1. Rheumatology: Approach to a Patient with Joint Pain

2. Objectives
To distinguish between articular (joint) vs periarticular (around a joint) pain
To differentiate arthralgia from arthritis
To distinguish between inflammatory and non-inflammatory joint complaints
To develop differential diagnoses of inflammatory , non-inflammatory arthritides, acute monoarthritis and polyarthritis

3. A 65-year-old female comes to the clinic for evaluation of right elbow pain. On examination, there is no swelling or tenderness of the elbow joint, but the olecranon bursa is noted to be swollen and tender. This is an example of:
Artricular pain
Periartricular pain
Referred pain
Neuropathic pain

4. Is the process articular or periarticular?
Artricular pain is true joint pain
Periarticular pain is defined as pain in structures around a joint eg. Tendinitis , bursitis , enthesitis
Referred pain is defined as pain that is referred to a location distant from the site of origin of pathology
Patients with pain in structures around a joint, (i.e., periarticular pain), can also present to you with the chief complaint of 'joint pain
Differential diagnosis of true articular process is very different from that of a periarticular process. '

5. Diagrammatic illustration of a joint and periarticular structures
Tendon –tough band of connective tissue that connects ms to bone ( Eg achillis tendon ) , Enthesitis – connective ts that attaches a tendon or ligament to bone , ligament bone to bone ( patellofemoral loigament ) , bursa is fluid filled space , provides as a cushion and free movement around the joint
Artricular – structures within the joint capsule / perarticular –structures outside the joint capsule

6. Periartricular pain

9. Articular, periarticular and referred pain

10. Hip pain

11. A 25-year-old female is seen in your clinic for evaluation of fatigue and diffuse joint pains. She reports pain in bilateral wrists, shoulders, MCPs and PIP joints. To diagnose this patient with arthralgia, she must have:
Heat in joints
Swelling in joints
Tenderness in joints
Redness in joints

12. Arthralgia vs. Arthritis
Arthralgia – Joint pain with tenderness
-No inflammation
Arthritis –Joint inflammation or structural damage
May not necessarily imply joint disease 
True joint disease

13. Causes of Arthralgia Systemic causes Articular causes Depression
Fibromyalgia
Thyroid disorders
Infections (viral infections , influenza)
Repetitive use of joint
Mechanical injury
Early osteoarthritis
Early presentation of rheumatic diseases
Treatment of underlying Disease will help resolve the joint pains

14. Distinguishing Arthralgia from Arthritis
Swelling is the most reliable clinical sign of arthritis

15. Inflammatory from non-inflammatory arthritis
Distinguishing inflammatory from non-inflammatory arthritis is a key branching point in evaluation of any patient with arthritis because it helps us
Formulate a differential diagnosis
Define further diagnostic workup
Decide whether your patient needs to be referred to rheumatology, orthopedics or can be managed in the primary care setting
By inflammatory arthritis, we mean that the joint inflammation or damage is driven primarily by the immune system (because of either autoimmune, crystalline or infectious causes). On the other hand, non-inflammatory arthritis, such as osteoarthritis, is primarily caused by cartilage damage due to aging, repetitive injury, or trauma to the structures in the joint

16. Differentiating inflammatory from non-inflammatory arthritis

17. Causes of inflammatory arthritis

18. Causes of non- inflammatory arthritis

19. So far ..

20. Using the history to diagnose a patient with a joint complaint
Questions to ask :
Q1: Exact location of pain ?
Q2: When is the pain/swelling/stiffness in the joints worst?
Q3: Do the joint symptoms improve with activity?
Q4: Do you have morning stiffness (i.e., joints are stiff in the mornings)? Does it last for less than or greater than 60 minutes?

21. Specific questions
Pain in front of shoulder /side of arm on activities such as combing hair
Rotator cuff impingement /tear
Pain in medial elbow with wrist flexion such as shaking hands , carrying suitcase
Medial epicondylitis ( Golfer’s elbow /Pitcher’s Elbow)
Pain on lateral elbow with wrist extension : using screwdriver , turning door knobs
Lateral Epicondylitis( Tennis Elbow )
Pain on dorsal thumb tendons with grasping
DeQuervain tenosynovitis
Pain on patella with kneeling
Prepatellar bursitis ( Clergyman’s knee or Housemaid’s Knee )
Pain on lateral thigh while sleeping on that side
Trochanteric bursitis
Pain along the back of heel and foot with stretching of ankle or standing on toes
Achilles Tendonitis
Pain in bottom of feet with first steps in morning
Plantar fascitis

22. Specific questions Pain in groin area / outer thigh when :
Getting into or out of the car
Getting into bath tub
Difficulty in bending over while sitting to tie shoe laces
Most likely To be caused by Hip joint
Pain in front of knee walking Up or downstairs ,Getting up from chair or kneeling or squatting
Knee Joint
Pain in buttock or leg with standing and walking that improved with rest and leaning forward on grocery cart
Back ( spinal stenosis )

23. The physical exam: Arthralgia vs. arthritis
LOOK – For redness, swelling or deformity
TOUCH - For heat or warmth
PALPATE - For tenderness or effusion/swelling
MOVE – To assess tenderness and limitation of range of motion in the joint
The presence of any one of these-swelling, warmth or erythema is diagnostic of arthritis, but the absence of all of these is diagnostic of arthralgia

24. Likely diagnosis by physical exam of joints
Bony enlargement , Heberden nodes , Bouchard nodes , crepitus on motion
Osteoarthritis
Acute onset erthema and warmth
Gout , septic arthritis , injury /trauma
Ulnar deviation , Boutonniere deformities
Rheumatoid arthritis
Dactylitis
Psoriatic arthritis , spondyloarthritis , Gout

26. Subcutaneous nodules
RA , SLE , acute Rheumatic fever
Subcutaneous Tophi
Gout
Skin Psoriasis, Nail bed pitting
Psoriatic arthritis
Viral exanthem
Viral Arthritis
Malar rash , alopecia , oro-nasal ulcers
SLE
Sclerodactaly , telengectasias
Scleroderma
Splinter H’ages , Janeway lesions
Subacute bacterial endocarditis
Scleritis
RA , SLE , vasculitis

27. Patterns of joint complaints

28. Summary of diagnosis by pattern of presentation

29. Thank you