The fewer joint affected type of arthritis (oligoarticular) is characterised by having four or fewer joints affected, with the larger joints more typically affected such as the knees and ankles. These children usually appear well even though they may limp on walking. If only one hip seems affected this is very unusual for this type of arthritis and a different condition such as Perthes disease should be suspected. If the joints, such as the knees, are affected over a long period then the large extensor muscles of the thighs can weaken and waste, with tight hamstrings leading the flexion contractures of the knees. If the legs are affected asymmetrically then the length of the legs can develop a discrepancy.

With a larger number of joints affected, a minimum of five or more, the child has the many joint or polyarticular form of arthritis, with typically joints affected on both sides, a so called symmetrical involvement. A mild fever may be present and there can be significant muscle weakness and limitation of normal functioning if the joints have a severe limitation in their ranges of motion. A complete physical examination of the patient is vital to ensure that the diagnosis is juvenile arthritis, in what areas the physical limitations exist and which type of arthritis the patient is suffering from.

Settling on the diagnosis of juvenile arthritis depends on a joint showing an effusion which is the presence of inflammatory fluid within the joint, along with other symptoms and signs such as warmth, redness, limited range of motion and pain. Some joints may have an effusion which is not apparent such as the hip, but they can still show limited movement of the joint and pain. It may not be possible to establish the diagnosis of juvenile arthritis as the fever and rashes may come on initially without the arthritis at the time, with the arthritis appearing later by several months. Enlargement of lymph nodes and the liver and tenderness of muscles may be evident.

In the many jointed polyarticular form of juvenile arthritis the weight bearing joints are typically affected in a symmetrical pattern, as are the small joints of the hand. There may be loss of the articular cartilage with areas of cartilage erosion and in some cases a fusion across the joint, with thickening of the synovial membranes and effusions within the joints. Long term changes in a joint which is arthritic can include partial dislocation, joint stiffness and contractures, bony enlargement and deformities, especially of the fingers. Other findings can be loss of bone stock around the joints and narrowing of the joint spaces due to cartilage loss.

A reduction of extension in the neck may not produce any symptoms but it is important to identify this as it can indicate arthritic changes in the cervical spine which can lead to partial dislocation (subluxation) of the upper neck bones, a potentially dangerous situation. The neck bones can also fuse together along the posterior structures. The jaw joints, the tempero-mandibular joints, may also be affected and lead to reduced amount of growth in the lower jaw with inability to open the mouth as wide as normal. There may also be involvement of the eyes in the inflammatory process.

Juvenile arthritis and other complex conditions are best managed by a specialised multidisciplinary team due to the numerous problems which patients have to do with family and patient education and schooling, drug treatments, physiotherapy and occupational therapy. It is rarely if ever successful to give isolated treatments to this patient group. Reviewing patients at regular intervals allows the drug treatments to be fine tuned towards a reduction in the morning stiffness and towards fewer affected joints until no symptomatic joints remain. A typical team to manage these conditions may include a physiotherapist, occupational therapist, social workers, a paediatric rheumatologist and nurse.

These patients do not routinely require surgical care although steroid injections into some joints can be useful. Knee and hip arthritis in polyarticular arthritic patients may be managed by joint replacement once bone growth has ceased at skeletal maturity. Resting for long periods is unhelpful and patients should be encouraged to keep active for a better end result.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Local Croydon Physiotherapists. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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