Presentation on theme: "Dr. Sami S. Eid Consultant Family Medicine"— Presentation transcript:
1 Dr. Sami S. Eid Consultant Family Medicine Approach to Joint PainDr. Sami S. EidConsultant 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 painTo 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 problemsRomatoid arthritisOsteoarthritisGout arthritisSeptic arthritisTendonitisTo 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 swellingThere 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 endingsInflammatory.Infectious arthritisRheumatoid arthritisCrystal deposition arthritisNon-inflammatoryOsteoarthritis.internal mechanical derangement
5 Joint pain may arise from (cont..) PathophysiologyJoint pain may arise from (cont..)Structures adjacent or a round to the joint (peri-articular)BursitisTendinitisExtra-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 PainTrauma : ( overuse – fractures – hemarthrosis). Most common – to all agesInternal 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 PainUncommon Causes :Avascular necrosis (H/O corticosteriod use or sickle cell anaemia)Neuropathy (Charcot ‘s Joint).OsteoarthritisOsteomyelitis.Lyme disease.Paget’s disease (Osteitis deformans)Tumor
9 Aetiology of Joint Pain Poly-articular Joint PainAcute polyarticular arthritis is most often due to the following:Infection (usually viral)Flare of a rheumatic diseaseChronic 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 CauseSuggestive FindingsDiagnostic Approach*Cause Suggestive Findings Diagnostic ApproachAcute rheumatic feverFever, cardiac symptoms and signs, and migrating inflammation of the large joints,Specific clinical criteria (Jones criteria), antistreptolysin O titers, group A streptococcal antigen testingHemoglobinopathies(eg, sickle cell disease or trait, thalassemias)Symmetric pain in joints of hands and feet -Bone pain, avascular necrosisYoung patients of African or Mediterranean , often with known diagnosisHb electrophoresisJuvenile idiopathic arthritisOligoarticular symmetric arthritis during childhood,.ANA and RF testingLyme disease arthritisErythema migrans, fever, malaise, headache, and myalgias in days to weeks after tick biteSerologic testing for antibodies against Borrelia burgdorferiOther 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 mouthX-ray and various serologies (eg, ANA, RF testing, anti-SS-A, anti-SS-B, anti-Scl-70)Sometimes skin or muscle biopsyPsoriatic arthritisPsoriasis, dactylitis (sausage digits), tendinitis, onychodystrophyClinical evaluationSometimes x-rayRASymmetric involvement of small and large jointsMore prevalent among womenSpecific clinical criteria, x-ray, anti-CCP, and RF testingSeptic arthritis (particularly that caused by Neisseria gonorrhea)Acute, severe pain; redness; swellingHigher index of suspicion in patients with risk factors for STDsArthrocentesisSerum sicknessFever, arthralgia, lymphadenopathy, and skin eruption 1–21 days after treatment with a biologic compound (eg, blood products, vaccines, protein concentrates)SLEMalar rash, oral ulcers, alopecia, history of serositis (eg, pleuritis pericarditis), RA-like polyarthralgiaUsually womenSerologic 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)ESRBiopsy 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 arthritisMalaise, lacy red malar rash, concomitant anemia in patients with parvovirus infectionJaundice with hepatitis BSystemic lymphadenopathy with HIVSometimes 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 insufficiencyMore common among young adult malesX-rayHLA-B27Behçet's syndromeOral and genital ulcers, sometimes eye painBegins in the 20sSpecific clinical criteriaCrystal-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)ArthrocentesisFibromyalgiaDiffuse myalgias, tender muscular points not involving joints, fatigue, sometimes irritable bowel syndromeUsually womenSpecific clinical criteria (see Fig. 1: Bursa, Muscle, and Tendon Disorders: Diagnosing fibromyalgia )Infective endocarditisFever, malaise, weight loss, heart murmur, embolic phenomenaBlood culturesESRTransesophageal echocardiographyOsteoarthritis‡Chronic pain usually in lower extremity joints, PIP and DIP joints, 1st carpometacarpal jointHeberden's nodes, Bouchard's nodesReactive and enteropathic arthritis‡Acute, asymmetric joint pain predominantly involving the lower extremities 1–3 wk after GI or GU infection (chlamydial urethritis)Clinical evaluationSometimes X-ray, STD testing, stool cultures
12 Evaluation I - History Symptoms of joint disease Pain Inflammatory joint diseasepresent 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 motionImproves 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 StiffnessStiffness 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 SwellingWith 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 HistorySymptoms of joint diseaseLimitation of motionLoss 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.WeaknessMuscle 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 HistorySymptoms of joint diseaseFatigueFatigue 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 HistoryTemporal pattern of arthritisThe onset of symptoms can be abrupt or insidious.With an abrupt onset, joint symptoms develop over minutes to hours. This may occur in:traumacrystalline synovitisinfection.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 durationchronic is 6 or more weeks in duration.
18 Temporal pattern of arthritis HistoryTemporal pattern of arthritisThe 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 involvementSymmetric 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 involvementSpondyloarthropathy 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 SpaceINon-gonococcal : S. aureus, BHSC, S. pneumonia, G-ve.IIGonococcal : precided by migratory tenosynovitis + Skin lesionsCrystal-induced ArthritisGout (monosodium urate crystals)Pseudogout (calcium pyrophosphate dihydrate crystals)TraumaCurrent Rheumatology Diagnosis & treatment
23 Differential Diagnosis of Chronic Monoarthritis Ch. Inflammatory MACh. Non-inflammatory MAInfectionNon-gonococcal septic arthritisGonococcalChronic Lyme diseaseMycobacterialFungalViralCrystl-induced arthritisGoutPeudogoutCalcium apatite crystalsMonoarticular presentation of oligoarthritis or polyathritisSpodyloarthropathyRheumatoid arthritisLupus & other systemic autoimmune diseasesSarcoidosisUncommon or RareFamilial Mediterranean feverAmyloidosisForeign-body (due to plant thorn, wood fragments, etc)Pigmented villonodular synovitisOsteoarthritisInternal derangments (e.g. torn meniscus)Chondromalacia patellaeOsteonecrosisUncommon or rareNeuropathic (Charcot) arthropathySarcoidosisAmyloidosisCurrent 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 Generalgeneral condition, fever, pulse, BPArticular or extra-articularJoint Inflammationswollen, red, , tender, hotFunctional impairmentpassive and active movementCrepitus during active or passive range of motionInstabilityJoint Deformity (flexion, subluxation, dislocation)
26 II – Physical Examination Other joints (including spine)Extra-articular featuresnails (pitting, ridging, hyperkeratosis)enthesitis, dactylitis and tenosynovitisnodules (elbows/ears)skin (local infection, psoriasis, keratoderma blenorrhagicum, balanitis)eyes (conjunctivitis, uveitis)mouth ulcers
27 Differential Diagnosis of Oligoathritis Acute OligoarthritisChronic OligoarthritisInflammatory CausesCommonSpondylarthropathyReactive arthritisAnklosing SpondylitisPsoriatic arthritisInflammatory bowel diseaseAtypical presentation of rheumatoid arthritisGoutUncommon or rareSubacute bacterial endocarditisSarcoidosisBehcet diseaseRelapsing polychondritisCeliac diseaseNon-inflammatory CausesOsteoarthritisHypothyroidismAmyloidosisInfectionDissaminated gonococcal infectionNon-gonococcal septic arthritisBacterial endocarditisViralPostinfectionReactive arthritisRheumatic feverSpondyloarthropathyAnklosing spondylitisPsoriatic arthritisInflammatory bowel diseaseOligoarticular presentation of rheumatoid arthritis, SLE, adult Still disease or other polyarthritisGout and pseudogoutCurrent Rheumatology Diagnosis & treatment
28 Differential Diagnosis of Polyathritis Acute PolyarthritisChronic PolyarthritisCommonAcute viral infectionsEarly disseminated Lyme diseaseRheumatoid diseaseSystemic lupus erythematosusUncommon or rareParaneoplastic polyarthritisRemitting seronegative symmetric polyarthritis with pitting edema (RS3PE)Acute SarcoidosisAdult onset Still diseaseSecondary SyphilisSystemic autoimmune diseases & vasculitidesWhipple diseaseInflammatory CausesCommonRheumatoid arthritisSystemic lupus erythematosusSpondylarthropathy (esp. psoriatic arthritis)Chronic hepatitis C infectionGoutDrug-induced lupus syndromesUncommon or rareParaneoplastic polyarthritisRemitting seronegative symmetric polyarthritis with pitting edema (RS3PE)Adult onset Still diseaseSystemic autoimmune diseases & vasculitidesSjogren syndromeViral inections other than hepatitis CWhipple diseaseNon-inflammatory CausesPrimary generalised osteoarthritisHemochromatosisCalcium pyrophosphate deposition diseaseCurrent Rheumatology Diagnosis & treatment
29 Some Suggestive Findings in Polyarticular Joint Pain Possible CauseGeneral findingsBone tenderness or chest painSickle cell crisisCoexisting tendinitisGonococcal or rheumatoid diseaseConjunctivitis, abdominal pain, and diarrheaReactive arthritisFever and malaiseInfection, gout, rheumatic disorders, vasculitisMalaise and lymphadenopathyAcute HIV infectionOral and genital ulcerBehçet's syndromeRaised silver plaquesPsoriatic arthritisRecent pharyngitis and migrating joint painRheumatic feverRecent vaccination or blood productSerum sicknessSkin ulcerations, rash, and abdominal painVasculitisTick bitesLyme arthritisUrethritisGonococcal or reactive arthritisMerck Manual Minute
32 Categorization of Synovial Fluid White blood cell countPolymorphonuclear neutrophilic leukocytesExamplesNormal0 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, myxedemaInflammatory2,000 to 50,000 per mm3 (2 to per L)>75% (0.75)Rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, Neisseria gonorrhoeae infectionSeptic>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