Approach To Joint Pain

Approach to
Joint Pain
Shamaila misbah
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?
Aetiology of Joint Pain
Mono-articular Pain
• Trauma :
• Internal derangement or intra-
articular trauma
• Infectious or Septic arthritis
• Reactive arthritis (Aseptic
inflammatory arthritis).
• Crystal-induced disease
• Periarticular syndromes (eg, bursitis,
epicondylitis, fasciitis, tendinitis,
tenosynovitis)
Mono-articular Pain
• Uncommon Causes :
– Avascular necrosis
– Neuropathy (Charcot ‘s Joint).
– Osteoarthritis
– Osteomyelitis.
– Lyme disease.
– Tumor
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)
Evaluation
I - History
Symptoms of joint disease
 Pain
o Inflammatory joint disease
o present both at rest and with motion.
o It is worse at the beginning than at the end of
usage.
Pain
o Non-inflammatory joint disease(ie, degenerative, traumatic, or

mechanical)
o Occurs mainly or only during motion
o Improves quickly with rest.
o Patients with advanced degenerative disease of the hips, spine,
or knees may also have pain at rest and at night.
I - History
 Stiffness
– Stiffness is a perceived sensation of
tightness when attempting to move
joints after a period of inactivity.
inflammatory arthritis,
the stiffness is present upon waking
and typically lasts 30-60 minutes or
longer.
non inflammatory arthritis, stiffness
is experienced briefly (eg, 15 min)
upon waking in the morning
I - History
 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. Mild
degrees of soft tissue swelling do occur and are
related to synovial cysts, thickening, or
effusions.
History
 Limitation of motion
• Loss of joint motion may be due to
structural damage, inflammation, or
contracture of surrounding soft
tissues.
 Weakness
• Muscle strength is often diminished
around an arthritic joint as a result of
disuse atrophy.
• Manifestations include decreased grip
strength, difficulty rising from a chair
or climbing stairs, and the sensation
that a leg is "giving way."
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:
o trauma
o crystalline synovitis
o infection.
 With an insidious pattern, joint symptoms
develop over weeks to months.
o It is typical of most forms of arthritis,
including rheumatoid arthritis (RA) and
osteoarthritis.
 Duration of symptoms is considered either acute or
chronic.
o Acute is less than 6 weeks in duration
o chronic is 6 or more weeks in duration.
History
Temporal pattern of arthritis
 The temporal patterns of joint involvement are migratory,
additive or simultaneous, and intermittent.
o With a migratory pattern,

(eg, acute rheumatic fever, disseminated
gonococcal infection).
o With an additive or simultaneous

pattern.
o With an intermittent pattern, episodic

involvement occurs, (eg, gout,
pseudogout, Lyme arthritis).
History
 Number of involved joints
o Monoarthritis is the involvement of one joint.
o Oligoarthritis is the involvement of 2-4 joints.
o Polyarthritis is the involvement of 5 or more joints.
 Symmetry of joint involvement

o Symmetric arthritis is characterized by involvement of the same
joints on each side of the body. This symmetry is typical of RA
and SLE.
o Asymmetric arthritis is characteristic of psoriatic arthritis,
reactive arthritis (Reiter syndrome), and Lyme arthritis.
History
 Distribution of affected joints
o The distal interphalangeal joints of the fingers are usually
involved in psoriatic arthritis, gout, or osteoarthritis but are
usually spared in RA.
o Joints of the lumbar spine are typically involved in ankylosing

spondylitis but are spared in RA.
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.
Extra-articular manifestations
 Skin lesions may be present in 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.
Mechanical vs. Inflammatory Arthritis
Latinis, K., et al
The Washington
Manual
Rheumatology
Subspecialty
Consult., LWW,
2003.
Categorization of Synovial Fluid
Polymorphonuclear
Categorization White blood cell count neutrophilic leukocytes Examples
Normal 0 to 200 per mm3 (0 to 0.2 3 109 per L) <25% (0.25) --
Osteoarthritis, internal
Non-inflammatory <2,000 per mm3 (2 X 109 per L) <25% (0.25) derangement, myxedema
Rheumatoid arthritis, psoriatic

Inflammatory 2,000 to 50,000 per mm3 (2 to 50 3 109 >75% (0.75) arthritis, gout, pseudogout,
per L) Neisseria gonorrhoeae infection
Septic arthritis (primary

Septic >50,000 per mm3 (50 X 109 per
L); Usually >90% (0.90) concern); occasionally, gout,
usually >100,000 per mm3 (100 X 109 pseudogout, reactive arthritis,
per L) Lyme disease
OSTEOARTHRITIS
OSTEOARTHROSIS
DEGENERATIVE JOINT DISEASE

DEFINITION
 Osteoarthritis OA is a degenerative disease

of diarthrodial (synovial) joints,
characterized by
 Breakdown of articular cartilage
 and proliferative changes of surrounding
bones
EPIDEMIOLOGY
 Osteoarthritis(OA) is the most common joint

disease
 OA of the knee joint is found in 70% of the
population over 60 years of age
 Radiological evidence of OA can be found in over
90 % of the population
CHARACTERISTICS OF OA
 OA is a chronic disease of the musculoskeletal

system, without systemic involvement
 OA is mainly a noninflammatory disease of
synovial joints
 No joint ankylosis is observed in the course of the
disease
CLASSIFICATION OF OA
 Primary OA Secondary OA Erosive (hand)OA
Etiology is unknown Etiology is known runs in families,

Risks for OA
 Advanced Age
 Female
 Genetics
 Obesity
 Occupation (overuse)
 Trauma
Symptoms and Signs
Square thumb
First MTP Osteoarthritis
Hallux
valgus with
bunion
RA Vs. OA
Features Rheumatoid Arthritis Osteoarthritis
Age of onset Can happen at any age Usually later in life
Speed of onset Rapid- weeks to months Slow- over years
Distribution Symmetrical polyarthritis Initially asymmetrical

monoarthritis
polyarthritis
Joints affected Small joints of hands and Weight bearing joints-
feet knees, hips
Duration of morning Stiffness worse in the Stiffness <1hour and worse
stiffness morning >1hour at the end of the day
(after activity)
Systemic symptoms Fatigue, fever, night -
sweats
Investigation
 Bloods
 FBC, U&Es, LFTs, ESR, CRP
 Imaging- 4 cardinal signs on Xray?

 Subchondrial sclerosis
 Osteophytes
 Narrowing of joint space

 Subchondrial cysts
Osteoarthritis: Management
 Non-Pharmacologic
 Exercises
 Strengthening
 Splinting
 Pharmacologic
 Oral Medications
 Topical Medications
 Injectable Medications
 Alternative/Complimentary Choices
 Surgery
Goals of Treatment
1. Pain Reduction
2. Improved Function
3. Changes the Disease
Outcome
4. Low Cost
5. Low Side Effects
Strength Training
Proper Footwear
Assistive Devices
Physical & Occupational Therapy
Exercise & Weight Loss

Education
Topical Medications
1. Capsaicin
2. Topical Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs)
Pennsaid, Diclofenac
Intra-Articular Corticosteroids
Pros
 Cheap
 Relatively Safe: 1 in 15-20,000 risk of infection
 Safe to do 4 injections in a single joint per year
Cons
 Short term benefit at 4 to 8 weeks but
negative at 12 and 24 weeks
Oral Medications
1. Simple Analgesics
2. Non-Steroidal Anti-Inflammatory
Medications (NSAIDs)
3. Narcotic Analgesics and non-narcotic
(tramadol)
4. Complimentary Therapy (Glucosamine)
Surgery for Osteoarthritis

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Approach to

• Is the problem acute or chronic?

• Acute polyarticular arthritis is most

o Non-inflammatory joint disease(ie, degenerative, traumatic, or

– With noninflammatory arthritis, the formation

o With a migratory pattern,

o With an additive or simultaneous

o With an intermittent pattern, episodic

 Symmetry of joint involvement

o Joints of the lumbar spine are typically involved in ankylosing

 Skin lesions may be present in SLE, dermatomyositis,

 Ocular symptoms or signs are also possible. Episcleritis

Normal 0 to 200 per mm3 (0 to 0.2 3 109 per L) <25% (0.25) --

Rheumatoid arthritis, psoriatic

Septic arthritis (primary

DEGENERATIVE JOINT DISEASE

 Osteoarthritis OA is a degenerative disease

 Osteoarthritis(OA) is the most common joint

 OA is a chronic disease of the musculoskeletal

 Primary OA Secondary OA Erosive (hand)OA

Etiology is unknown Etiology is known runs in families,

Features Rheumatoid Arthritis Osteoarthritis

Age of onset Can happen at any age Usually later in life

Speed of onset Rapid- weeks to months Slow- over years

Distribution Symmetrical polyarthritis Initially asymmetrical

 Imaging- 4 cardinal signs on Xray?

 Narrowing of joint space

Physical & Occupational Therapy

Exercise & Weight Loss

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