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) |