APPROACH TO JOINT PAIN

Dr Anoop R Prasad

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

 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.

 In children JRA Childhood SLE Rheumatic Fever Vasculitis Juvenile Dermatomyositis

: 58% : 14% : 12% : 7% : 2%

Best Practice & Research Clinical Rheumatology Vol. 22, No. 4, pp. 583604, 2008

NORMAL JOINT

 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 )

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

ARTHRALGIA
Fibromyalgia Bursitis Tendinitis Hypothyroidism Neuropathic pain Metabolic bone disease Depression Drugs

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

 POLYARTHRITIS: Rheumatoid Arthritis Systemic lupus Erythrematosus Viral arthritis Reiters disease (Reactive arthritis) Psoriatic arthritis

Articular Vs. Periarticular

Clinical feature Articular Anatomic Synovium, structure cartilage, capsule Diffuse, deep Painful site Active/passive, Pain on all planes movement Common Swelling Periarticular Tendon, bursa, ligament, muscle, bone Focal point Active, in few planes Uncommon

HISTORY
Duration of complaints (acute<6wk versus chronic>6wk). 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)

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)

 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

 Acute polyarticular: Reactive arthritis Viral arthritis Post viral arthritis Drug-induced arthritis Poncet's arthritis Sarcoidosis

 Chronic polyarticular: Rheumatoid arthritis Spondarthritis {AS, Reiter's, lBD-associated, uSpA Juvenile spondylitis. Ps A) Psoriatic arthritis Juvenile Idiopathic Arthritis

 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

 Pattern: Fleeting / migratory : Rheumatic fever Gonococcemia Meningococcemia Viral Arthritis Acute Leukemia Additive: SLE RA

Age
<30= SLE, Ankylosing spondylitis, Reactive Arthritis. 30-50= RA, Systemic sclerosis, Gout.

>50= OA, Pseudogout, PMR

Any Age group= Psoriatic arthritis, Enteropathic arthritis

 Extra articular manifestations :

EXAMINATION
JOINT: Swelling, warmth, effusion inflammatory Deformity Synovial thickening Active and passive movements both restrictedarthritis, passive normal & active restricted- enthesitis Number of joints involved

Extra articular manifestations

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 -

Rheumatoid Arthritis Factor

Antibody against the Fc portion of IgG. above 20 IU/mL, 1:40, or over the 95th percentile 75-80% sensitivity, 85-90% specificity, 60% PPV, 92% NPV 80% pts with RA, 70% with Sjogrens Epstein-Barr virus or Parvovirus infection 5-10% of healthy persons chronic hepatitis

primary biliary cirrhosis, any chronic viral infection, Bacterial endocarditis, leukemia, dermatomyositis, infectious mononucleosis, systemic sclerosis, systemic lupus erythematosus (SLE)(20-30%)

 Anti ccp (cyclic citrullinated peptide): Sensitivity 80% Specificity 85- 98% ANA - Systemic lupus erythematosus (lupus or SLE) over 95% Progressive systemic sclerosis (scleroderma) - 6090% Rheumatoid Arthritis - 25-30% Sjogrens syndrome - 40-70% Felty's syndrome - 100% Juvenile arthritis - 15-30% Anti dsDNA -- SLE

 Serum uric acid - >7mg/dl to be significant 0.1% develop gout if <7, 0.5% if 7-8.9, 5% if >9 Synovial fluid analysis: Monoarthritis Suspicion of infection Suspicion of crystal-induced arthritis Suspicion of hemarthrosis Differentiating inflammatory from noninflammatory arthritis

RADIOLOGY

 12 OCTOBER- WORLD ARTHRITIS DAY 16 OCTOBER - WORLD SPINE DAY 17 OCTOBER- WORLD TRAUMA DAY 20 OCTOBER - WORLD OSTEOPOROSIS DAY