Examination of joint pain

Patients may report "joint" pain regardless of whether the cause involves the joint itself or surrounding
(periarticular) structures such as tendons and bursae; in both cases, pain in or around a single joint will be
referred to as monoarticular pain. Pain originating within a joint (arthralgia) may be caused by joint
inflammation (arthritis). Inflammation tends to result in accumulation of intra-articular fluid (effusion)
and clinical findings of warmth, swelling, and uncommonly erythema. With effusion, prompt assessment
is essential to exclude infection. Acute monoarticular pain is sometimes caused by a disorder that
characteristically causes polyarticular pain (eg, rheumatoid arthritis) and thus may be the initial
manifestation of a polyarthritis (eg, psoriatic arthritis, rheumatoid arthritis

Etiology

The most common causes of acute monoarticular pain overall are the following:

 Injury
 Infection
 Crystal-induced arthritis

With injury, a history of trauma is usually present and suggestive. Injury can affect intra-articular
and/or periarticular structures and involve direct injury (eg, twisting during a fall) or overuse (eg,
repetitive motion, prolonged kneeling).

Infection most often involves the joint (septic arthritis), but periarticular structures, including
bursae, overlying skin, and adjacent bone, also may become infected.

Among young adults, the most common causes are the following:

 Injury (most common)

 Infection
 Primary inflammatory disorders (eg, gout)

Among older adults, the most common nontraumatic causes are the following:

 Osteoarthritis (most common)

 Crystal-induced arthritis (usually gout or calcium pyrophosphate arthritis [pseudogout])

The most dangerous cause of joint pain at any age is acute infectious (septic) arthritis. Prompt
drainage, IV antibiotics, and sometimes operative joint lavage may be required to minimize
permanent joint damage and prevent sepsis and death.

Rare causes of monoarticular pain include osteonecrosis, pigmented villonodular synovitis,

hemarthrosis (eg, in hemophilia or coagulopathies), tumors (see table Some Causes of Pain in
and Around a Single Joint), and disorders that usually cause polyarticular pain, such as reactive
arthritis and enteropathic arthritis.
The most common cause of periarticular pain is injury, including overuse. Common periarticular
disorders include bursitis and tendinitis; epicondylitis (eg, lateral epicondylitis), fasciitis, and
tenosynovitis can also develop. Periarticular infection is less common.

Sometimes, pain is referred to a joint. For example, a splenic injury may cause left shoulder pain,
and children with a hip disorder may complain of knee pain.

Evaluation
Acute monoarticular joint pain requires rapid diagnosis because infectious (septic) arthritis
requires rapid treatment.

Clinical evaluation should determine whether the joint or periarticular structures are the cause of
symptoms and whether there is joint inflammation. If signs of inflammation are present or the
diagnosis is unclear, symptoms and signs of polyarticular and systemic disorders should be
sought.

History

History of present illness should focus on the location of pain, acuity of onset (eg, abrupt,
gradual), whether the problem is new or recurrent, and whether other joints have caused pain in
the past. Also, temporal patterns (eg, persistent vs intermittent), associated symptoms (eg,
swelling), exacerbating and mitigating factors (eg, activity), and any recent or past trauma to the
joint should be noted. Patients should also be asked about unprotected sexual contact (indicating
risk of sexually transmitted diseases), previous Lyme disease, and possible tick bites in areas
where Lyme disease is endemic.

Review of systems may provide clues to systemic disorders. Review of systems should seek
extra-articular symptoms of causative disorders, including fever (infection, sometimes crystal-
induced arthritis), urethritis (gonococcal arthritis or reactive arthritis), rash or eye redness
(reactive or psoriatic arthritis), history of abdominal pain and diarrhea (inflammatory bowel
disease), and recent diarrhea or genital lesions (reactive arthritis).

Past medical history is most likely to be helpful if pain is chronic or recurrent. Past medical
history should identify known joint disorders (particularly gout and osteoarthritis), conditions
that may cause or predispose to monoarticular joint pain (eg, bleeding disorder, bursitis,
tendinitis), and disorders that can predispose to a joint disorder (eg, sickle cell disease or chronic
corticosteroid use predisposing to osteonecrosis). Drug history should be reviewed, particularly
for use of anticoagulants, quinolone antibiotics (tendinitis), or diuretics (gout). A family history
should also be obtained (some spondyloarthropathies).

Physical examination

A complete physical examination is done. All major organ systems (eg, skin and nails, eyes,
genitals, mucosal surfaces, heart, lungs, abdomen, nose, neck, lymph nodes, neurologic system)
should be examined, as well as the musculoskeletal system. Vital signs are reviewed for fever.
Examination of the head, neck, and skin should note any signs of conjunctivitis, psoriatic
plaques, tophi, or ecchymoses. Genital examination should note any discharge or other findings
suggesting sexually transmitted diseases.

Because involvement of other joints can be clues to a polyarthritis and a systemic disorder, all
joints should be inspected for tenderness, deformities, erythema, and swelling.

Palpation helps determine the location of tenderness. Palpation also helps detect joint effusion,
warmth, and bony hypertrophy. The joint can also be compressed without flexing or extending it.
Range of motion is assessed actively and passively, with attention to the presence of crepitus and
whether pain is triggered by joint motion (passive as well as active). For injuries, the joint is
stressed with various maneuvers (as tolerated) to identify disruption of cartilage or ligaments (eg,
in the knee, valgus and varus tests, anterior and posterior drawer tests, Lachman test, McMurray
test). Findings should be compared with those in the contralateral unaffected joint to help detect
more subtle changes. Noting whether the tenderness is directly over the joint line or adjacent to it
or elsewhere is particularly helpful in determining whether pain (particularly when the knee is
involved) is articular or periarticular.

Large effusions in the knee are typically readily apparent. The examiner can check for minor
effusions by pushing the suprapatellar pouch inferiorly and then pressing medially on the lateral
side of the patella on an extended knee. This maneuver causes swelling to appear (or be
palpable) on the medial side. Large knee effusions in obese patients are best detected with
ballottement of the patella. In this technique, the examiner uses both hands to push in toward the
center of the knee from all four quadrants and then uses 2 or 3 fingers to push the patella down
into the trochlear groove and releases it. Clicking or a feeling that the patella is floating suggests
an effusion.

Periarticular structures also should be examined for point tenderness, such as at the insertion of a
tendon (enthesitis), over a tendon (tendinitis), or over a bursa (bursitis). With some types of
bursitis (eg, olecranon, prepatellar), swelling and sometimes erythema may be localized at the
bursa.

Red flags

The following findings are of particular concern:

 Erythema, warmth, effusion, and decreased range of motion

 Fever with acute joint pain
 Acute joint pain in a sexually active young adult
 Skin breaks with signs of cellulitis adjacent to the affected joint
 Underlying bleeding disorder or use of anticoagulants
 Systemic or extra-articular symptoms

Interpretation of findings
Recent significant trauma suggests that injury is the cause (eg, fracture, meniscal tear, or
hemarthrosis). However, trauma does not rule out other causes, and patients often mistakenly
attribute newly developed nontraumatic pain to an injury. Testing is often necessary to rule out
serious causes and establish the diagnosis.

Acuteness of onset is an important feature. Severe joint pain that develops over hours suggests
crystal-induced arthritis or, less often, infectious arthritis. Previous attacks of rapid-onset
monarthritis suggest recurrence of crystal-induced arthritis, particularly if that diagnosis had
been confirmed previously. Gradual onset of joint pain is more typical of rheumatoid arthritis or
noninfectious arthritis. Gradual onset, although uncommon in acute bacterial infectious arthritis,
can occur in certain infectious arthritides (eg, mycobacterial, fungal).

Whether pain is intra-articular, periarticular, or both (eg, in gout, which can affect intra- and
extra-articular structures) and whether there is inflammation are key determinations, based
mainly on physical findings. Pain during rest and on initiating activity suggests joint
inflammation, whereas pain worsened by movement and relieved by rest suggests mechanical or
noninflammatory disorders (eg, osteoarthritis). Pain that is worse with passive as well as active
joint motion on examination, and that restricts joint motion, usually indicates inflammation.
Increased warmth and erythema also suggest inflammation, but these findings are often
insensitive, so their absence does not rule out inflammation.

Pain that worsens with active but not passive motion may indicate tendinitis or bursitis, as can
tenderness or swelling localized over a bursa or tendon insertion site. Tenderness or swelling at
only one side of a joint, or away from the joint line, suggests an extra-articular origin (eg,
tendons or bursae); localized joint line tenderness or more diffuse involvement of the joint
suggests an intra-articular cause. Compressing the joint without flexing or extending it is not
particularly painful in patients with tendinitis or bursitis but is quite painful in those with
arthritis.

Involvement of the first metatarsophalangeal joint (podagra) suggests gout but can also result
from infectious arthritis, reactive arthritis, or psoriatic arthritis.

Symptoms indicating dermatologic, cardiac, or pulmonary involvement suggest disorders that are
systemic and more commonly result in polyarticular joint pain.

Testing

Joint aspiration (arthrocentesis) for synovial fluid examination should be done in patients with
joint effusion. Synovial fluid examination includes white blood cell (WBC) count with
differential, Gram stain and cultures, and microscopic examination for crystals using polarized
light. Finding crystals in synovial fluid confirms crystal-induced arthritis but does not rule out
coexisting infection. A noninflammatory synovial fluid (eg, < 1000/mcL [< 1 × 109/L] WBCs) is
more suggestive of osteoarthritis or trauma. Hemorrhagic fluid is consistent with hemarthrosis.
Synovial fluid WBC counts can be very high (eg, > 50,000/mcL [> 50 × 109/L] WBCs) in both
infectious and crystal-induced arthritis. Sometimes, molecular techniques, such as polymerase
chain reaction, are used to detect the presence of microorganisms.
For some patients with prior confirmed gouty arthritis, a recurrent episode may not require any
testing. However, if infection is a reasonable possibility, or if symptoms do not rapidly resolve
after appropriate therapy for gouty arthritis, arthrocentesis should be done.

X-rays rarely change the diagnosis in acute monarthritis unless fracture is suspected. X-rays may
reveal signs of joint damage in patients with a long history of recurrent arthritis. Other imaging
tests (eg, CT, bone scan, but most often MRI) are rarely necessary acutely but may be indicated
for diagnosis of certain specific disorders (eg, osteonecrosis, tumor], occult fracture, pigmented
villonodular synovitis).

Blood tests (eg, erythrocyte sedimentation rate [ESR], rheumatoid factor, anti-cyclic citrullinated
peptide [anti-CCP] antibody) may help support a clinically suspected diagnosis of a systemic
inflammatory disorder (eg, rheumatoid arthritis). Serum urate level should not be used to
diagnose gout because it is neither sensitive nor specific and does not necessarily reflect the
presence of intra-articular uric acid deposits.