Approach to a Patient with Joint Pain

Last updated: March 11, 2026

Table Of Contents

Overview
Differentials for Joint Pain
History
Polyarthropathy and Age
Periarticular vs. articular pain
Neurogenic pain
Referred pain
Inflammatory vs. non-inflammatory arthritis

Overview

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

Arthralgia
Arthritis
Synovitis
Tenosynovitis
Myositis
Enthesitis

Term	Definition
Arthralgia	Inflammation of tendon sheets, e.g. in fibrotic disease or gonococcal arthritis
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 at the site of attachment of a ligament, tendon, or capsule (pathognomonic for seronegative spondyloarthropathies)
Myositis	Inflammation of the muscle
Enthesitis	Inflammation of tendon sheets, e.g., in fibrotic disease or gonococcal arthritis

Differentials for Joint Pain

Classification	Differentials
Trauma	Gonococcal, non-gonococcal, Lyme disease, viral, tuberculosis, fungal
Infectious (septic)	Rheumatoid arthritis, Reiter’s syndrome, psoriatic arthritis, systemic lupus erythematosus, sjogren syndrome, ankylosing spondylitis, acute rheumatic fever
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 was 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 without 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 inflamed? (erythematous, warm, swollen)
- Chronicity: Is it a recent onset (acute) or an 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	SLE, Rheumatoid arthritis, psoriatic arthropathy, enteropathic arthropathy	Gout, generalised osteoarthritis, polymyalgia rheumatica
Middle age	Rheumatoid arthritis, sicca syndrome, generalised osteoarthritis, polymyositis rheumatica	Rheumatoid arthritis, sicca syndrome, generalised osteoarthritis, polymyagia rheumatic
Elderly	Polymyalgia rheumatic

Periarticular vs. articular pain

	Periarticular	Articular
Pain	Both active and passive movement are limited	All movements are painful
Range of movement	Active movement may be limited, but passive movement is full	Tenderness over the affected periarticular structure
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 is often normal, but the 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)

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

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