Joint pain in primary care

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Dr Ruziaton bt Hasim

Dr Salinah bt Mohd Mudri

Pakar Perubatan Keluarga

JOINT PAIN In Primary Care


INTRODUCTION

• Joint pain is discomfort that arises from any joint

• It is sometimes called arthritis, arthralgia and rheumatism1

• Arthritis: an inflammatory conditions of the joints

• Arthralgia: joint pain of non inflammatory conditions

• Rheumatism: pain at or around a joint which is not due to joint2

• Chronic pain is defined as a pain that lasts longer than 3 months.


• Pain

• Stiffness

• Swelling

• Limitation of motion

• Weakness

• Inflammatory joint disease : pain occur at rest and with motion, worse at the beginning of usage than at the end.

• Non-inflammatory joint disease (ie, traumatic, or mechanical): pain occurs during movement, improves quickly with rest

SIGNS AND SYMPTOMS OF JOINT PAIN


SHOULDER PAIN


CAUSES OF SHOULDER PAIN Pain origin Differential diagnosis

Pain arising from the shoulder

• Rotator cuff disorders: rotator cuff tendinopathy, impingement, subacromial bursitis, rotator cuff tears

• Glenohumeral disorders: capsulitis (“frozen shoulder”), arthritis

• Acromioclavicular disease

• Traumatic dislocation

Pain arising from elsewhere

• Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain

• Polymyalgia rheumatic

• Malignancy: apical lung cancers, metastases


HISTORY AND PHYSICAL EXAMINATION HISTORY EXAMINATION

• Onset and characteristics • Functional impact • Pain at rest /movement • Night pain • Any neck thoracic or upper limb

pain? • History of acute trauma, shoulder

pain, or instability during certain movement?

• Systemic symptoms of illness • Significant comorbidity (diabetes,

stroke, cancer)

• Examine neck, axilla and chest wall • Assess range of movement of cervical

spine • Inspect shoulder for swelling,

wasting and deformity • Palpate sternoclavicular,

acromioclavicular and glenohumeral joints for tenderness, warm, swelling and crepitus

• Assesss stability and range of movement (active, passive, resisted)

• Specific diagnostic tests • Neurological examination of both

upper limbs


SPECIFIC DIAGNOSTIC TESTING

Specific tests Diagnosis

Drop arm test Rotator Cuff Tear

Apprehension test Test For Anterior

Instability Positive In

Recurent Shoulder

Dislocation.

Impingement test Impingement

Syndrome



RED FLAGS IN SHOULDER PAIN Features Possible diagnosis

History of cancer, symptoms and signs of cancer,

unexplained deformity, mass or swelling

Tumor

Red skin, fever systemically unwell Infection

Trauma, epileptic fit, electric shock, loss of rotation

and normal shape

Shoulder Dislocation

Trauma, acute disabling pain, significant weakness,

positive drop arm test

Acute Rotator Cuff

Tear

Unexplained wasting, significant sensory or motor

deficit

Neurological Lesion



TREATMENT

• A holistic approach: pharmacological & non-pharmacological

• Adequate analgesia (paracetamol, NSAIDs drugs - regular / PRN basis)

• Self-motivation

• Encourage activity

• Give written patient information sheet.

REFERRAL CRITERIA

• Pain lasting more than 6 months with functional disability

• Diagnostic uncertainty

• Positive Red flags.


SHOULDER PAIN EXERCISES


HIP PAIN


CAUSES OF HIP PAIN

Anterior hip Lateral Posterior

Differential

diagnosis

Osteoarthritis Osteoarthritis Sciatic nerve irritation

secondary to

spondyloarthritis /

lumbar disc herniation

Avascular Necrosis Bone tumor Muscle strain

Hip fracture Radiating lumbar

disease

Hip flexor muscle

strains or tendonitis,

and iliopsoas

bursitis


Integrating the history and physical examination to diagnose hip pain Disorder

Presentation and exam findings

Anterior pain

Osteoarthritis Gradual onset anterior thigh/groin pain worsening with

weight-bearing.

Limited range of motion with pain, especially internal rotation

Hip flexor muscle

strain/tendonitis

History of overuse or sports injury.

Tenderness over specific muscle or tendon

Iliopsoas bursitis Anterior pain and associated snapping sensation.

Tenderness with deep palpation over femoral triangle.

Etiology from overuse, acute trauma, or rheumatoid arthritis

Hip fracture

(proximal femur)

Fall or trauma followed by inability to walk.

Limb externally rotated, abducted, and shortened.

Pain with any movement

Inflammatory

arthritis

Morning stiffness or associated systemic symptoms.

Previous history of inflammatory arthritis.

Limited range of motion and pain with passive motion

Avascular

necrosis of

femoral head

Dull ache in groin, thigh, and buttock usually with risk factors

(corticosteroid exposure, alcohol abuse).

Limited range of movement with pain.


RED FLAGS OF HIP PAIN

• Fever, malaise

• Night sweats, night pain, weight loss

• Previous history of cancer

• Trauma/assault (fall, blow, lifting)

• Intravenous drug abuse

• Long term use of immunosuppressants

• Pain that is not relieved with rest and continues through the night

** An accumulation of multiple red flags requires immediate medical referral



HIP EXERCISES


KNEE PAIN


CAUSES OF KNEE PAIN

• The knee joint is prone to injury because of its complexity and weight bearing function.

• The most common knee problem in primary care are:

• Ligament injuries

• Meniscus injuries

• Osteoarthritis


PHYSICAL EXAMINATION & DIAGNOSIS

Examination: Description:

Inspection Attitude of the lower limbs ( genu varus / genu valgus)

Skin changes ( scar/sinus/swelling/inflammation)

Wasting of muscles

Walking ( gait) Normal, antalgic, shuffling, short limb, and high stepping

Palpation Temperature of the knee

Patella tap to assess intraarticular fluid collection

Range of

movement

Lift both feet up ( with hips flexed and knee extended)

Patient to flex the knee and hip actively & passively to

assess the posible range of movement


KNEE LIGAMENTAL INJURIES

SIGNS AND SYMPTOMS

• Ligaments injuries involve high energy injuries

• Patients may present with knee swelling within an hour or two and associated with ‘clunk’ or ‘popping’ sensation at the time of injury

• Once pain subsides patients would feel instability


SPECIFIC TESTS FOR LIGAMENT INJURIES

Specific tests Diagnosis

Valgus stress Medial collateral ligament

Varus stress Lateral collateral ligament

Lachman test: Anterior cruciate ligament injury

Anterior drawer test Anterior cruciate ligament injury

Posterior drawer test posterior cruciate ligament injury



LIGAMENTAL INJURIES:TREATMENT OPTIONS

• In general, torn collateral ligaments heal without surgery whilst torn cruciate ligaments require surgery.

• Non pharmacology treatment: ACL performance brace

• Surgery: ligaments replacement with a graft.


Signs and symptoms:

• Presented with pain associated with trauma, mechanical symptoms and joints swelling.

• History of locking episodes.

Physical examination & diagnosis:

• Joint line tenderness & joint line pain with deep flexion associated with swelling / effusion over the point tenderness

MENISCUS INJURIES


SPECIFIC TESTS FOR MENISCUS INJURY

Specific

tests

How to perform the test Diagnosis

MC

MURRAY’S

TEST

• Physicians flexing the patient hip &

knee and palpating for a pop or click as

the tibia is externally or internally

rotated.

• Assess medial / lateral

meniscus tear

APLEY /

GRINDING

TEST

• Test was performed with patient in

prone position by rotating the tibia on

the femur and applying compression to

reproduce join line pain.

• Medial knee join line

tenderness indicates medial

meniscus tear & lateral knee

join line pain tenderness

indicates lateral meniscus

tear.



MENISCUS INJURY: TREATMENT OPTIONS

• Surgery: in general meniscus tear require arthroscopy surgery to maximize the shock absorption in the joint.

• Removal: if repair can’t be done, removal of the torn meniscus will be done and the particular cartilage will now take over the role of absorber.


Signs and symptoms

• joint pain, stiffness and reduced range of motions.

Physical examination & dignosis

• joint line tenderness, effusion & reduce range of movement

KNEE OSTEOARTHRITIS


KNEE ARTHRITIS: TREATMENT OPTIONS

Non surgical treatment:

• Anti- inflammatory medicines

• Supplements

• Braces

• Corticosteroids shots / therapeutics injections

• Viscosupplementation shots

• Weight loss

• Cane, crutches, walker

• Physiotherapy

Surgical treatment:

• Unicompartmental knee replacement

• Total knee replacement


KNEE ARTHRITIS

Red flags in knee pain:

• Systemic Complaints – fever, weight loss, pain at rest, night pain

When to refer

• Inability to bear weight

• Extreme of age

• Locking

• Bilateral knee pain

• Other joint involvement – e.g: Hip


SPECIFIC EXERCISES FOR KNEE ARTHRITIS


Thank you

Documents

Joint pain in primary care