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
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.
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)
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, Sjögren'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 1–21 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-Schönlein 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
Behçet'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 1–3 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
o
History
Distribution of affected joints
o
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-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.
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
joint injection (steroid and LA) DMARD if chronic surgery (synovectomy, replacement)
education, wt loss, physio joint injection (steroid/LA or hyuralonate) surgery