Overuse injury mimicking juvenile RA

Janis Kelly

March 01, 2005

March 1, 2005

Dusseldorf, Germany - A teenage boy with persistent swelling of the proximal interphalangeal (PIP) joints of both hands but without other indicators of juvenile rheumatoid arthritis (RA) proved to have overuse injuries caused by his nervous tic of repeatedly cracking his finger joints. Dr Benedikt Ostendorf (Heinrich-Heine-University, Dusseldorf. Germany) and colleagues report this case in the March 2005 issue of the Annals of the Rheumatic Diseases [ 1 ]. Ostendorf tells rheuma wire that although magnetic resonance imaging (MRI) is not usually needed to make the diagnosis of juvenile inflammatory arthritis (JIA), it can play an important role in difficult diagnoses such as this one.

The MRI was the key instrument for us in imaging the exact joint pathology, which was without signs of synovitis or arthritis.

"The MRI was the key instrument for us in imaging the exact joint pathology, which was without signs of synovitis or arthritis. This raised doubt about the history and all the findings [of previous examinations]," Ostendorf says.

Discrepant clinical, radiological, and lab findings

Ostendorf became involved in this case when the 14-year-old patient was referred to the rheumatology department after his joint swellings did not respond to nonsteroidal anti-inflammatory drug (NSAID) therapy and 3 other medical consultations had produced contradictory findings. The patient had presented to his doctor with a 3-month history of joint swelling. He had been referred to an orthopedic surgeon because arthritis was suspected.

The surgeon's workup included blood tests for C-reactive protein and for rheumatoid factor (RF), both of which were normal. Conventional x-ray showed soft-tissue swelling of the PIP joints, and a presumptive diagnosis of juvenile RA led to treatment with an NSAID. When this did not resolve the problem, the patient was referred to a second orthopedist, who did 3-phase bone scintigraphy scans that revealed intensive "hot spots" at the PIP joints and at the epiphyseal growth plates in the legs and arms.

The patient was then referred to Ostendorf's department, where additional examinations were done. The patient denied having any symptoms other than finger swellings of both hands. There was no hypermobility and no functional restriction.

The patient had normal erythrocyte sedimentation rate, C-reactive protein, RF, cyclic citrullinated peptide, antinuclear antibodies, and HLA-B27. Follow-up radiographs of hands and feet were normal, and ultrasound showed no tendon or ligament injuries, synovial effusion, or active synovitis.

Ostendorf, who had performed considerable research on the use of MRI of the hands and feet in RA [ 2 , 3 ], then did MRI of the right hand, which showed the interesting combination of periarticular swelling of the PIP joint capsules but no damage to cartilage or bone.

MRI image of the right hand showing periarticular swelling of soft tissue as well asof the joint capsule at PIP joints 2 and 3 (arrow) without signs of beginning osteodestruction or marrow edema.

"In the diagnostic algorithm evaluating a case of possible RA, MRI of hands and feet can be used as an additional tool aimed at earlier and more accurate diagnosis of early RA or differential diagnosis, when other imaging modalities are normal. MRI might allow an earlier decision to start appropriate medication in patients with, eg, early RA," Ostendorf says.

Based on this, the investigators "reevaluated the patient's history radically." They then discussed with the patient the apparent contradiction between the clinical findings and the results of imaging and tests.

"Our first idea was an overuse due to some type of sports (eg, karate), but the patient denied such activities. Then we asked him directly if he suffered from any nervous tic, such as cracking his fingers. He finally reported a nervous habit that he had had for at least 2 years: cracking his fingers 10 times a minute," Ostendorf says.

This led to a diagnosis of "overuse syndrome secondary to a nervous tic" as a psychiatric disorder rather than JIA. The patient was referred to a psychiatric consultant for behavioral therapy but stopped after a few sessions without having benefited.


  1. Ostendorf B, Iking-Konert C, Cohnen M, et al. Finger joint swellings in a teenager: juvenile rheumatoid arthritis or a psychiatric disorder? Ann Rheum Dis 2005; 4:501-502. Abstract.

  2. Ostendorf B, Scherer A, Modder U, et al. Diagnostic value of magnetic resonance imaging of the forefeet in early rheumatoid arthritis when findings on imaging of the metacarpophalangeal joints of the hands remain normal. Arthritis Rheum 2004; 50: 094-102. Abstract.

  3. Ostendorf B, Peters R, Dann P, et al. Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis. Arthritis Rheum 2001; 44:2492-502. Abstract.



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