Approach to Joint Pain

Dr. Tahir BashirDr. Tahir BashirAssistant Professor Medical Unit-IVAssistant Professor Medical Unit-IV

SIMSSIMS

There may be :o Pain (arthralgia).o Inflammation (arthritis) - redness, warmth, and

swelling There may be:

o Only a single joint involved (mono-articular).o Multiple joints involved.

The pain may occur :o Only with use, suggesting a mechanical problem

(eg, osteoarthritis, tendinitis).o At rest, suggesting inflammation (eg, crystal

disease, septic arthritis). 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

o Non-inflammatory Osteoarthritis. internal mechanical derangement

Pathophysiology

Joint pain may arise from (cont..) Structures adjacent or a round to the joint (peri-

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

fibromyalgia). Referred Pain from more distant sites

Pathophysiology

• 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?

Basic principles

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.– Paget’s disease (Osteitis deformans)– Tumor

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.

I - History Symptoms of joint disease

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

Number of involved joints o Monoarthritis is the involvement of one joint. o Oligoarthritis is the involvement of 2-4 joints. o Polyarthritis is the involvement of 5 or more

joints.

Symmetry of joint involvement o Symmetric arthritis is characterized by

involvement of the same joints on each side of the body. This symmetry is typical of RA and SLE.

o Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

History

Common Causes of Acute Monoarthritis

EvaluationII – 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 PolyarthritisAcute Polyarthritis

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

• Uncommon or rare 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 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

• Non-inflammatory Causes Primary generalised osteoarthritis Hemochromatosis Calcium pyrophosphate deposition disease

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

Evaluation

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• Crystal arthritis

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

Management

• Sero-negative spondyloarthritis joint injection (steroid and LA) DMARD if chronic surgery (synovectomy, replacement)

• Osteoarthritis education, wt loss, physio joint injection (steroid/LA or

hyuralonate) surgery