycobacterium tuberculosis in synovial tissue
Gout Hydroxyapatite deposits in synovial tissue appear as clumps of
material that stain with alizarin red S and have a typical
appearance on electron micrography
Pseudogout Tophus like deposits of pyrophosphate crystals in the
subsynovial tissue

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