Approach to a Patient with Joint Pain

Overview

Joint pain is a common presentation across different demographics and can present as:

• Arthralgia
• Arthritis
• Synovitis
• Tenosynovitis
• Myositis
• Enthesitis

Term	Definition
Arthralgia	Pain that is at the joint or referred to the joint; muscle, tendon, bone e.g. enthesistis
Arthritis	Inflammation of the joint structure (a pathological process)
Synovitis	Inflammation of the synovial fluid. Any systemic inflammatory disease can cause synovitis (and arthralgia) since synovial fluid is an ultrafiltrate of the seru
Tenosynovitis	Inflammation of tendon sheets e.g. in fibrotic disease or gonococcal arthritis
Myositis	Inflammation of the muscle
Enthesitis	Inflammation at the site of attachment of a ligament, tendon or capsule (pathognomonic for seronegative spondyloarthropathies)

Differentials for Joint Pain

Classification	Differentials
Trauma	Sprain, strain, fracture, dislocation, tendon or ligament or meniscal tear, tendonitis
Infectious (septic)	Gonococcal, non-gonococcal, lyme disease, viral, tuberculosis, fungal
Crystal arthropathies	Gout, pseudogout
Degenerative	Osteoarthritis
Malignancy	Solid tumor metastasis, lymphoma, leukemia, osteosarcoma, osteochondroma
Inflammatory	Rheumatoid arthritis, reiter’s syndrome, psoriatic arthritis, systemic lupus erythematosus, sjogren syndrome, ankylosing spondylitis, acute rheumatic fever

History

In patients with joint pain, it is important to conduct thorough history taking, physical exam and investigations to identify the following 4 features of an articular syndrome:

• Inflammatory vs. non-inflammatory
• Temporal pattern: Acute vs. chronic
• Spatial pattern: Monoarthritis vs. polyarthritis, and whether there is axial involvement
• Presence of extra-articular or systemic manifestations (constitutional symptoms, eyes, skin, respiratory or CNS involvement, co-morbidities)

Joint pain can affect one or multiple joints. Monoarthritis refers to the involvement of one joint. Oligoarthritis/ pauciarthritis refers to 2 – 4 joints being involved. In polyarthritis, 5 or more joints are involved. It is also important to distinguish whether the joint pain was additive (one joint was affected before other joints followed) or migratory (one joint affected, resolves, and then another is affected).

• Screening questions
  • Do you have any pain or stiffness in your muscles, joints or back?
  • Can you dress yourself completely wihtout any difficulty?
  • Can you walk up and down the stairs comfortably?
• SLICE
  • Systemic symptoms: does the patient have other systemic symptoms e.g. fever, chills, fatigue, rash, etc.
  • Location: Which joint is sore? Is it one, some or multiple? Is it symmetrical or asymmetrical:
  • Inflammation: Is the joint inflammed? (erythematous, warm, swollen)
  • Chronicity: Is it a recent onset (acute) or insidious onset (chronic)? Does the pain come and go or is it constant? What time of day is the pain worse?
  • Evidence of trauma: Does the patient have any factors in their history that point to trauma?ain
• Duration
  • Acute: presentation within hours to days
  • Chronic: presentation for weeks or longer
• Location: joint, spine, muscle or bone
• Referred pain**:** common with disc prolapse, carpal tunnel syndrome
• Constant, intermittent or episodic
• Severity – aching
• Quality: neuropathic or arthritis

Polyarthropathy and Age

	Male	Female
Young	Reactive arthritis, ankylosing spondylitis, psoriatic arthropathy, enteropathic artropathy	SLE, Rheumatoid arthritis, psoriartic arthropathy, enteropathic arthropathy
Middle age	Gout, generalised osteoarthritis, polymyagia rheumatic	Rheumatoid arthritis, sicca syndrome, generalised osteoarthritis, polymyagia rheumatic
Elderly	Polymyalgia rheumatic

Periarticular vs. articular pain

	Periarticular	Articular
Pain	Only few selective movements are painful	All movements are painful
Range of movement	Active movement may be limited, but passive movement is full	Both active and passive movement is limited
Other features	Tenderness over affected periarticular structure	Tenderness over the joint line, crepitus, capsular swelling, effusion, warmth

Neurogenic pain

• Pain caused by abnormal neural activity secondary to injury, disease or dysfunction
• Often presents with dysesthesia (disrupted touch sensation)
• Range of motion often normal, but neurological exam may reveal abnormalities

Referred pain

• Pain is often unrelated to movement, has ‘visceral’ timing, is poorly localised, and may be relieved by rubbing the affected part.
• Range of motion is normal

Inflammatory vs. non-inflammatory arthritis

	Inflammatory arthritis	Non-inflammatory arthritis
Joint involvement	Small joints are often affected (MCP, DIP)	Involvement of larger joints e.g. hip, knee
Age	Younger age of onset (20 – 40 years)	Older age of onset
Onset	Rapid onset	Slow onset
Extra-articular symptoms	Extra-articular symptoms are common	No systemic symptoms
Symmetry	Symmetrical	Asymmetrical
Presentation	Painful, swollen, warm joints	Painful joints without swelling
Synovial fluid	WBC elevation in synovial fluid (> 2000 mm3) in septic arthritis	WBC elevation in synovial fluid (< 2000 mm3)