Arthritis ICD-10: M00.0 – Symptoms and Treatment

Arthritis ICD-10: M00.0 – Disease Definition and Causes

Polyarthritis is inflammation in multiple joints. Unlike oligoarthritis, which affects 2-4 joints, arthritis is diagnosed when four or more joints are inflamed. Its inflammation can occur simultaneously or sequentially.

The main symptoms of arthritis include pain, swelling, and restricted movement in multiple joints. Initially, movement is limited due to pain. As the disease progresses, joints gradually deform, leading to directional deformities and joint surface fragmentation (continued bone degradation) and bone stiffening (joint fixation due to bone accumulation).

Chronic arthritis leads to a reduction in the size of the muscles surrounding the inflamed joint, resulting in muscle weakness.

Causes of Arthritis
Arthritis is not a standalone disease; sometimes it results from joint diseases such as rheumatoid arthritis or psoriatic arthritis. In other cases, arthritis is a symptom of other diseases, whether rheumatic or non-rheumatic.

The following causes of arthritis can be identified:

1. Autoimmune inflammation (rheumatoid arthritis).
2. Psoriasis with the development of psoriatic arthritis.
3. Systemic connective tissue diseases:

• Systemic lupus erythematosus.
• Acute rheumatic fever.
• Systemic vasculitis, and others.

1. Infectious diseases (streptococcal infection, syphilis, brucellosis, and others).
2. Immune-allergic reactions, where circulating immune complexes deposit on the joint membrane. These reactions can occur in the presence of genetic predisposition and can occur after bacterial infection, within one week to one month after recovery.
3. Metabolic disorders with the formation and deposition of crystals in the joints, such as gout, pyrophosphate arthritis, and calcium phosphate crystal deposition diseases.
4. Injuries, whether acute (shoulder dislocation, ligament tear, etc.) or chronic (repeated joint injuries in overweight individuals or those engaged in heavy repetitive work, such as using jackhammers).

Disease Spread:
According to a multicenter study in 2004, complaints of joint pain were present in 28%. In this context, the number of joint-related complaints increases with the age of the patients. This is attributed to the natural wear and tear of joint cartilage, declining immunity with age, presence of chronic infections, hormonal imbalances, obesity, and other factors.

The prevalence of different types of arthritis varies. Twelve million people suffer from connective tissue diseases, and “rheumatoid arthritis” has been diagnosed in 300,000 patients (according to data for 2017 and 2018). The distribution of the disease also depends on gender and age, as well as the type of arthritis. For example, women suffer three times more from rheumatoid arthritis than men. Women primarily suffer from systemic lupus erythematosus (SLE) “butterfly rash,” while Reiter’s syndrome appears more frequently in young men.

Arthritis Symptoms:

All types of arthritis are characterized by three main symptoms: pain, swelling, and restricted movement in four or more joints. As arthritis progresses over time, muscle strength diminishes due to disuse.

Arthritis can gradually involve joints, or inflammation can occur in multiple joints simultaneously.

In the case of migratory arthritis (associated with systemic lupus erythematosus “butterfly rash,” acute rheumatic fever, etc.), pain initially appears in one or several joints. After some time, the typical pain of arthritis fades in these joints and affects other joints. In contrast to migratory arthritis, in the case of continuous recurrent arthritis (rheumatoid arthritis, osteoarthritic inflammation, etc.), the patient experiences pain, swelling, and restricted movement in one or a group of joints. These symptoms lessen during rest and worsen with the return of an episode.

The pain in arthritis carries an “inflammatory” nature: it is bothersome, appears in the morning or the latter half of the night, and diminishes after movement begins. The intensity of pain may vary depending on the severity of inflammation. Morning stiffness in joints often lasts from half an hour to several hours. For example, in the case of arthritis in small hand joints, the patient may feel as if wearing tight gloves. In the case of large joint damage, the patient may find it difficult to get out of bed.

The second most important sign of arthritis is joint swelling. Swelling is associated with inflammatory changes in the synovial membrane and the accumulation of inflammatory fluid in the joint space. The synovial membrane is the inner surface of the joint space that produces synovial fluid. In chronic arthritis, scar tissue and roughness develop, penetrating the soft tissues surrounding the joints, leading to joint shape changes. As arthritis progresses, joints deform due to bone surface destruction, bone growth, joint dislocation, and bone fusion.

Joint swelling in arthritis may be accompanied by a local rise in temperature, making the joints warm to the touch. The skin color over them may also change, from reddish (redness) in infectious arthritis to increased pigmentation (darker coloring) in advanced rheumatoid arthritis.

Another accompanying sign of arthritis is restricted movement in the joints. This symptom appears in most forms of arthritis. Some joint-neurological diseases are exempt (e.g., syphilis), where joints retain their ability to move despite significant bone damage. This is due to the lack of pain sensation in patients with syphilis due to damage to pain receptors.

For some diseases associated with arthritis, skin manifestations such as “butterfly rash” in systemic lupus erythematosus, psoriatic patches, etc., may appear. Additionally, arthritis may cause general manifestations such as fever, general weakness, and toxic symptoms (loss of appetite, mild nausea, increased heart and respiratory rates, lethargy, etc.).

Classification and Stages of Progressive Arthritis:

Classification by Period:

• Acute (up to 3 months).
• Subacute (up to 6 months).
• Continuous (up to 9 months).
• Chronic (more than 9 months).

Classification by Cause:

• Infectious diseases, including infectious-allergic (reactive) diseases.
• Non-infectious (rheumatoid, psoriatic, etc.).

Classification Adopted by the First National Rheumatology Conference in 1971:

• Joint inflammations as independent forms of diseases.
• Joint inflammations associated with other diseases.

Examples of Independent Forms:

• Rheumatoid arthritis – an inflammatory autoimmune disease characterized by erosive joint damage and organ atrophy: heart, blood vessels, lungs, liver, and kidneys.
• Psoriatic arthritis.
• Ankylosing spondylitis.
• Specific joint inflammations resulting from infection (syphilis, tuberculosis, viruses, etc.).
• Infectious-allergic arthritis (reactive).
• Rheumatoid arthritis. It develops due to an alpha hemolytic streptococcal infection, characterized by mobile swelling in large and medium joints without deformity. It is distinguished by rapid improvement (within 1-2 weeks) under treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
• Reiter’s disease – a disease primarily caused by Chlamydia. It is characterized by effects on the reproductive organs, joints, and eyes. Arthritis in this case affects leg joints: ankle, small foot joints, and heel.

Other Classifications:

• Allergic arthritis. Differs from reactive infectious arthritis in that inflammatory changes in the joints occur due to exposure to non-infectious agents such as animal fur and household cleaning substances.
• Arthritis in cases of systemic connective tissue diseases (systemic lupus erythematosus, systemic vasculitis, recurrent osteoarthritic inflammation, etc.).
• Arthritis in cases of metabolic disorders (gout, etc.).
• Other secondary joint inflammations (resulting from blood diseases, lung diseases, malignant tumors, etc.).

Identifying a Special Category for Joint Inflammations Resulting from Injuries:

• Joint inflammations arising after injury require special treatment. For effective treatment, the damage to the joint must be repaired. Surgical procedures may be required to rehabilitate and reconstruct the joint structure.

Complications of Rheumatoid Arthritis:

Internal Joint Complications:

• Joint destruction is one of the common complications of arthritis, more frequent in conditions like rheumatoid arthritis and psoriatic arthritis but present to some extent in any type of arthritis. Joint cartilage destruction occurs with the progression of bone resorption disease. In bone resorption disease, joint cartilage is gradually destroyed and dissolved, joint spaces narrow, and pathological patterns appear on joint edges.
• Cystic changes in bone beneath the joint cartilage, bone deterioration, mono- or multi-layered erosion of joint surfaces, bone resorption, and destruction of bone ends (end sections) beneath the joint cartilage can be observed. This leads to joint complications in arthritis – joint and bone deformities in multiple directions and formation of bony scars. As a result, joint mobility is severely reduced: joint motion range is reduced by 60-90% (i.e., unable to bend or open), muscle strength in the hands is reduced during rest, grip function suffers, and foot support function is impaired.

External Joint Manifestations:

• For many arthritis conditions (such as psoriatic arthritis, rheumatoid arthritis, etc.), external manifestations are a distinctive feature. In some cases, joint pain may be one of the primary symptoms of the disease, for example, in acute rheumatic fever, systemic lupus erythematosus, vasculitis, etc. Among the external manifestations of arthritis, focus is on cardiovascular diseases, amyloidosis, neuropathy, phimosis, central lung diseases, and skin manifestations.
• One-third of rheumatoid arthritis and systemic lupus erythematosus patients show early signs of arterial stiffness. Half of myocardial infarction cases and sudden coronary death occur at higher rates in rheumatoid arthritis patients. Half of the deaths in patients with rheumatic diseases are attributed to cardiovascular problems associated with arterial stiffness (southern chest, coronary artery disease, progressive cardiovascular failure).
• Due to its heavy adaptive nature, arthritis is considered a psychologically impactful factor, triggering various psychological disorders, mostly depressive. Continuous psychological stress is the cause. The mixed feedback mechanism between the adrenal glands and the hypothalamus-pituitary axis leads to increased intestinal inflammation, chronic pain, fatigue, anxiety disorders, and depression.

Diagnosis of Arthritis:

When suspecting someone has rheumatoid arthritis, they should consult a general practitioner. Diagnosing rheumatoid arthritis relies on the clinical presentation of the disease, personal medical history, laboratory tests, and instrumental examinations.

Complaints and Examination:

• Patients typically complain of pain, swelling, and reduced movement in four or more joints.
• During examination:
• Joint size may be enlarged (due to swelling or deformity).
• The skin over the affected joint may be warm, and redness or hyperpigmentation may be visible in this area.
• Active movements the patient performs independently (such as sitting, bending the arms at the elbows, raising the arms above the head, etc.) and/or passive movements performed by the physician during complete muscle rest of the patient may be restricted.
• Joint deformity, usually manifesting as joint dislocations and bone fusion, may occur. Pain and swelling may occur with joint deformity, which may not be noticeable in the presence of existing joint inflammation.

When examining a patient with rheumatoid arthritis, consideration should be given to the condition of their skin and mucous membranes. Psoriatic plaques or scales, “butterfly” rash, round erythematous lesions, hair loss, dermatitis (intense redness of the skin usually in the form of rash) – these and other dermatological diseases are features of various conditions including arthritis.

Laboratory Diagnosis of Rheumatoid Arthritis:
Laboratory diagnostic methods are widely used both for differential diagnosis of rheumatoid arthritis (to differentiate it from other diseases) and also to determine its activity.
Blood analysis is the most commonly used method in clinical practice to diagnose arthritis. There are specific markers for autoimmune joint damage:

• Elevated levels of anti-cyclic citrullinated peptide antibodies alongside rheumatoid factor indicate rheumatoid arthritis in 98% of cases.
• Anti-double-stranded DNA antibodies and antinuclear antibodies indicate systemic lupus erythematosus.
• In cases of lung inflammation or inflammation-sensitive arthritis, microbial antigen antibodies may sometimes appear in blood tests. A specific immune analysis is performed to detect these antibodies.
  Erythrocyte sedimentation rate (sedimentation rate) and C-reactive protein (CRP) levels are used to determine the activity of the inflammatory process. Analysis of leukocyte distribution is essential as a diagnostic criterion: decreased white blood cell count and platelet count (decreased white blood cell count and platelet count) occur in systemic lupus erythematosus, while increased platelet count and slight decrease in white blood cell count (increased platelet count and white blood cell count) occur in rheumatoid arthritis.

Synovial Fluid Analysis: Synovial fluid is obtained for analysis when performing joint puncture. Uric acid may be detected in cases of gout (these crystals can be clearly seen under polarized light microscopy), and increased white blood cell count and total cell count (increased white blood cell count and total cell count) may occur in rheumatoid arthritis.

Differential Diagnosis of Rheumatoid Arthritis:
Differential diagnosis of rheumatoid arthritis largely depends on the location of the disease process, especially at the onset of the disease. For example, rheumatoid arthritis often begins in the interphalangeal joints of the hand bones and is characterized by their symmetrical involvement. It’s important to note an exception for the metacarpophalangeal joint: it is never affected in rheumatoid arthritis. For the simple arthritis form of psoriasis, the joints between the bones at the fingertips (closest to the nails) are usually affected first.
Reiter’s disease typically starts by affecting one of the large joints in the leg, but if left untreated, the inflammatory process eventually involves other joints.

Treatment of Polyarthritis:

This includes rheumatoid arthritis, psoriatic arthritis, connective tissue disease-associated arthritis, and others, usually requires long-term or lifelong treatment. Treatment for arthritis can be divided into “symptom modification” and “disease modification”.

Symptom-modifying treatment aims to reduce symptoms (pain and joint restriction) and improve the quality of life for patients, and includes:

1. Nonsteroidal anti-inflammatory drugs (NSAIDs): These are first-line treatments for arthritis and work to alleviate pain and joint inflammation. They are used in any type of arthritis.
2. Corticosteroids (steroids) such as methylprednisolone and prednisolone: These potent anti-inflammatory drugs are used as first-line treatment for active forms of systemic lupus erythematosus, rheumatoid arthritis with systemic signs, and other systemic vascular diseases. They are also prescribed in cases of recurrent arthritis if NSAIDs are not effective.
3. Immune modulators, such as aminoquinolones: These are used when rheumatoid arthritis development is mild.

Please note that the use of these treatments depends on the patient’s condition and the doctor’s recommendations.

Disease-modifying Treatment:
Immunosuppressants:

• Examples: Methotrexate, Azathioprine, Cyclosporine, Arava (Leflunomide), and others.
• These drugs work by reducing the activity of some immune cells and inhibiting the growth of synovial membrane cells, improving laboratory indicators, reducing symptoms, and delaying joint damage.

Biological DMARDs (Biological Disease Modifying Anti-Rheumatic Drugs):

• These drugs are becoming increasingly important in treating various types of arthritis, especially rheumatoid and psoriatic arthritis, cluster arthritis, systemic vascular inflammation, and connective tissue diseases.
• They inhibit autoimmune disorders and slow down the process of joint damage.
• These drugs are prescribed in most cases for patients with elevated laboratory activity, clear joint disorders, and effects on internal organs (e.g., the eyes). Their use is also shown in cases of long-term arthritis that do not respond to basic medications. There are studies proving the effectiveness of using them in the early stages of the disease. The effect of biological drugs occurs quickly, so using them concurrently with NSAIDs is not advisable. Methotrexate may be prescribed to enhance the effect of biological drugs and reduce their toxic effects on the body.

Physical Therapy:
Natural procedures can be used to reduce pain and inflammation. Electricity or phonophoresis with medication, the effect of different frequency currents, magnetism, and magnetic laser can be used.
Many clinical studies show the effectiveness of using magnet therapy and low-level laser radiation on specific molecules in the mechanism of arthritis formation (rheumatoid arthritis and osteoarthritis). As a result of the effect of these physical factors, pain anesthesia improves and joint condition in patients. Physical therapy should be directed when laboratory activities are low, for example, when the erythrocyte sedimentation rate is less than 35 mm/hour and the C-reactive protein concentration is less than 10-15 mg/liter. Physical therapy may increase pain initially, but the situation improves after 1-2 weeks.

Outcomes and Prevention:
In most cases, arthritis in multiple sites is significantly disabling. For example, in cases of rheumatoid arthritis or Reiter’s disease, individuals under 40-50 years old become disabled just 3-5 years after the onset of the disease due to joint deformities and bone adhesions. Initially, the patient loses the ability to work, and eventually, they cannot perform even regular daily activities such as household chores, self-care, dressing, and bathing.
Additionally, patients with rheumatic diseases are at increased risk of early death. This is due to reduced patient mobility, susceptibility to infections, and the development of accompanying cardiovascular diseases, such as atherosclerosis, myocarditis with valve formation, angina pectoris, and others. Often, cardiovascular diseases are the main cause of death in these patients. Patient deaths should be associated with the development of fibrosis rather than rheumatic effects on the heart.

Prevention of Arthritis:
For immune-mediated arthritis (such as rheumatoid arthritis, psoriatic arthritis, etc.), there are no primary preventive measures because their exact causes are unknown.
Primary prevention may be possible in cases of arthritis resulting from infection or allergy. To avoid their development, the following measures are recommended:

1. Avoid unprotected sexual intercourse.
2. Detect and treat infections in a timely manner, such as pharyngitis, gonorrhea, syphilis, brucellosis, etc.
   For patients with weight gain, especially with high blood pressure and metabolic disorders, primary prevention of gouty arthritis should be implemented. This prevention includes achieving a balance in uric acid levels by reducing weight and following a low purine diet. When necessary, medications that reduce uric acid formation or increase its excretion via urine can be used.

Article Author:

Dr. Ibrahim Mansour
A general practitioner and orthopedic specialist with 9 years of experience in the emergency department. Specializes in treating infectious diseases and gastrointestinal diseases, with a focus on skeletal aspects using therapeutic, surgical, and conservative methods for injuries, including sports-related ones, and major joint diseases in the extremities. His area of interest includes joint-preserving procedures in the knee and hip joints.

Sources:

• Belov B.S., Kuzmina N.N., Medyntseva N.G. Acute Rheumatic Fever in the 21st Century. Problems and Solutions. Medical Council, 2016, No. 9, pp. 96–101.
• Erdes Sh.F., Galushko E.A., Bakhtina L.A. et al. Prevalence of Arthralgia and Joint Swelling in Residents of Different Regions of the Russian Federation. Scientific and Practical Rheumatology, 2004, No. 4, pp. 42–47.
• Fedotov V.P. Reiter’s Disease. History, Etiology, Epidemiology, Pathogenesis, Clinical Course, Skin Lesions, Eye Involvement, Musculoskeletal System, and Other Organs: Clinical Lecture. Dermatology. Cosmetology. Sexopathology, 2016, No. 1–4, pp. 82–107.
• Lila A.M., Gaponova T.V. Reactive Arthritis: Features of Pathogenesis and Therapeutic Tactics. RMJ. Rheumatology, 2010, No. 27, p. 1663.
• Teplyakova O.V. et al. Septic Arthritis in Adults. Clinical Microbiology and Antimicrobial Chemotherapy, 2015, No. 3, pp. 187–206.