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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Approach to Joint Pain