Download - Approach to Joint Pain
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APPROACH TO JOINT PAIN
Dr Anoop R Prasad
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INTRODUCTION
15% of patients in general practice presents with
musculo-skeletal complaints
Most common cause of long term pain and disability
Joint diseases account for half of all chronic conditions in
people aged 60 and over
Osteoarthritis accounts for half of all chronic conditions
in persons aged over 65. 25 % of people over the age of
60 have significant pain and disability from osteoarthritis
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Low back pain is the most frequent cause of limitation of
activity in the young and middle aged, one of commonest
reasons for medical consultation, and the most frequent
occupational injury. Back pain is the second leading
cause of sick leave.
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In children
JRA : 58%
Childhood SLE : 14%
Rheumatic Fever : 12% Vasculitis : 7%
Juvenile Dermatomyositis : 2%
Best Practice & Research Clinical
Rheumatology
Vol. 22, No. 4, pp. 583604, 2008
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NORMAL JOINT
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Is it Arthritis or Arthralgia?
Presence of swelling of joint (synovial fluid , bony)
Local warmth
Tenderness along the joint line Redness (e.g. septic arthritis. acute gout .etc.)
Range of motion (often reduced)
Any deformity
( Rubor, Calor, Dolor, Tumor, Functio laesa )
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INFLAMMATORY
Rubor, calor, dolor, tumor,
Functio laesa
Decreases with activity,increase with rest
EMS > 1 hour
Systemic symptoms like
fever, weight loss, LOA
ESR, CRP
NONINFLAMMATORY
No classical signs
Increases with activity,decrease with rest
EMS < 1 hour
No systemic symptoms
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ARTHRALGIA
Fibromyalgia
Bursitis
Tendinitis
Hypothyroidism Neuropathic pain
Metabolic bone disease
Depression
Drugs
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ARTHRITIS
MONOARTHRITIS: Trauma
Infection: DGI Skin lesion.
Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection.
Crystal induced arthritis Monosodium Urate crystals (MPJ)
Ca pyrophosphate dihydrate crystals (knee)
Lyme disease Systemic Rheumatoid diseases:
Seronegative spondyloarthropathy (Reactive arthritis,psoriatic arthritis, Inflammatory BD..)
Sarcoid periarthritis
RA Osteoarthritis
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POLYARTHRITIS:
Rheumatoid Arthritis
Systemic lupus Erythrematosus
Viral arthritis Reiters disease (Reactive arthritis)
Psoriatic arthritis
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Articular Vs. PeriarticularClinical feature Articular Periarticular
Anatomic
structure
Painful site
Pain onmovement
Swelling
Synovium,
cartilage,capsule
Diffuse, deep
Active/passive,all planes
Common
Tendon, bursa,
ligament,muscle, bone
Focal point
Active, in fewplanes
Uncommon
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HISTORY
Duration of complaints (acute6wk).
Number of Joints involved (mono, oligo or
polyarthritis).
Distribution of joints involved (peripheral, axial,sparing some joints)
Pattern of involvement (recurrent, additive, migratory
etc.)
History of joint swelling Duration of early morning stiffness (prolonged in
Inflammatory arthritis)
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Extra-articular complaints (e.g. fever, rash, alopecia,
oral ulcers, photosensitivity etc.)
Associated medical illness (e.g. psoriasis.
hypothyroidism, tuberculosis, IBD) Significant past history (similar episode of arthritis.
drug allergy. peptic ulcer)
Family history of rheumatic disease (e.g. gout.
spondarthritis)
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Acute mono articular :
Septic arthritis orthopedic and medical emergency
Crystal induced gout , pseudogout
Hemarthrosis - as in Hemophilia Chronic mono articular :
Osteoarthritis
Monoarticular presentation of RA or psoriatic arthritis
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Acute polyarticular:
Reactive arthritis
Viral arthritis
Post viral arthritis Drug-induced arthritis
Poncet's arthritis
Sarcoidosis
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Chronic polyarticular:
Rheumatoid arthritis
Spondarthritis {AS, Reiter's, lBD-associated, uSpA
Juvenile spondylitis. Ps A) Psoriatic arthritis
Juvenile Idiopathic Arthritis
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Distribution:
Symmetrical- upper and lower limb eg. RA, SLE
Asymmetric - psoriatic, gout, spondyloarthritidis
Fist metatarsal gout Hand joints with sparing of DIP RA
Axial joints OA, AS, Spondyloarthritis, RA ( only
cervical spine)
DIP : OA, Ps A
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Pattern:
Fleeting / migratory :
Rheumatic fever
Gonococcemia Meningococcemia
Viral Arthritis
Acute Leukemia
Additive:
SLE
RA
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Age
50= OA, Pseudogout, PMR
Any Age group= Psoriatic arthritis, Enteropathic arthritis
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Extra articular manifestations :
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EXAMINATION
JOINT:
Swelling, warmth, effusion inflammatory
Deformity
Synovial thickening Active and passive movements both restricted-
arthritis, passive normal & active restricted- enthesitis
Number of joints involved
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Extra articular manifestations
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INVESTIGATIONS
CBC thrombocytosis, leukocytosis in inflammatory
Acute phase reactants ESR, CRP
Urine analysis pus cells in reactive arthritis, active
sediments( 2-5 rbc, rbc cast, wbc cast) in SLE, vasculitis
Viral serologies HBsAg, HCV, EBV,
Chikungunya,Parvo
Serologies
RF -
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primary biliary cirrhosis,
any chronic viral infection,
Bacterial endocarditis,
leukemia, dermatomyositis,
infectious mononucleosis,
systemic sclerosis,
systemic lupus erythematosus (SLE)(20-30%)
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Anti ccp (cyclic citrullinated peptide):
Sensitivity 80%
Specificity 85- 98%
ANA - Systemic lupus erythematosus (lupus or SLE) -over 95%
Progressive systemic sclerosis (scleroderma) - 60-
90%
Rheumatoid Arthritis - 25-30% Sjogrens syndrome - 40-70%
Felty's syndrome - 100%
Juvenile arthritis - 15-30%
Anti dsDNA -- SLE
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Serum uric acid - >7mg/dl to be significant
0.1% develop gout if 9
Synovial fluid analysis:
Monoarthritis Suspicion of infection
Suspicion of crystal-induced arthritis
Suspicion of hemarthrosis
Differentiating inflammatory from noninflammatoryarthritis
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RADIOLOGY
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12 OCTOBER- WORLD ARTHRITIS DAY16 OCTOBER - WORLD SPINE DAY17 OCTOBER- WORLD TRAUMA DAY20 OCTOBER - WORLD OSTEOPOROSIS DAY
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