Musculoskeletal System and Disorders
Rheumatoid Arthritis (RA)
Rheumatoid arthritis is a chronic inflammatory disease that affects the joints. This usually affects the
peripheral joints, hands, feet, and wrists. This disorder is caused by the immune system mistakenly
attacking the synovium cells and tissues, which are healthy, and cover the joints. This releases
chemicals to attack surrounding bones, cartilage, ligaments, and tendons. Resulting in the joint
losing shape and alignment. There are risk factors which could increase the possibility of developing
RA. This includes if you are a woman, and as the disorder is hereditary, if it runs in the family. If left
untreated, RA could cause joint deformities and damage, spread of inflammation to other areas of
the body such as the heart which causes chest pain.
Some symptoms of RA include:
Throbbing and aching pain of the joints and morning stiffness (flares)
Red and Inflamed joints
Tiredness, lack of energy, fatigue
Mouth and eye dryness – as a result of spreading inflammation
Accumulation of fluid
Figure 1 - Rheumatoid Vs Healthy Joint
RA can most commonly be exemplified in the hands. The
joints most affected are the metacarpophalangeal (MCP)
joints. These are the 5 condyloid joints we have that connect
the proximal phalanges to the head of metacarpal bones.
This joint allows motion primarily in two planes, including
flexion or extension, abduction or adduction, and partial
circumduction. These movements are caused by the
extrinsic muscles which are located in the forearm such as
the extensor digitorum and connected to the hand by flexor
and extensor tendons. The intrinsic muscles are located
within the hand, such as the lumbricals. The ligaments
which connect the metacarpal bones together are the deep
metacarpal ligaments, and the ligaments forming a capsular
sac around the MCP joints are the collateral ligaments.
With rheumatoid arthritis, inflammation is a common symptom. This excessive inflammation for
prolonged durations may lead to rheumatoid nodules (lumps of tissue) developing, which can extend
from the hands and to other areas such as the forearm. In addition, this affects the tendons and
ligaments by making them inflamed, leading to tears or ruptures. The extrinsic muscles are affected
as it tries to contract and pull onto the bones of the hand through the tendons. However, the tears
can lead to detachment. Therefore, there is a lack of motion or weakness, trying to move or perform
actions can be painful or even cause further damage. Over time, muscles are weakened from
reduced movement leading to contractures. The synovium produces synovial fluid to lubricate
surfaces of the bones in the MCP joint. However, when the immune system attacks this with cells, it
causes inflammation to the synovium and excess synovial fluid is produced. Excess creates an
accumulation of fluid, and ligaments are weakened from the stretching. The looser and weaker
ligaments are, the less stable a joint is due to decreased support. Further damage to the joint is
caused by the formation of abnormal tissues of inflammatory cells from the immune system called
pannus. Pannus releases chemicals which damage surrounding tissues such as ligaments, cartilage
and the bones making up the MCP joint. Over time, this results in deformities of the whole hand if
untreated as the disease can spread to surrounding joints. These joint deformities can lead to
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, Musculoskeletal System and Disorders
restriction or loss of motion, and when moving, causing pain – negatively affecting everyday life
activities and increasing difficulty.
Treatments
Currently, there is no cure for Rheumatoid Arthritis. However, there are corrective treatments to aid
in controlling and reducing the symptoms experienced with the disease.
Figure 2 - Deformities
The first treatment method is non-steroidal, anti-
inflammatory drugs (NSAIDs). These are medications
such as ibuprofen or aspirin that can be prescribed or
bought in stores, with a function of relieving pain and
reducing inflammation. These work by blocking the
production of prostaglandins (a lipid) from the
cyclooxygenase enzyme which primarily has a function
to trigger the inflammatory response.
A second treatment is disease-modifying, anti-rheumatic
drugs (DMARDs). These are also medications such as methotrexate. They have a function of
inhibiting the activity of the chemicals that are released by the immune system to mistakenly attack
the healthy synovium tissues and cells of the joint. Taking these would prevent damage such as
deformities occurring to nearby tissues such as ligaments, cartilage, and tendons.
Out of the two medications here, the most recommended is the DMARDs. This is because the
advantage of taking this medication is that it blocks the activity of the chemicals which damage the
joint and surrounding tissues which destroys and deforms the joint. This reduces the possibilities of
deformations occurring, as well as slowing down the disease, (which gets progressively worse if
untreated). In addition, methotrexate is known for reducing inflammation which can possibly spread
to other areas of the body. The disadvantages of utilising DMARDs are the side effects on the body
such as nausea, headaches, and a sore mouth. In addition, DMARDs, in less common cases, could
affect the liver, blood cells or the lungs negatively. Therefore, tests are regularly carried out to
identify if the body is reacting or altered negatively and to stop use immediately if so. However, this
drug is most commonly used by many to manage RA effectively as it can be paired with other drugs
such as biological treatments to obtain ease and comfort. NSAIDs are not recommended in
moderate cases of RA. This is because it only works to decrease inflammation and pain. As a result,
NSAIDs do not slow down the disease; allowing it to continue and cause further damage over time.
The side effects of NSAIDs include nausea and stomach pains due to the stomach lining (which
protects the stomach from the acid) being broken down, this may result in internal bleeding.
Therefore, ibuprofen should not be utilised for prolonged durations.
For moderate to severe cases of rheumatoid arthritis where medications are not effective, surgery is
recommended. This surgical procedure is called arthroscopy which utilises keyhole surgery. Small
incisions are made on the skin and an arthroscope is placed inside to reach the joint for visualisation
and to identify the inflamed joint. The surgeon will then remove the inflamed or damaged tissue
surrounding the joints using tools through other incisions. Once removed, the incisions are sealed.
As always, there are risks and complications associated with this surgery. However, these are rare,
the risks include reactions to the anaesthetic utilised, further damage to the joint, bleeding, or
infections. Because this procedure utilises keyhole surgery, the risks such as infections are low, and
recovery is quick. Other disadvantages of arthroscopy include less/tight workspace as the tissues and
bones of the hand are compact. There are possibilities of damaging nerves that are in the
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, Musculoskeletal System and Disorders
surrounding area. However, improvements and modern technology has allowed arthroscopy of the
hand and MCP joint possible by utilising smaller instruments, tools and having surgeons with the
correct training and experience. As RA cannot be cured, surgery only helps in temporarily managing
pain and inflammation, also easing joint movement, depending on the severity of damage inflicted
to the healthy joints. For the most effective way to treat and manage symptoms of RA, arthroscopy
should be undertaken for relief as well as taking DMARDs as they are considered to safe to use
especially for longer durations where some medicines like NSAIDs should not be taken.
Inflammation of tissues causes a restricted range of motion for the MCP joint due to the pain when
attempting to move or performing strenuous work. Therefore, by continuing with arthroscopy
surgery, this inflammation is removed and reduced which allows the body and its tissues to heal, and
gain strength, over a short duration of time. Without the inflammation, there is no longer severe
pain when performing actions or moving, which returns the body back to its normal functioning
state – enabling improved, natural range of movement for the MCP joint. DMARDs such as
Methotrexate are efficient in controlling RA in the hands and the rest of the body. These drugs
contribute to the prevention of joint damage by supressing the immune system and limiting the
cause of inflammation and stiffness. With these symptoms controlled, pain is relieved. With both of
these treatments combined, this restores the natural range of motions of the MCP joint including
flexion/extension, abduction/adduction, and partial circumduction, with an improved quality of life.
As pain is relieved in both options, this enables individuals suffering with RA to return to normal life
events and everyday activities such as working and sleeping (with comfort).
Structure of MSK system
Human Skeleton
Figure 3 – Division of the Skeleton
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