1. Dr. Sami S. Eid Consultant Family Medicine
Approach to Joint Pain
Dr. Sami S. Eid
Consultant Family Medicine

2. Objectives At the end of this session, the trainees should be able:
To know the pathophysiology of joint pain .
To list common causes of joint pain
To examine major joints (knee, ankle, hip, elbow, shoulder)
To provide a systematic approach to the investigation and differential diagnosis of patients presenting with joint pain.
To describe diagnosis and treatment of the important joint problems
Romatoid arthritis
Osteoarthritis
Gout arthritis
Septic arthritis
Tendonitis
To describe referral criteria for common joint problems

3. Pathophysiology There may be : There may be: The pain may occur :
Pain (arthralgia).
Inflammation (arthritis) - redness, warmth, and swelling
There may be:
Only a single joint involved (mono-articular).
Multiple joints involved.
The pain may occur :
Only with use, suggesting a mechanical problem (eg, osteoarthritis, tendinitis).
At rest, suggesting inflammation (eg, crystal disease, septic arthritis).
There may or may not be fluid within the joint (effusion).

4. Pathophysiology Joint pain may arise from:
Structures within the joint (intra-articular):
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
Inflammatory.
Infectious arthritis
Rheumatoid arthritis
Crystal deposition arthritis
Non-inflammatory
Osteoarthritis.
internal mechanical derangement

5. Joint pain may arise from (cont..)
Pathophysiology
Joint pain may arise from (cont..)
Structures adjacent or a round to the joint (peri-articular)
Bursitis
Tendinitis
Extra-articular disorders (eg, polymyalgia rheumatica, fibromyalgia).
Referred Pain from more distant sites

6. Basic principles 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?

7. 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)

8. 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

9. Aetiology of Joint Pain
Poly-articular Joint Pain
Acute polyarticular arthritis is most often due to the following:
Infection (usually viral)
Flare of a rheumatic disease
Chronic polyarticular arthritis in adults is most often due to the following:
RA (inflammatory)
Osteoarthritis (noninflammatory)
Chronic polyarticular arthritis in children is most often due to the following:
Juvenile idiopathic arthritis

10. Poly-articular disorders
Cause
Suggestive Findings
Diagnostic Approach*
Cause Suggestive Findings Diagnostic Approach
Acute rheumatic fever
Fever, cardiac symptoms and signs, and migrating inflammation of the large joints,
Specific clinical criteria (Jones criteria), antistreptolysin O titers, group A streptococcal antigen testing
Hemoglobinopathies
(eg, sickle cell disease or trait, thalassemias)
Symmetric pain in joints of hands and feet -Bone pain, avascular necrosis
Young patients of African or Mediterranean , often with known diagnosis
Hb electrophoresis
Juvenile idiopathic arthritis
Oligoarticular symmetric arthritis during childhood,.
ANA and RF testing
Lyme disease arthritis
Erythema migrans, fever, malaise, headache, and myalgias in days to weeks after tick bite
Serologic testing for antibodies against Borrelia burgdorferi
Other rheumatic diseases (eg, polymyositis/dermatomyositis, scleroderma, Sjögren's syndrome, polymyalgia rheumatica)
Depends on specific rheumatic disease and can include specific dermatologic manifestations, dysphagia, muscle soreness, or dry eyes and dry mouth
X-ray and various serologies (eg, ANA, RF testing, anti-SS-A, anti-SS-B, anti-Scl-70)
Sometimes skin or muscle biopsy
Psoriatic arthritis
Psoriasis, dactylitis (sausage digits), tendinitis, onychodystrophy
Clinical evaluation
Sometimes x-ray RA
Symmetric involvement of small and large joints
More prevalent among women
Specific clinical criteria, x-ray, anti-CCP, and RF testing
Septic arthritis (particularly that caused by Neisseria gonorrhea)
Acute, severe pain; redness; swelling
Higher index of suspicion in patients with risk factors for STDs
Arthrocentesis
Serum sickness
Fever, arthralgia, lymphadenopathy, and skin eruption 1–21 days after treatment with a biologic compound (eg, blood products, vaccines, protein concentrates)
SLE
Malar rash, oral ulcers, alopecia, history of serositis (eg, pleuritis pericarditis), RA-like polyarthralgia
Usually women
Serologic testing (eg, ANA, RF, anti-dsDNA)
Systemic vasculitis (eg, giant cell arteritis, Henoch-Schönlein purpura, hypersensitivity vasculitis, polyarteritis nodosa, Wegener's granulomatosis)
Various and sometimes vague extra-articular symptoms, including abdominal pain, renal failure, sinonasal pathology, and dermatologic lesions (eg rash, ulcers, purpura, nodules)
ESR
Biopsy of any suspected affected area (eg, kidney, skin)
Viral arthritis (particularly parvovirus but also enterovirus, adenovirus, Epstein-Barr, coxsackievirus, cytomegalovirus, rubella, mumps, hepatitis B, hepatitis C, varicella, HIV)
Less severe than septic arthritis
Malaise, lacy red malar rash, concomitant anemia in patients with parvovirus infection
Jaundice with hepatitis B
Systemic lymphadenopathy with HIV
Sometimes parvovirus serologies or other virologic testing based on clinical suspicion

11. Oligo-articular disorders
Ankylosing spondylitis‡
Back pain and symmetric involvement of the large joints, iritis, tendinitis, aortic insufficiency
More common among young adult males
X-ray
HLA-B27
Behçet's syndrome
Oral and genital ulcers, sometimes eye pain
Begins in the 20s
Specific clinical criteria
Crystal-induced arthritis§ (eg, uric acid, Ca pyrophosphate, Ca hydroxyapatite)
Acute onset of severe pain, redness, swelling (particularly in the great toe or knee for uric acid deposition)
Arthrocentesis
Fibromyalgia
Diffuse myalgias, tender muscular points not involving joints, fatigue, sometimes irritable bowel syndrome
Usually women
Specific clinical criteria (see Fig. 1: Bursa, Muscle, and Tendon Disorders: Diagnosing fibromyalgia )
Infective endocarditis
Fever, malaise, weight loss, heart murmur, embolic phenomena
Blood cultures
ESR
Transesophageal echocardiography
Osteoarthritis‡
Chronic pain usually in lower extremity joints, PIP and DIP joints, 1st carpometacarpal joint
Heberden's nodes, Bouchard's nodes
Reactive and enteropathic arthritis‡
Acute, asymmetric joint pain predominantly involving the lower extremities 1–3 wk after GI or GU infection (chlamydial urethritis)
Clinical evaluation
Sometimes X-ray, STD testing, stool cultures

12. Evaluation I - History Symptoms of joint disease Pain
Inflammatory joint disease
present both at rest and with motion.
It is worse at the beginning than at the end of usage.
Non-inflammatory joint disease(ie, degenerative, traumatic, or mechanical)
Occurs mainly or only during motion
Improves quickly with rest.
Patients with advanced degenerative disease of the hips, spine, or knees may also have pain at rest and at night.
Pain that arises from small peripheral joints tends to be more accurately localized than pain arising from larger proximal joints. For example, pain arising from the hip joint may be felt in the groin or buttocks, in the anterior portion of the thigh, or in the knee.

13. I - History Symptoms of joint disease
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 minutes or longer.
With noninflammatory arthritis, stiffness is experienced briefly (eg, 15 min) upon waking in the morning or following periods of inactivity.

14. 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.

15. Symptoms of joint disease
History
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."

16. Symptoms of joint disease
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.

17. Temporal pattern of arthritis
History
Temporal pattern of arthritis
The onset of symptoms can be abrupt or insidious.
With an abrupt onset, joint symptoms develop over minutes to hours. This may occur in:
trauma
crystalline synovitis
infection.
With an insidious pattern, joint symptoms develop over weeks to months.
It is typical of most forms of arthritis, including rheumatoid arthritis (RA) and osteoarthritis.
Duration of symptoms is considered either acute or chronic.
Acute is less than 6 weeks in duration
chronic is 6 or more weeks in duration.

18. Temporal pattern of arthritis
History
Temporal pattern of arthritis
The temporal patterns of joint involvement are migratory, additive or simultaneous, and intermittent.
With a migratory pattern, inflammation persists for only a few days in each joint (eg, acute rheumatic fever, disseminated gonococcal infection).
With an additive or simultaneous pattern, inflammation persists in involved joints as new ones become affected.
With an intermittent pattern, episodic involvement occurs, with intervening periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis).

19. History Number of involved joints Symmetry of joint involvement
Monoarthritis is the involvement of one joint.
Oligoarthritis is the involvement of 2-4 joints.
Polyarthritis is the involvement of 5 or more joints.
Symmetry of joint involvement
Symmetric arthritis is characterized by involvement of the same joints on each side of the body. This symmetry is typical of RA and SLE.
Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

20. History Distribution of affected joints
The distal interphalangeal joints of the fingers are usually involved in psoriatic arthritis, gout, or osteoarthritis but are usually spared in RA.
Joints of the lumbar spine are typically involved in ankylosing spondylitis but are spared in RA.
Distinctive types of musculoskeletal involvement
Spondyloarthropathy involves entheses, leading to heel pain (inflammation at the insertions of the Achilles tendon and/or plantar fascia), dactylitis (sausage digits), tendonitis, and back pain (sacroiliitis and vertebral disc insertions).
Gout commonly involves tendon sheaths and bursae, resulting in superficial inflammation.

21. History Extra-articular manifestations
Constitutional symptoms suggest an underlying systemic disorder and are not expected in patients with degenerative joint disease. These may include fatigue, malaise, and weight loss.
Skin lesions may be present. Physical examination of the skin, but not the joints, may indicate the specific diagnosis of a number of rheumatic diseases. Examples include SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum.
Ocular symptoms or signs are also possible. Episcleritis and scleritis may be associated with RA or Wegener granulomatosis, anterior uveitis with ankylosing spondylitis, and iridocyclitis with juvenile RA. Conjunctivitis may be caused by reactive arthritis.

22. Common Causes of Acute Monoarthritis
Bacterial Infection of the Joint Space I
Non-gonococcal : S. aureus, BHSC, S. pneumonia, G-ve. II
Gonococcal : precided by migratory tenosynovitis + Skin lesions
Crystal-induced Arthritis
Gout (monosodium urate crystals)
Pseudogout (calcium pyrophosphate dihydrate crystals)
Trauma
Current Rheumatology Diagnosis & treatment

23. Differential Diagnosis of Chronic Monoarthritis
Ch. Inflammatory MA
Ch. Non-inflammatory MA
Infection
Non-gonococcal septic arthritis
Gonococcal
Chronic Lyme disease
Mycobacterial
Fungal
Viral
Crystl-induced arthritis
Gout
Peudogout
Calcium apatite crystals
Monoarticular presentation of oligoarthritis or polyathritis
Spodyloarthropathy
Rheumatoid arthritis
Lupus & other systemic autoimmune diseases
Sarcoidosis
Uncommon or Rare
Familial Mediterranean fever
Amyloidosis
Foreign-body (due to plant thorn, wood fragments, etc)
Pigmented villonodular synovitis
Osteoarthritis
Internal derangments (e.g. torn meniscus)
Chondromalacia patellae
Osteonecrosis
Uncommon or rare
Neuropathic (Charcot) arthropathy
Sarcoidosis
Amyloidosis
Current Rheumatology Diagnosis & treatment

24. Evaluation II – 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.

25. 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)

26. 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

27. Differential Diagnosis of Oligoathritis
Acute Oligoarthritis
Chronic Oligoarthritis
Inflammatory Causes
Common
Spondylarthropathy
Reactive arthritis
Anklosing Spondylitis
Psoriatic arthritis
Inflammatory bowel disease
Atypical presentation of rheumatoid arthritis
Gout
Uncommon or rare
Subacute bacterial endocarditis
Sarcoidosis
Behcet disease
Relapsing polychondritis
Celiac disease
Non-inflammatory Causes
Osteoarthritis
Hypothyroidism
Amyloidosis
Infection
Dissaminated gonococcal infection
Non-gonococcal septic arthritis
Bacterial endocarditis
Viral
Postinfection
Reactive arthritis
Rheumatic fever
Spondyloarthropathy
Anklosing spondylitis
Psoriatic arthritis
Inflammatory bowel disease
Oligoarticular presentation of rheumatoid arthritis, SLE, adult Still disease or other polyarthritis
Gout and pseudogout
Current Rheumatology Diagnosis & treatment

28. Differential Diagnosis of Polyathritis
Acute Polyarthritis
Chronic 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
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
Current Rheumatology Diagnosis & treatment

29. Some Suggestive Findings in Polyarticular Joint Pain
Possible Cause
General findings
Bone tenderness or chest pain
Sickle cell crisis
Coexisting tendinitis
Gonococcal or rheumatoid disease
Conjunctivitis, abdominal pain, and diarrhea
Reactive arthritis
Fever and malaise
Infection, gout, rheumatic disorders, vasculitis
Malaise and lymphadenopathy
Acute HIV infection
Oral and genital ulcer
Behçet's syndrome
Raised silver plaques
Psoriatic arthritis
Recent pharyngitis and migrating joint pain
Rheumatic fever
Recent vaccination or blood product
Serum sickness
Skin ulcerations, rash, and abdominal pain
Vasculitis
Tick bites
Lyme arthritis
Urethritis
Gonococcal or reactive arthritis
Merck Manual Minute

30. Investigations Urinalysis Haematology - FBC, ESR, clotting
Biochemistry - U&E, LFTs, urate, CRP
Immunology
Microbiology
blood/urine/stool/urethral/sputum cultures
serology

31. Investigations Synovial fluid Imaging 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

32. Categorization of Synovial Fluid
White blood cell count
Polymorphonuclear neutrophilic leukocytes
Examples
Normal
0 to 200 per mm3 (0 to per L)
<25% (0.25) --
Non-inflammatory
<2,000 per mm3 (2 X 109 per L)
Osteoarthritis, internal derangement, myxedema
Inflammatory
2,000 to 50,000 per mm3 (2 to per L)
>75% (0.75)
Rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, Neisseria gonorrhoeae infection
Septic
>50,000 per mm3 (50 X 109 per L); usually >100,000 per mm3 (100 X 109 per L)
Usually >90% (0.90)
Septic arthritis (primary concern); occasionally, gout, pseudogout, reactive arthritis, Lyme disease

33. Evaluation
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34. Management General Infection Haemarthrosis 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

35. Management Reactive arthritis Crystal 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

36. Management Sero-negative spondyloarthritis Osteoarthritis
joint injection (steroid and LA)
DMARD if chronic
surgery (synovectomy, replacement)
Osteoarthritis
education, wt loss, physio
joint injection (steroid/LA or hyuralonate)
surgery

37. Thanks
Dr. Sami eid