Expert Care for Arthritis & Joint Pain

Understanding Arthritis in the Indian Context

Arthritis—joint inflammation causing pain, stiffness, and swelling—affects over 180 million Indians, more than diabetes, cancer, and heart disease combined. At Ajuda Hospitals, our arthritis management program delivers personalized care from conservative therapies to advanced biologics and surgical reconstruction, helping patients preserve joints and maintain active lifestyles.

Two major types:

Osteoarthritis (OA) – "Wear-and-Tear" Arthritis

• Prevalence: 1 in 5 Indians over age 60; knee OA most common
• Cause: Cartilage breakdown from age, obesity, prior injury, genetics, occupational stress (squatting, kneeling)
• Pattern: Asymmetric (one knee worse than other), no systemic symptoms
• X-ray: Joint space narrowing, osteophytes (bone spurs), subchondral sclerosis
• Treatment: Weight loss, exercise, NSAIDs, injections → surgery if failed

Rheumatoid Arthritis (RA) – Autoimmune Inflammatory Arthritis

• Prevalence: 0.5-1% population; onset age 30-50, female 3:1 ratio
• Cause: Autoimmune attack on joint synovium (lining)—genetics + environmental triggers
• Pattern: Symmetric (both hands/feet), morning stiffness >1 hour, fatigue, fever
• Blood Tests: Rheumatoid factor (RF) 70% positive, anti-CCP antibodies 95% specific
• Treatment: Early aggressive DMARDs (methotrexate) + biologics → prevents joint destruction

Indians develop knee OA earlier than Westerners due to floor-sitting, squatting lifestyles, and genetic predisposition. RA prevalence similar to global rates but underdiagnosed—many attribute symptoms to "body pain" or vitamin D deficiency, delaying treatment until joint erosion occurs.

When to Consult Our Arthritis Specialists

Red Flags for Rheumatoid Arthritis (urgent rheumatology referral):

• Symmetric small joint swelling (hands MCP/PIP, feet MTP)
• Morning stiffness >1 hour, improving with activity
• Systemic symptoms: Fatigue, low-grade fever, weight loss
• Positive RF or anti-CCP antibodies

Window of Opportunity: Starting DMARDs within 3 months of RA symptom onset prevents joint erosion and deformity. Delayed treatment (>6 months) = irreversible damage.

Our Diagnostic Approach

Clinical Assessment & Pattern Recognition

Osteoarthritis Features:

• Age: Usually >50; younger if prior joint injury (ACL tear, meniscus damage)
• Joint Distribution: Knees (medial compartment), hips, hands (DIP/PIP, thumb base), lumbar/cervical spine. Spares MCP, wrists, ankles, elbows.
• Pain Pattern: Worse with activity, relieved by rest. Mechanical pain (locking, catching). Minimal morning stiffness (<30 min).
• Exam: Bony enlargement (Heberden nodes at DIP, Bouchard nodes at PIP), crepitus, limited ROM, effusion in flares. No systemic signs.

Rheumatoid Arthritis Features:

• Age: Onset 30-50 (can occur any age)
• Joint Distribution: Symmetric hands (MCP, PIP, wrists), feet (MTP), shoulders, elbows, knees. Spares DIP, spine.
• Pain Pattern: Worse in morning, improves with activity. Prolonged stiffness >1 hour. Systemic fatigue.
• Exam: Soft tissue swelling (boggy synovitis), warmth, tenderness, reduced grip strength. Swan-neck/boutonniere deformities if chronic. Extra-articular: Rheumatoid nodules (elbows, fingers), interstitial lung disease, pericarditis.

Functional Assessment:

• WOMAC Score (OA): 24-item questionnaire—pain, stiffness, function. Monitors OA severity and treatment response.
• DAS28 Score (RA): Disease Activity Score—counts 28 tender/swollen joints + ESR/CRP. <2.6 = remission, <3.2 = low disease activity, >5.1 = high disease activity.

Laboratory Testing

Inflammatory Markers:

• ESR (Erythrocyte Sedimentation Rate): Elevated in RA (>40 mm/hr), normal in OA unless acute flare
• CRP (C-Reactive Protein): More specific than ESR; tracks RA disease activity—guides DMARD titration

Rheumatoid Arthritis Serology:

• Rheumatoid Factor (RF): Positive in 70-80% RA (but also 5-10% healthy elderly, hepatitis C, other CTD)
• Anti-CCP (Anti-Cyclic Citrullinated Peptide): 95% specific for RA; predicts erosive disease, poor prognosis. Positive years before symptom onset in many patients.
• ANA (Antinuclear Antibody): Screens for lupus, mixed connective tissue disease if atypical features present

Baseline Safety Labs for DMARD Therapy:

• CBC (methotrexate can cause bone marrow suppression)
• Liver enzymes (MTX hepatotoxicity; avoid if alcohol abuse or hepatitis)
• Creatinine (dose-adjust DMARDs in renal impairment)
• Hepatitis B/C, TB screening (biologics can reactivate latent infections)

Synovial Fluid Analysis (if effusion present):

• Differentiates inflammatory (RA, gout, infection) vs non-inflammatory (OA, trauma) arthritis
• OA: WBC <2,000/µL, clear yellow fluid
• RA: WBC 5,000-50,000/µL, turbid
• Gout: Negatively birefringent urate crystals
• Pseudogout: Positively birefringent calcium pyrophosphate crystals
• Septic arthritis: WBC >50,000/µL, Gram stain/culture positive

Imaging Studies

X-rays (First-Line):

Osteoarthritis Grading (Kellgren-Lawrence):

• Grade 0: Normal
• Grade 1: Doubtful—minute osteophyte
• Grade 2: Mild—definite osteophyte, possible joint space narrowing
• Grade 3: Moderate—moderate joint space narrowing, multiple osteophytes
• Grade 4: Severe—large osteophytes, marked joint space loss, subchondral sclerosis, bone-on-bone

Rheumatoid Arthritis X-ray Findings:

• Early: Soft tissue swelling, periarticular osteopenia (juxta-articular bone loss)
• Late: Joint space narrowing (uniform vs OA non-uniform), marginal erosions (bare areas at joint margins)
• Hands/feet PA views detect erosions; order at baseline and annually to track progression

Ultrasound (Emerging Gold Standard for RA):

• Gray-Scale: Detects synovial thickening, erosions earlier than X-ray (3-6 months earlier)
• Power Doppler: Quantifies active inflammation (hyperemia). Positive Doppler = active synovitis requiring therapy escalation.
• Guided Injections: Real-time needle visualization ensures intra-articular placement (95% accuracy vs 70% landmark-based).

MRI (Reserved for Complex Cases):

• Cartilage lesions (OA)—evaluates focal defects amenable to cartilage restoration vs diffuse degeneration
• Bone marrow edema (pre-erosive changes in RA), occult fractures, soft tissue pathology
• Expensive; not routine but high sensitivity for early inflammatory arthritis

Differential Diagnosis

Rule out conditions mimicking OA/RA:

• Gout/Pseudogout: Acute monoarthritis (podagra), elevated uric acid, crystal-positive joint fluid
• Psoriatic Arthritis: Psoriasis + DIP involvement, dactylitis (sausage digits), nail pitting
• Septic Arthritis: Acute onset <24-48 hrs, fever, single hot swollen joint, WBC >50,000/µL
• Polymyalgia Rheumatica: Proximal muscle pain (shoulders, hips), age >50, dramatic response to prednisone
• Fibromyalgia: Widespread musculoskeletal pain, normal labs/imaging—distinct from arthritis

Treatment Pathways

Osteoarthritis Management (Stepwise Approach)

Step 1: Conservative Non-Pharmacological Therapy

Weight Loss:

• 1 kg body weight loss = 4 kg reduced knee load during walking
• 5-10% weight reduction significantly improves pain, function (Level 1 evidence)
• Dietitian-led program: Calorie deficit 500 kcal/day, high-protein diet, portion control

Exercise & Physiotherapy:

• Low-Impact Aerobic: Swimming, cycling, elliptical—30 min, 5 days/week. Reduces pain 40%, improves function 30%.
• Quadriceps Strengthening: Eccentric exercises, leg press, straight-leg raises. Weak quads accelerate OA progression.
• ROM Exercises: Prevent flexion contractures—full extension critical for normal gait.

Assistive Devices:

• Walking stick (contralateral hand)—reduces knee load 25%
• Unloader brace (valgus brace for medial OA)—shifts load to lateral compartment
• Shoe inserts: Lateral wedge insoles for medial OA; cushioned insoles reduce impact

Complementary Therapies:

• Heat/ice therapy, TENS (transcutaneous electrical nerve stimulation), acupuncture—variable evidence but low risk

Step 2: Pharmacological Therapy

Oral Medications:

• Acetaminophen (Paracetamol): First-line for mild OA. 1g TID. Safe but limited efficacy (NNT 10).
• NSAIDs (Ibuprofen, Diclofenac, Naproxen): More effective than acetaminophen but GI/cardiovascular risks. Use lowest dose, shortest duration. COX-2 selective (celecoxib) if high GI risk.
• Topical NSAIDs (Diclofenac gel): Effective for knee/hand OA; fewer systemic side effects than oral.
• Tramadol: Weak opioid for moderate pain unresponsive to NSAIDs. Addiction potential; avoid long-term.
• Duloxetine (SNRI): 60 mg daily—approved for chronic musculoskeletal pain including OA. Useful if comorbid depression/neuropathy.

Supplements:

• Glucosamine 1500mg + Chondroitin 1200mg daily: Meta-analyses show modest benefit (10-20% pain reduction) for mild-moderate knee OA. 3-month trial; discontinue if no benefit. No disease modification (doesn't regenerate cartilage).
• Vitamin D: Correct deficiency (target >30 ng/mL). Deficiency associated with OA progression.

Step 3: Intra-articular Injections

Corticosteroid Injections:

• Rapid anti-inflammatory effect; 70-80% responders; effect lasts 6-12 weeks
• Ultrasound-guided knee injection: 40-80 mg triamcinolone or methylprednisolone + 1-2 mL lidocaine
• Limit 3-4 injections/year/joint (cartilage toxicity with excessive use)
• Best for acute OA flares, effusion-related pain

Viscosupplementation (Hyaluronic Acid):

• Restores synovial fluid viscosity, lubricates joint
• Options: Single high-molecular-weight (Synvisc-One) or 3-5 weekly low-molecular-weight injections
• Best for K-L Grade 2-3 (mild-moderate OA); little benefit Grade 4 (bone-on-bone)
• Effectiveness controversial—meta-analyses show small-moderate benefit; patient variability high
• Avoid if active synovitis, allergy to avian proteins (some HA derived from rooster combs)

PRP (Platelet-Rich Plasma):

• Autologous blood centrifuged to concentrate platelets (growth factors: PDGF, TGF-β, VEGF)
• 2-3 injections spaced 2-4 weeks
• Emerging evidence for knee OA: Superior to HA in some RCTs; 60-70% responders
• Avoid NSAIDs/corticosteroids 2 weeks before/after (inhibit platelet function)
• Not FDA-approved (off-label); insurance coverage variable

Step 4: Surgical Options

Arthroscopic Debridement/Lavage:

• Removes loose bodies, torn meniscus, smooths rough cartilage
• Effective for mechanical symptoms (locking, catching) NOT diffuse OA pain
• High-quality RCTs show NO benefit over sham surgery for degenerative OA without mechanical symptoms

Osteotomy (Joint-Preserving Surgery):

• High tibial osteotomy (HTO) for medial OA with varus alignment (bow-legs)
• Realigns mechanical axis to lateral compartment—offloads medial side
• Delays knee replacement 5-10 years in young, active patients (<55 years)
• Success: 80% good-excellent results at 5 years

Unicompartmental (Partial) Knee Replacement:

• Replace only medial or lateral compartment if arthritis isolated
• Faster recovery, more natural feel than total knee replacement
• Requires intact ACL/PCL, opposite compartment cartilage healthy
• 15% require conversion to total knee at 10 years

Total Joint Replacement:

• Definitive treatment for end-stage OA (K-L Grade 4, bone-on-bone)
• See Joint Replacement service for details
• 95% pain relief; 90% satisfied at 10 years

Rheumatoid Arthritis Management (Treat-to-Target Strategy)

Goal: Achieve remission (DAS28 <2.6) or low disease activity (DAS28 <3.2) within 6 months. Prevents joint erosion and disability.

First-Line: Conventional DMARDs

Methotrexate (MTX):

• Gold standard; start 15 mg/week oral, escalate to 25 mg if tolerated
• Mechanism: Inhibits dihydrofolate reductase—suppresses immune activation
• Folic acid 5 mg weekly (different day than MTX) prevents side effects (nausea, mouth sores, hair loss)
• Monitor CBC, liver enzymes every 8-12 weeks
• Contraindications: Pregnancy (teratogenic), liver disease, alcohol abuse
• 70% respond within 3-6 months; takes 6-12 weeks to see effect

Hydroxychloroquine (HCQ):

• 200-400 mg daily; milder DMARD
• Used alone for mild RA or combo with MTX
• Side effect: Retinal toxicity (rare)—annual ophthalmology screening

Sulfasalazine:

• 2-3 g daily; alternative to MTX if intolerant
• Side effects: GI upset, rash, bone marrow suppression

Leflunomide:

• 10-20 mg daily; alternative to MTX
• Teratogenic; requires washout before conception (cholestyramine)

Triple DMARD Therapy (MTX + HCQ + Sulfasalazine):

• More effective than MTX alone; comparable to MTX + biologic but lower cost
• India guideline: Attempt triple DMARD before escalating to biologics (cost considerations)

Second-Line: Biologic DMARDs & JAK Inhibitors

Indications: Inadequate response to MTX ± triple DMARD after 3-6 months (DAS28 >3.2), or aggressive disease with poor prognostic factors (high RF/anti-CCP, erosions).

TNF Inhibitors:

• Adalimumab (Humira): 40 mg SC every 2 weeks
• Etanercept (Enbrel): 50 mg SC weekly
• Infliximab (Remicade): IV infusion 3-5 mg/kg at 0, 2, 6 weeks then every 8 weeks
• Mechanism: Block TNF-alpha (pro-inflammatory cytokine)
• Response: 60-70% achieve low disease activity
• Side effects: Infection risk (TB reactivation—screen before starting), injection site reactions, rare demyelination/CHF
• Contraindications: Active infection, TB, hepatitis B (reactivation risk), heart failure

IL-6 Inhibitors:

• Tocilizumab (Actemra): 162 mg SC weekly or IV monthly
• Mechanism: Blocks IL-6 receptor—reduces inflammation, acute phase reactants
• Benefits: Normalizes CRP/ESR (useful if using inflammatory markers to monitor disease)
• Side effects: Elevated cholesterol, GI perforation (rare), neutropenia

JAK Inhibitors (Oral Small Molecules):

• Tofacitinib (Xeljanz): 5 mg BID
• Baricitinib (Olumiant): 2-4 mg daily
• Mechanism: Inhibit Janus kinases—block multiple cytokine pathways
• Advantages: Oral (vs injectable biologics), rapid onset (1-2 weeks)
• Side effects: Infection, herpes zoster reactivation (higher than TNF inhibitors), thrombosis (FDA black box warning)

B-Cell Depletion:

• Rituximab (Rituxan): IV infusion; depletes CD20+ B-cells
• Reserved for TNF inhibitor failures or if RF/anti-CCP high

Treat-to-Target Protocol:

• Assess DAS28 every 3 months
• If not at target (<2.6 or <3.2), escalate therapy:
  1. Optimize MTX dose (25 mg weekly)
  2. Add second DMARD (triple therapy)
  3. Add biologic or JAK inhibitor
  4. Switch to alternative biologic if no response

Glucocorticoids – Bridging Therapy

Low-Dose Prednisone:

• 5-10 mg daily as bridge while waiting for DMARD effect (takes 6-12 weeks)
• Rapid symptom control; taper after 3-6 months (chronic use causes osteoporosis, diabetes, cataracts)
• Intra-articular steroid injections for individual swollen joints

Surgical Options for RA

Synovectomy:

• Remove inflamed synovium arthroscopically (knee, wrist)
• If persistent synovitis despite medical therapy—prevents further cartilage/tendon damage
• 60-70% pain relief for 2-5 years; synovitis eventually recurs

Tendon Repair:

• RA can rupture tendons (extensor pollicis longus, Achilles)
• Early repair restores function; delayed diagnosis may be irreparable

Joint Replacement:

• End-stage RA with destroyed joint (hip, knee, shoulder, MCP, elbow)
• Pain relief excellent (95%); function depends on soft tissue quality

Wrist Fusion:

• If severe wrist destruction—fusion provides stability, pain relief
• Sacrifices motion but preserves hand function better than flail unstable wrist

Technology & Innovation

Ultrasound-Guided Precision Injections

Real-Time Visualization: Needle tracked in real-time; ensures intra-articular placement (vs extra-articular or periarticular soft tissue).

Success Rates:

• Knee: 95% accuracy (vs 80% landmark-based)
• Hip: 95% accuracy (vs 50% landmark-based—difficult anatomically)
• Shoulder, ankle: Significant improvement over blind technique

Power Doppler for RA: Detects subclinical synovitis (active inflammation without clinically swollen joint). Positive Doppler predicts flare, erosion progression—guides DMARD escalation before damage occurs.

Precision Medicine in RA

Pharmacogenomics: MTHFR polymorphisms predict MTX toxicity/response. Not routine yet but emerging.

Biomarker-Guided Therapy: Multi-biomarker disease activity score (Vectra DA)—12 serum proteins predict disease activity, joint damage. Supplements clinical exam in unclear cases.

Preventing Complications

OA Progression Prevention

Weight Management: Most modifiable risk factor. Every 1 kg lost = 4x force reduction on knees.

Avoid High-Impact Sports: Prolonged running, jumping sports accelerate OA in pre-existing cartilage damage. Switch to low-impact (swimming, cycling, yoga).

Correct Malalignment Early: Bow-legs (varus) or knock-knees (valgus) >10° accelerates OA. Osteotomy in young patients prevents premature joint replacement.

RA Joint Destruction Prevention

Early Aggressive Treatment: Start DMARD within 3 months of symptom onset. Delays >6 months = irreversible erosions.

Treat-to-Target: Don't accept "doing okay." Aim for remission/low disease activity—prevents disability long-term.

Infection Prophylaxis on Biologics: Annual flu/pneumonia vaccines. Screen for TB, hepatitis B before starting. Live vaccines contraindicated.

Osteoporosis Prevention: RA + glucocorticoids = high fracture risk. Calcium 1200 mg + vitamin D 1000 IU daily. Bisphosphonates if T-score < -2.5.

Why Ajuda for Arthritis Care?

Take the First Step

If joint pain is limiting your life—difficulty with stairs, sleep disruption, or inability to work—expert arthritis care can restore your function and quality of life. Early intervention for RA prevents irreversible joint damage. Conservative management for OA delays or avoids surgery for years.

Schedule Your Consultation: Call 9010550550 or WhatsApp to book an arthritis evaluation. Bring prior X-rays, blood tests, and medication list.

Reclaim your mobility and pain-free living with Ajuda's comprehensive arthritis program.