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Approach to Joint Pain

Dr. Sami S. Eid


Consultant Family Medicine

Objectives
At 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

Pathophysiology

There may be :
o

Pain (arthralgia). Inflammation (arthritis) - redness, warmth, and swelling Only a single joint involved (mono-articular). Multiple joints involved. Only with use, suggesting a mechanical problem (eg, osteoarthritis, tendinitis). At rest, suggesting inflammation (eg, crystal disease, septic arthritis).

There may be:


o o

The pain may occur :


o o

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


Osteoarthritis. internal mechanical derangement

Non-inflammatory

Pathophysiology
Joint pain may arise from (cont..)

Structures adjacent or a round to the joint (periarticular)


o o o

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

Referred Pain from more distant sites

Basic principles

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?

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. Pagets 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
Acute rheumatic fever Hemoglobinopathies
(eg, sickle cell disease or trait, thalassemias)

Suggestive Findings
Fever, cardiac symptoms and signs, and migrating inflammation of the large joints, Symmetric pain in joints of hands and feet -Bone pain, avascular necrosis Young patients of African or Mediterranean , often with known diagnosis Oligoarticular symmetric arthritis during childhood,. Erythema migrans, fever, malaise, headache, and myalgias in days to weeks after tick bite Depends on specific rheumatic disease and can include specific dermatologic manifestations, dysphagia, muscle soreness, or dry eyes and dry mouth

Diagnostic Approach
Specific clinical criteria (Jones criteria), antistreptolysin O titers, group A streptococcal antigen testing Hb electrophoresis

Juvenile idiopathic arthritis Lyme disease arthritis Other rheumatic diseases (eg, polymyositis/dermatomyositis, scleroderma, Sjgren's syndrome, polymyalgia rheumatica) Psoriatic arthritis RA

ANA and RF testing Serologic testing for antibodies against Borrelia burgdorferi X-ray and various serologies (eg, ANA, RF testing, anti-SS-A, anti-SS-B, anti-Scl-70) Sometimes skin or muscle biopsy Clinical evaluation Sometimes x-ray Specific clinical criteria, x-ray, anti-CCP, and RF testing

Psoriasis, dactylitis (sausage digits), tendinitis, onychodystrophy Symmetric involvement of small and large joints More prevalent among women

Septic arthritis (particularly that caused by Acute, severe pain; redness; swelling Neisseria gonorrhea) Higher index of suspicion in patients with risk factors for STDs Fever, arthralgia, lymphadenopathy, and skin eruption 121 days after treatment with a biologic compound (eg, blood products, vaccines, protein concentrates) SLE Malar rash, oral ulcers, alopecia, history of serositis (eg, pleuritis pericarditis), RA-like polyarthralgia Usually women Systemic vasculitis (eg, giant cell arteritis, Various and sometimes vague extra-articular symptoms, including abdominal Henoch-Schnlein purpura, pain, renal failure, sinonasal pathology, and dermatologic lesions (eg rash, hypersensitivity vasculitis, polyarteritis ulcers, purpura, nodules) nodosa, Wegener's granulomatosis) Viral arthritis (particularly parvovirus but also enterovirus, adenovirus, Epstein-Barr, coxsackievirus, cytomegalovirus, rubella, mumps, hepatitis B, hepatitis C, varicella, HIV) Less severe than septic arthritis Malaise, lacy red malar rash, concomitant anemia in patients with parvovirus infection Jaundice with hepatitis B Systemic lymphadenopathy with HIV Serum sickness

Arthrocentesis Clinical evaluation

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

ESR Biopsy of any suspected affected area (eg, kidney, skin)

Arthrocentesis Sometimes 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 insufficiency More common among young adult males Oral and genital ulcers, sometimes eye pain Begins in the 20s X-ray HLA-B27

Behet's syndrome

Specific clinical criteria

Crystal-induced arthritis (eg, Acute onset of severe pain, redness, swelling (particularly in uric acid, Ca pyrophosphate, Ca the great toe or knee for uric acid deposition) hydroxyapatite) Fibromyalgia Diffuse myalgias, tender muscular points not involving joints, fatigue, sometimes irritable bowel syndrome Usually women Fever, malaise, weight loss, heart murmur, embolic phenomena

Arthrocentesis

Specific clinical criteria (see Fig. 1: Bursa, Muscle, and Tendon Disorders: Diagnosing fibromyalgia ) Blood cultures ESR Transesophageal echocardiography X-ray

Infective endocarditis

Osteoarthritis

Chronic pain usually in lower extremity joints, PIP and DIP joints, 1st carpometacarpal joint Heberden's nodes, Bouchard's nodes Acute, asymmetric joint pain predominantly involving the lower extremities 13 wk after GI or GU infection (chlamydial urethritis)

Reactive and enteropathic arthritis

Clinical evaluation Sometimes X-ray, STD testing, stool cultures

Evaluation I - History
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.

I - History
Symptoms of joint disease

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.

History

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 duration o 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 o o

Monoarthritis is the involvement of one joint. Oligoarthritis is the involvement of 2-4 joints. Polyarthritis is the involvement of 5 or more joints. Symmetric arthritis is characterized by involvement of the same joints on each side of the body. This symmetry is typical of RA and SLE. Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

Symmetry of joint involvement


o

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. 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-Schnlein 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.

Common Causes of Acute Monoarthritis

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 Gout Peudogout Calcium apatite crystals

Ch. Non-inflammatory MA
Osteoarthritis Internal derangments (e.g. torn meniscus) Chondromalacia patellae Osteonecrosis Uncommon or rare Neuropathic (Charcot) arthropathy Sarcoidosis Amyloidosis

Crystl-induced arthritis

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
Current Rheumatology Diagnosis & treatment - 2004

Evaluation II 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 Oligoathritis


Acute Oligoarthritis
Infection
Dissaminated gonococcal infection Non-gonococcal septic arthritis Bacterial endocarditis Viral Reactive arthritis Rheumatic fever

Chronic Oligoarthritis
Inflammatory Causes Common
Spondylarthropathy Reactive arthritis Anklosing Spondylitis Psoriatic arthritis Inflammatory bowel disease Atypical presentation of rheumatoid arthritis Gout Subacute bacterial endocarditis Sarcoidosis Behcet disease Relapsing polychondritis Celiac disease

Postinfection

Spondyloarthropathy
Reactive arthritis Anklosing spondylitis Psoriatic arthritis Inflammatory bowel disease

Uncommon or rare

Oligoarticular presentation of rheumatoid arthritis, SLE, adult Still disease or other polyarthritis Gout and pseudogout

Non-inflammatory Causes Common


Osteoarthritis Hypothyroidism Amyloidosis

Uncommon or rare

Current Rheumatology Diagnosis & treatment - 2004

Differential Diagnosis of Polyathritis


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

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
Primary generalised osteoarthritis Hemochromatosis Calcium pyrophosphate deposition disease

Non-inflammatory Causes

Current Rheumatology Diagnosis & treatment - 2004

Some Suggestive Findings in Polyarticular Joint Pain


Finding Possible Cause

General findings

Bone tenderness or chest pain Coexisting tendinitis

Sickle cell crisis Gonococcal or rheumatoid disease

Conjunctivitis, abdominal pain, and diarrhea


Fever and malaise Malaise and lymphadenopathy Oral and genital ulcer Raised silver plaques Recent pharyngitis and migrating joint pain Recent vaccination or blood product Skin ulcerations, rash, and abdominal pain Tick bites

Reactive arthritis
Infection, gout, rheumatic disorders, vasculitis Acute HIV infection Behet's syndrome Psoriatic arthritis Rheumatic fever Serum sickness Vasculitis Lyme arthritis

Urethritis
Merck Manual Minute - 2009

Gonococcal or reactive arthritis

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


Polymorphonuclear neutrophilic leukocytes
<25% (0.25)

Categorization Normal

White blood cell count


0 to 200 per mm3 (0 to 0.2 3 109 per L)

Examples

-Osteoarthritis, internal derangement, myxedema Rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, Neisseria gonorrhoeae infection

Non-inflammatory

<2,000 per

mm3

(2 X

109

per L)

<25% (0.25)

Inflammatory

2,000 to 50,000 per per L)

mm3

(2 to 50 3

109

>75% (0.75)

Septic

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

mm3

109 per

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

Crystal arthritis

Management
Sero-negative spondyloarthritis

joint injection (steroid and LA) DMARD if chronic surgery (synovectomy, replacement)
education, wt loss, physio joint injection (steroid/LA or hyuralonate) surgery

Osteoarthritis