Approach to Joint Pain

Dr. Sami S. EidConsultant Family Medicine

ObjectivesAt the end of this session, the trainees should be able:

• To know the pathophysiology of joint pain .

• To list common causes of joint pain

• To examine major joints (knee, ankle, hip, elbow, shoulder)

• To provide a systematic approach to the investigation and

differential diagnosis of patients presenting with joint pain.

• To describe diagnosis and treatment of the important joint

problems

– Romatoid arthritis

– Osteoarthritis

– Gout arthritis

– Septic arthritis

– Tendonitis

• To describe referral criteria for common joint problems

There may be :o Pain (arthralgia).o Inflammation (arthritis) - redness, warmth, and

swelling There may be:

o Only a single joint involved (mono-articular).o Multiple joints involved.

The pain may occur :o Only with use, suggesting a mechanical problem

(eg, osteoarthritis, tendinitis).o At rest, suggesting inflammation (eg, crystal

disease, septic arthritis). There may or may not be fluid within the joint

(effusion).

Pathophysiology

Joint pain may arise from: Structures within the joint (intra-articular):

o Sources of pain within the joint include the joint capsule, periosteum, ligaments, subchondral bone, and synovium, but not the articular cartilage, which lacks nerve endings

o Inflammatory. Infectious arthritis Rheumatoid arthritis Crystal deposition arthritis

o Non-inflammatory Osteoarthritis. internal mechanical derangement

Pathophysiology

Joint pain may arise from (cont..) Structures adjacent or a round to the joint (peri-

articular)o Bursitis o Tendinitis o Extra-articular disorders (eg, polymyalgia rheumatica,

fibromyalgia). Referred Pain from more distant sites

Pathophysiology

• Is the problem acute or chronic?• Is it an articular or extra-articular problem?• Is it a mono or oligo/poly arthritis?• Are there features of joint inflammation?• Are there extra-articular features?• Is the arthritis part of a more generalised

complaint?

Basic principles

Aetiology of Joint Pain Mono-articular Pain

• Trauma : ( overuse – fractures – hemarthrosis). Most common – to all ages

• Internal derangement or intra-articular trauma (Meniscus injury – ligament tear)

• Infectious or Septic arthritis (eg, bacterial, fungal, viral, mycobacterial, spirochetal, parasitic). Most important to rule out.

• Reactive arthritis (Aseptic inflammatory arthritis).

• Crystal-induced disease (gout or pseudogout)• Periarticular syndromes (eg, bursitis,

epicondylitis, fasciitis, tendinitis, tenosynovitis)

Aetiology of Joint Pain Mono-articular Pain

• Uncommon Causes :– Avascular necrosis (H/O corticosteriod use or sickle

cell anaemia) – Neuropathy (Charcot ‘s Joint).– Osteoarthritis– Osteomyelitis.– Lyme disease.– Paget’s disease (Osteitis deformans)– Tumor

Aetiology of Joint Pain Poly-articular Joint Pain

• Acute polyarticular arthritis is most often due to the following: – Infection (usually viral)– Flare of a rheumatic disease

• Chronic polyarticular arthritis in adults is most often due to the following: – RA (inflammatory)– Osteoarthritis (noninflammatory)

• Chronic polyarticular arthritis in children is most often due to the following: – Juvenile idiopathic arthritis

Poly-articular disorders Cause Suggestive Findings Diagnostic Approach*

Cause Suggestive Findings Diagnostic Approach

Acute rheumatic fever Fever, cardiac symptoms and signs, and migrating inflammation of the large joints,

Specific clinical criteria (Jones criteria), antistreptolysin O titers, group A streptococcal antigen testing

Hemoglobinopathies (eg, sickle cell disease or trait, thalassemias)

Symmetric pain in joints of hands and feet -Bone pain, avascular necrosisYoung patients of African or Mediterranean , often with known diagnosis

Hb electrophoresis

Juvenile idiopathic arthritis Oligoarticular symmetric arthritis during childhood,. ANA and RF testing

Lyme disease arthritis Erythema migrans, fever, malaise, headache, and myalgias in days to weeks after tick bite

Serologic testing for antibodies against Borrelia burgdorferi

Other rheumatic diseases (eg, polymyositis/dermatomyositis,

scleroderma, Sjögren's syndrome, polymyalgia rheumatica)

Depends on specific rheumatic disease and can include specific dermatologic manifestations, dysphagia, muscle soreness, or dry eyes and dry mouth

X-ray and various serologies (eg, ANA, RF testing, anti-SS-A, anti-SS-B, anti-Scl-70)Sometimes skin or muscle biopsy

Psoriatic arthritis Psoriasis, dactylitis (sausage digits), tendinitis, onychodystrophy Clinical evaluationSometimes x-ray

RA Symmetric involvement of small and large joints More prevalent among women

Specific clinical criteria, x-ray, anti-CCP, and RF testing

Septic arthritis (particularly that caused by Neisseria gonorrhea)

Acute, severe pain; redness; swellingHigher index of suspicion in patients with risk factors for STDs

Arthrocentesis

Serum sickness Fever, arthralgia, lymphadenopathy, and skin eruption 1–21 days after treatment with a biologic compound (eg, blood products, vaccines, protein concentrates)

Clinical evaluation

SLE Malar rash, oral ulcers, alopecia, history of serositis (eg, pleuritis pericarditis), RA-like polyarthralgiaUsually women

Serologic testing (eg, ANA, RF, anti-dsDNA)

Systemic vasculitis (eg, giant cell arteritis, Henoch-Schönlein purpura,

hypersensitivity vasculitis, polyarteritis nodosa, Wegener's granulomatosis)

Various and sometimes vague extra-articular symptoms, including abdominal pain, renal failure, sinonasal pathology, and dermatologic lesions (eg rash, ulcers, purpura, nodules)

ESRBiopsy of any suspected affected area (eg, kidney, skin)

Viral arthritis (particularly parvovirus but also enterovirus, adenovirus, Epstein-Barr, coxsackievirus, cytomegalovirus, rubella, mumps, hepatitis B, hepatitis C, varicella,

HIV)

Less severe than septic arthritisMalaise, lacy red malar rash, concomitant anemia in patients with parvovirus infectionJaundice with hepatitis BSystemic lymphadenopathy with HIV

ArthrocentesisSometimes parvovirus serologies or other virologic testing based on clinical suspicion

Oligo-articular disorders

Ankylosing spondylitis‡ Back pain and symmetric involvement of the large joints, iritis, tendinitis, aortic insufficiencyMore common among young adult males

X-rayHLA-B27

Behçet's syndrome Oral and genital ulcers, sometimes eye painBegins in the 20s

Specific clinical criteria

Crystal-induced arthritis§ (eg, uric acid, Ca pyrophosphate, Ca

hydroxyapatite)

Acute onset of severe pain, redness, swelling (particularly in the great toe or knee for uric acid deposition)

Arthrocentesis

Fibromyalgia Diffuse myalgias, tender muscular points not involving joints, fatigue, sometimes irritable bowel syndromeUsually women

Specific clinical criteria (see Fig. 1: Bursa, Muscle, and Tendon Disorders: Diagnosing fibromyalgia

)

Infective endocarditis Fever, malaise, weight loss, heart murmur, embolic phenomena

Blood culturesESR

Transesophageal echocardiography

Osteoarthritis‡ Chronic pain usually in lower extremity joints, PIP and DIP joints, 1st carpometacarpal jointHeberden's nodes, Bouchard's nodes

X-ray

Reactive and enteropathic arthritis‡

Acute, asymmetric joint pain predominantly involving the lower extremities 1–3 wk after GI or GU infection (chlamydial urethritis)

Clinical evaluationSometimes X-ray, STD testing, stool cultures

Symptoms of joint disease Pain

o Inflammatory joint disease o present both at rest and with motion. o It is worse at the beginning than at the end of usage.

o Non-inflammatory joint disease(ie, degenerative, traumatic, or mechanical) o Occurs mainly or only during motion o Improves quickly with rest. o Patients with advanced degenerative disease of the hips, spine, or

knees may also have pain at rest and at night. o Pain that arises from small peripheral joints tends to be more

accurately localized than pain arising from larger proximal joints. For example, pain arising from the hip joint may be felt in the groin or buttocks, in the anterior portion of the thigh, or in the knee.

EvaluationI - History

Stiffness – Stiffness is a perceived sensation of tightness

when attempting to move joints after a period of inactivity. It typically subsides over time. Its duration may serve to distinguish inflammatory from non-inflammatory forms of joint disease.

– With inflammatory arthritis, the stiffness is present upon waking and typically lasts 30-60 minutes or longer.

– With noninflammatory arthritis, stiffness is experienced briefly (eg, 15 min) upon waking in the morning or following periods of inactivity.

I - History Symptoms of joint disease

Swelling – With inflammatory arthritis, joint swelling is

related to synovial hypertrophy, synovial effusion, and/or inflammation of periarticular structures. The degree of swelling often varies over time.

– With noninflammatory arthritis, the formation of osteophytes leads to bony swelling. Patients may report gnarled fingers or knobby knees. Mild degrees of soft tissue swelling do occur and are related to synovial cysts, thickening, or effusions.

I - History Symptoms of joint disease

Symptoms of joint disease Limitation of motion

• Loss of joint motion may be due to structural damage, inflammation, or contracture of surrounding soft tissues.

• Patients may report restrictions on their activities of daily living, such as fastening a bra, cutting toenails, climbing stairs, or combing hair.

Weakness • Muscle strength is often diminished around an

arthritic joint as a result of disuse atrophy. • Weakness with pain suggests a musculoskeletal cause

(eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause.

• Manifestations include decreased grip strength, difficulty rising from a chair or climbing stairs, and the sensation that a leg is "giving way."

History

Symptoms of joint disease

Fatigue • Fatigue is usually synonymous with

exhaustion and depletion of energy in patients with arthritis.

• With inflammatory polyarthritis, the fatigue is usually noted in the afternoon or early evening.

• With psychogenic disorders, the fatigue is often noted upon arising in the morning and is related to anxiety, muscle tension, and poor sleep.

History

Temporal pattern of arthritis The onset of symptoms can be abrupt or insidious.

With an abrupt onset, joint symptoms develop over minutes to hours. This may occur in: o trauma o crystalline synovitis o infection.

With an insidious pattern, joint symptoms develop over weeks to months. o It is typical of most forms of arthritis, including

rheumatoid arthritis (RA) and osteoarthritis.

Duration of symptoms is considered either acute or chronic.

o Acute is less than 6 weeks in durationo chronic is 6 or more weeks in duration.

History

Temporal pattern of arthritis The temporal patterns of joint involvement are

migratory, additive or simultaneous, and intermittent. o With a migratory pattern, inflammation persists

for only a few days in each joint (eg, acute rheumatic fever, disseminated gonococcal infection).

o With an additive or simultaneous pattern, inflammation persists in involved joints as new ones become affected.

o With an intermittent pattern, episodic involvement occurs, with intervening periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis).

History

Number of involved joints o Monoarthritis is the involvement of one joint. o Oligoarthritis is the involvement of 2-4 joints. o Polyarthritis is the involvement of 5 or more joints.

Symmetry of joint involvement o Symmetric arthritis is characterized by involvement

of the same joints on each side of the body. This symmetry is typical of RA and SLE.

o Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

History

Distribution of affected joints o The distal interphalangeal joints of the fingers are

usually involved in psoriatic arthritis, gout, or osteoarthritis but are usually spared in RA.

o Joints of the lumbar spine are typically involved in ankylosing spondylitis but are spared in RA.

Distinctive types of musculoskeletal involvement o Spondyloarthropathy involves entheses, leading to heel

pain (inflammation at the insertions of the Achilles tendon and/or plantar fascia), dactylitis (sausage digits), tendonitis, and back pain (sacroiliitis and vertebral disc insertions).

o Gout commonly involves tendon sheaths and bursae, resulting in superficial inflammation.

History

Extra-articular manifestations Constitutional symptoms suggest an underlying

systemic disorder and are not expected in patients with degenerative joint disease. These may include fatigue, malaise, and weight loss.

Skin lesions may be present. Physical examination of the skin, but not the joints, may indicate the specific diagnosis of a number of rheumatic diseases. Examples include SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum.

Ocular symptoms or signs are also possible. Episcleritis and scleritis may be associated with RA or Wegener granulomatosis, anterior uveitis with ankylosing spondylitis, and iridocyclitis with juvenile RA. Conjunctivitis may be caused by reactive arthritis.

History

Common Causes of Acute Monoarthritis

BACTERIAL INFECTION OF THE JOINT SPACE

I Non-gonococcal : S. aureus, BHSC, S. pneumonia, G-ve.

II Gonococcal : precided by migratory tenosynovitis + Skin lesions

CRYSTAL-INDUCED ARTHRITIS

I Gout (monosodium urate crystals)

II Pseudogout (calcium pyrophosphate dihydrate crystals)

TRAUMA

Current Rheumatology Diagnosis & treatment - 2004

Differential Diagnosis of Chronic Monoarthritis

Ch. Inflammatory MA

• Infection– Non-gonococcal septic arthritis– Gonococcal– Chronic Lyme disease– Mycobacterial– Fungal– Viral

• Crystl-induced arthritis– Gout– Peudogout– Calcium apatite crystals

• Monoarticular presentation of oligoarthritis or polyathritis

– Spodyloarthropathy– Rheumatoid arthritis– Lupus & other systemic autoimmune diseases

• Sarcoidosis• Uncommon or Rare

– Familial Mediterranean fever– Amyloidosis– Foreign-body (due to plant thorn, wood fragments, etc)– Pigmented villonodular synovitis

Ch. Non-inflammatory MA

• Osteoarthritis• Internal derangments (e.g. torn

meniscus)• Chondromalacia patellae• Osteonecrosis• Uncommon or rare

– Neuropathic (Charcot) arthropathy

– Sarcoidosis– Amyloidosis

Current Rheumatology Diagnosis & treatment - 2004

EvaluationII – Physical Examination

The musculoskeletal examination helps distinguish joint inflammation (eg, RA) from joint damage (eg, degenerative joint disease). It can also help elucidate the site of musculoskeletal involvement (eg, synovitis, enthesitis, tenosynovitis, bursitis) and the distribution of joint involvement.

I – Physical Examination

General general condition, fever, pulse, BP

Articular or extra-articular Joint Inflammation

swollen, red, , tender, hot Functional impairment

passive and active movement Crepitus during active or passive range of motion Instability Joint Deformity (flexion, subluxation, dislocation)

II – Physical Examination

Other joints (including spine) Extra-articular features

nails (pitting, ridging, hyperkeratosis) enthesitis, dactylitis and tenosynovitis nodules (elbows/ears) skin (local infection, psoriasis,

keratoderma blenorrhagicum, balanitis)

eyes (conjunctivitis, uveitis) mouth ulcers

Differential Diagnosis of OligoathritisAcute Oligoarthritis

• Infection– Dissaminated gonococcal infection– Non-gonococcal septic arthritis– Bacterial endocarditis– Viral

• Postinfection– Reactive arthritis– Rheumatic fever

• Spondyloarthropathy– Reactive arthritis– Anklosing spondylitis– Psoriatic arthritis– Inflammatory bowel disease

• Oligoarticular presentation of rheumatoid arthritis, SLE, adult Still disease or other polyarthritis

• Gout and pseudogout

Chronic Oligoarthritis• Inflammatory Causes• Common

– Spondylarthropathy• Reactive arthritis• Anklosing Spondylitis• Psoriatic arthritis• Inflammatory bowel disease

– Atypical presentation of rheumatoid arthritis– Gout

• Uncommon or rare– Subacute bacterial endocarditis– Sarcoidosis– Behcet disease– Relapsing polychondritis– Celiac disease

• Non-inflammatory Causes• Common

– Osteoarthritis

• Uncommon or rare– Hypothyroidism– Amyloidosis

Current Rheumatology Diagnosis & treatment - 2004

Differential Diagnosis of PolyathritisAcute Polyarthritis

• Common Acute viral infections Early disseminated Lyme disease Rheumatoid disease Systemic lupus erythematosus

• Uncommon or rare Paraneoplastic polyarthritis Remitting seronegative symmetric

polyarthritis with pitting edema (RS3PE) Acute Sarcoidosis Adult onset Still disease Secondary Syphilis Systemic autoimmune diseases &

vasculitides Whipple disease

Chronic Polyarthritis• Inflammatory Causes• Common

Rheumatoid arthritis Systemic lupus erythematosus Spondylarthropathy (esp. psoriatic arthritis) Chronic hepatitis C infection Gout Drug-induced lupus syndromes

• Uncommon or rare Paraneoplastic polyarthritis Remitting seronegative symmetric polyarthritis

with pitting edema (RS3PE) Adult onset Still disease Systemic autoimmune diseases & vasculitides Sjogren syndrome Viral inections other than hepatitis C Whipple disease

• Non-inflammatory Causes Primary generalised osteoarthritis Hemochromatosis Calcium pyrophosphate deposition disease

Current Rheumatology Diagnosis & treatment - 2004

Some Suggestive Findings in Polyarticular Joint Pain

Finding Possible Cause

General findings

Bone tenderness or chest pain Sickle cell crisis

Coexisting tendinitis Gonococcal or rheumatoid disease

Conjunctivitis, abdominal pain, and diarrhea Reactive arthritis

Fever and malaise Infection, gout, rheumatic disorders, vasculitis

Malaise and lymphadenopathy Acute HIV infection

Oral and genital ulcer Behçet's syndrome

Raised silver plaques Psoriatic arthritis

Recent pharyngitis and migrating joint pain Rheumatic fever

Recent vaccination or blood product Serum sickness

Skin ulcerations, rash, and abdominal pain Vasculitis

Tick bites Lyme arthritis

Urethritis Gonococcal or reactive arthritis

Merck Manual Minute - 2009

Investigations

• Urinalysis• Haematology - FBC, ESR, clotting• Biochemistry - U&E, LFTs, urate, CRP• Immunology• Microbiology

– blood/urine/stool/urethral/sputum cultures

– serology

Investigations• Synovial fluid

volume/viscosity/cellularity polarised light microscopy (crystals) gram stain/culture

• Imaging plain films

loss of joint space, osteophytes, subchondral cysts, osteosclerosis, erosions, chondrocalcinosis

arthrogram, MRI, bone scan

Categorization of Synovial Fluid

Categorization White blood cell count Polymorphonuclear

neutrophilic leukocytes Examples

Normal 0 to 200 per mm3 (0 to 0.2 3 109 per L) <25% (0.25) --

Non-inflammatory <2,000 per mm3 (2 X 109 per L) <25% (0.25)Osteoarthritis, internal derangement, myxedema

Inflammatory 2,000 to 50,000 per mm3 (2 to 50 3 109 per L)

>75% (0.75)Rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, Neisseria gonorrhoeae infection

Septic >50,000 per mm3 (50 X 109 per L); usually >100,000 per mm3 (100 X 109 per L)

Usually >90% (0.90)Septic arthritis (primary concern); occasionally, gout, pseudogout, reactive arthritis, Lyme disease

Evaluation

©2008 UpToDate® • www.uptodate.com

Management

• General education, Physiotherapy analgesics and/or anti-inflammatory drugs

• Infection (if in doubt, treat until culture result)

Gram +ve flucloxacillin, benzylpenicillin, Gram -ve 3rd generation cephalosporin 6 weeks in total (2 iv, 4 po)

• Haemarthrosis joint aspiration

Management

• Reactive arthritis joint injection (steroid and local anaesthetic) ophthalmology review screen partner (?) DMARD (Disease Modifying Anti-Rheumatic Drugs)

(sulphasalazine/MTX) if chronic• Crystal arthritis

NSAID/colchicine/joint injection (steroid/LA) lifestyle review Allopurinol if recurrent, tophaceous or

erosive

Management

• Sero-negative spondyloarthritis joint injection (steroid and LA) DMARD if chronic surgery (synovectomy, replacement)

• Osteoarthritis education, wt loss, physio joint injection (steroid/LA or

hyuralonate) surgery

THANKSDR. SAMI EID