Joint Pain

Aka: Joint Pain, Arthralgia, Joint Stiffness, Joint Swelling, Arthropathy, Arthritis, Inflamed joint, Joint Pain Causes, Arthralgia Causes

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II. Definitions

  1. Arthritis
    1. Joint inflammation
  2. Arthralgia
    1. Joint Pain without inflammation

III. History: General

  1. See Monoarticular Arthritis
  2. See Polyarticular Arthritis
  3. Duration
    1. Acute (<2 to 6 weeks of symptoms)
    2. Subacute (2 to 6 weeks of symptoms)
    3. Chronic (>6 weeks of symptoms)
  4. Number of joints involved
    1. Monoarticular Arthritis
    2. Pauciarticular (Oligoarticular, 2-4 joints involved)
    3. Polyarticular Arthritis
    4. Migratory Arthritis
  5. Symmetric or Asymmetric (Polyarticular)
    1. Symmetric Polyarticular Arthritis
    2. Asymmetric Polyarticular Arthritis
  6. Course
    1. Intermittent
    2. Constant
  7. Distribution
    1. Spine and sacroiliac joints
    2. Medium and large joints (Shoulder, elbows, hips, knees)
    3. Small joints (wrists, fingers, toes)
  8. Joint inflammatory findings (synovitis or inflammatory Arthritis)
    1. Joint Swelling
    2. Joint erythema
    3. Prolonged morning Joint Stiffness (>1 hour)
    4. Pain and stiffness is better with activity and worse with rest
    5. Symmetric Polyarthritis

IV. History: Exposures and past medical history

  1. Triggers
    1. Joint Trauma (e.g. Traumatic Arthrotomy)
    2. Overuse
  2. Underlying conditions
    1. Prior affected joint surgery or procedures
  3. Infectious Disease
    1. Hepatitis C
    2. Human Immunodeficiency Virus (HIV)
    3. Lyme Disease
    4. Parvovirus B19
    5. Sexually Transmitted Infection (e.g. Gonorrhea, Syphilis)
  4. Drug Induced lupus examples
    1. Hydralazine (most common cause)
    2. Procainamide
    3. Isoniazid
    4. Minocycline
    5. Terbinafine
    6. Phenytoin
    7. Ethosuximide
    8. D-Penicillamine
    9. Proton Pump Inhibitors

V. History: Red Flags

  1. Septic Joint Symptoms
    1. Fever
    2. Fatigue
    3. Weight loss
    4. Night Sweats

VI. History: Systemic Inflammatory Findings

  1. Rashes
    1. See Cutaneous Signs of Rheumatic Disease
    2. Psoriasis
    3. Parvovirus
    4. Systemic Lupus Erythematosus
  2. Oral Ulcers and Genital Ulcers
    1. Examples: Reiter's Syndrome
    2. Behcet's Syndrome
    3. Systemic Lupus Erythematosus
  3. Raynaud Phenomenon
    1. Systemic Lupus Erythematosus
    2. Systemic Sclerosis
  4. Serositis with Pleurisy or Pericarditis
    1. Lupus Serositis
    2. Rheumatoid Arthritis
  5. Sicca Syndrome with Dry Eyes (Xerophthalmia) or Dry Mouth (Xerostomia)
    1. Sjogren's Syndrome
  6. Bowel inflammation (Enteropathic Arthritis)
    1. Spondyloarthropathy (Reactive Arthritis or Reiter's Syndrome)
    2. Crohn's Disease
    3. Ulcerative Colitis
  7. Vasculitis (e.g. CVA or TIA)
    1. Rheumatoid Arthritis
    2. Systemic Lupus Erythematosus
    3. Scleroderma
    4. Hepatitis B
    5. Hepatitis C
  8. Dactylitis (Sausage Digit)
    1. Spondyloarthropathy (Psoriasis, Reactive Arthritis, Ankylosing Spondylitis)
    2. Gout
    3. Sarcoidosis
    4. Skeletal Tuberculosis

VII. Exam: Distinguish pain source

  1. Articular (e.g. Arthritis, synovitis, joint contractures)
    1. Painful and reduced active AND passive range of motion
    2. Inflammatory Arthritis (red, warm, swollen, tender joints)
    3. Noninflammatory Arthritis
  2. Nonarticular or Periarticular (e.g. Muscles and tendons, ligaments, bursa)
    1. Normal passive range of motion
    2. Painful and reduced active range of motion and weak resisted range of motion
    3. Evaluate overlying skin and bursa

VIII. Labs: First Line

  1. Complete Blood Count (CBC)
  2. Synovial Fluid Exam (Joint Aspiration)
    1. Single most important test
    2. Diagnoses Septic Arthritis as well as crystal Arthropathy (gout, Pseudogout)
    3. See Synovial Fluid White Blood Cell Count
  3. C-Reactive Protein
    1. More reliable acute phase reactant than ESR
  4. Erythrocyte Sedimentation Rate (ESR)
  5. Antinuclear Antibody (ANA)
    1. Positive with many Rheumatologic Conditions
    2. Higher Specificity for SLE with High ANA titer, positive Anti-dsDNA and Anti-Sm
  6. Anti-Citrullinated Peptide Antibody
    1. Most specific for Rheumatoid Arthritis (especially erosive disease)
  7. Rheumatoid Factor (RF)
    1. Nonspecific (positive for Hepatitis C, Tuberculosis, SBE, SLE, Vasvculitis)
  8. Serum Uric Acid
    1. Low Test Sensitivity and Test Specificity for gout
    2. Serum Uric Acid is often low in acute exacerbations, and high in unaffected patients

IX. Labs: Second-Line (consider)

  1. Additional Infectious Arthropathy labs
    1. Lyme Titer
    2. Parvovirus IgM
    3. Hepatitis B Serology (HBsAg, HBeAg)
    4. Hepatitis C Serology
    5. Human Immunodeficiency Virus (HIV)
  2. Synovial biopsy indications (unclear cases)
    1. Sarcoidosis
    2. Tuberculosis
    3. Hemochromatosis
    4. Whipple Disease
    5. Rheumatoid Arthritis
  3. Skin or tissue biopsy indications
    1. Temporal Arteritis
    2. Discoid Lupus
    3. Vasculitis
    4. Glomerulonephritis
    5. Pulmonary Vasculitis

X. Evaluation

  1. Single joint involved
    1. See Monoarthritis for evaluation
  2. Multiple Joints WITH Synovitis (joint localized inflammation)
    1. See Polyarthritis for causes
    2. Symptoms >6 weeks suggests systemic Rheumatologic Condition
      1. Obtain first line labs above
      2. Consider second line labs as indicated
    3. Symptoms <6 weeks suggests Viral Arthritis (or early Rheumatologic Disease)
      1. Start with Complete Blood Count and Liver Function Tests
      2. Consider Viral Hepatitis Serology
      3. Consider Parvovirus B19 testing
      4. Consider Lyme Disease in endemic regions
      5. Consider first line labs above if persistent or severe symptoms
  3. Multiple Joints WITHOUT synovitis
    1. Consider Fibromyalgia if pain is localized to Tender Points
    2. Consider Osteoarthritis in sporadic Joint Pain
    3. Consider Non-Rheumatologic Differential Diagnosis (see Polyarthritis)
    4. Consider XRay of involved regions
    5. Labs to consider
      1. Serum Calcium
      2. Liver Function Tests
      3. Viral Hepatitis Serology
      4. Thyroid Stimulating Hormone

XI. Imaging

  1. See XRay Changes in Rheumatic Conditions
  2. XRay
    1. Acute Monoarthritis
      1. XRay affected joint
      2. Initial XRay most often normal
    2. Polyarthritis
      1. XRay symptomatic joints or those most consistent with suspected condition
  3. CT or MRI of affected joint
    1. Not a first line study
    2. Use only for specific indications
  4. Joint Ultrasound
    1. May demonstrate joint erosions (e.g. Rheumatoid Arthritis)

XII. References

  1. Pujalte (2015) Am Fam Physician 92(1):35-41 [PubMed]
  2. Shmerling in Helfgott (2021) Evaluation of the adult with Polyarticular pain, UpToDate, accessed 5/11/2022

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