Painful Joints

Definitions:
Joint pain: A feeling of distress, suffering and discomfort caused by
stimulation of specialized nerve ending in one or more
joints regardless of physical findings.

Acute paiful joint: duration less than 8 weeks.

Chronic: more than 8 weeks.

Mooarthritis: involve only one joint.

Pauciarthritis: involve 2 to 5 joints.

Polyarthritis: involve more than 5 joints.

Epidemiology:
Around 10% of family practice visits in USA are due to joint problems
forming the 14th commonest cause for visit.

Risk Factors:
A lot of factors are believed to interact to cause varying degrees of
articular disease in individual patients. These include:
• Aging: Due to separation of the collagen network.
• Genetic factors: rheumatological diseases.
• Obesity: increase loading distress
• Neuropathy: Abnormal muscle tone may result in
osteoarthritis by transferring abnormal forces to the joints.
• Deposition diseases: (e.g.: hemochromatosis, Wilson’s
disease, gout, etc…). These cause deposition of substances
in the cartilage matrix which can disturb loading forces.
• Infections: e.g. Brucellosis, gonorrhea, influenza, rubella.

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• Trauma:
• Hypermobility syndromes.
• Psychological problems e.g. school phobia.

Differential diagnosis
A. Mono-articular
• Infections: e.g. Gonorrhea, Brucellosis
• Crystal induced arthropathies: e.g. (Gout or pseudo-
gout)
• Trauma
• Solitary joint involvement of poly-articular disease
e.g. single joint involvement in rheumatoid arthritis,
osteoarthritis, psoriatic arthritis
• Rieter’s syndrome
• Ankylosing spondylitis
• Viral synovitis

B. Poly articular
• Osteoarthritis
• Sickle cell disease
• Rheumatoid arthritis
• Systemic lupus erythromatosus (SLE)
• Gonococcemia
• Viremia
• Psoriatic arthritis
• Subacute bacterial endocarditis (SBE)
• Scleroderma

Interviewing
Aim:
1. To role out serious diagnosis.
2. To establish a good rapport with patient
3. To guide management plan.

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Socio-demographic Data:

Age: Young tumor is more common

Old Osteoarthritis is more prevalent.
Sex: Female: Rheumatologic diseases are more
common among females.
Occupation: Over use of the joint can cause
osteoarthritis

Chief complaint:
Pain:
Duration:
Short might indicate Infection or Trauma
Long: might indicate osteoarthritis, rheumatoid arthritis,
connective tissue disease or fibromyalagia

Variation:
Nocturnal: occurs more in tumor

Aggravating factor:
• Increase with use indicates osteoarthritis. Or endonitis

• Pain only with movement in certain direction indicates

non- articular pain

• Pain that in all direction indicates that the couse is

arthritic.

Location: Mono-articular.
Poly-articular
Symmetrical: R .arthritis

Pattern: Migratory: Rheumatic fever

Gonococcemia
Reiter’s syndrome

Stiffness: Morning stiffness more than 45 minutes might

indicate inflammatory arthritis
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Joint function: normal indicates that it is non-articular pain.

Symptoms of inflammation: - Swelling

- Redness
- Warmness
- Tenderness

Fever: - Infection
- Connective tissue disease
- Tumor

Weight loss: - Infection

- Tumor

Risk factors Raw milk ingestion; infection (brucellosis)

Trauma
Sexual history (Sexually transmitted Infection)

System involved: Back pain, joint pain, swollen joints, warm

joints, joint deformities, muscle weakness,
history of gout, osteoarthritis or rheumatoid
arthritis.

Complications (Impact)
Effect on daily activity: e.g. Absence from work
Deformity

Past medical history:

Surgical: Previous surgery in a specific joint
Trauma, accident
Medical: History of infection e.g. Brucellosis
Hematological disease
Rheumatological disease
Diabetes Mellitus

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Family history:
Similar problem in the family
Rheumatological disease in the family

Drugs history
Prescribed drug:
Pyrazinamide, isoniazid: can cause a lupus- like syndrome.
you need to specify; name, cost, side- effects, compliance, dose
of each drug.

Over the counter (drug side effects)

epigastric pain.
constipation,
others

Abused drug: I.V. drug: can couse infection like hepatitis or HIV
Steroid: mmunocompromized

Lifestyle:
Exercise: type, frequency
Hobbies: contact with animals: Brucellosis
Smoking: if positive take detailed history (see Smoking
cessation)
Alcohol use or abuse

Psychosocial:
Idea: What are the patient beliefs about his problem; he might
think he has black magic

Concern: Patient may think it is a serious problem: e.g. SLE

He may think this will make him unable to do his
regular work

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Expectations:
Reassure the patient that there is no serious problem
Patient might expect prescribing physiotherapy
He may expect investigation e.g. MRI
He may want intra-articular injections
He may ask for a referral to a well known orthopedician
He may expect a sick leave

Effect: Explore How does the joint pain affect patient negatively
on his/her life

Work: e.g. he is a soldier and can not do his job properly.

Home: Impact of the patient’s problem on his family member;
he can not perform his daily home work.

Socially: He can not participate in social activity or cannot

practise his usual hobbies.

Depression: Check depression criteria starting with quick screen

for his/her mood and interest in social occasions.

Anxiety: Check anxiety criteria. e.g. unexplained worry, etc.

Stress: Check for source of stress in patient’s life e.g. A pressure

from his peers at the work place
Financial problems exaggerated by current problem or
presence of social stressors

Support system:
At home: the patient’s wife/husband, relatives, housemaid
relationships.

Work: help from colleagues, special organizations..

Friend help and support
Community: Agencies that can help him, medically or
financially.

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Hidden agenda: Try to explore if the patient has any hidden

agenda e.g. he has other problems with
stigma e.g. sexual problems or he wants to
get something e.g. financial, sick leave, etc.

Physical Examination
Aim:
• To rule out serious/urgent diagnosis
• To determine a specific diagnosis
• To determine patient’s activity
• To determine patient’s comfort
• To maintain rapport with patient

General observation of the patient Well or ill looking

Gait (describe)
Vital signs High Temperature:
infection
Rheumatological disease
Pulse
Blood pressure

Weight and height: (Body Mass Index): Obesity

Skin:
Malar rash or mouth ulcers (SLE).
Nail pitting: ? psoriatic arthritis
Papillovesicular pustular lesions (gonococcemia)
Tophi (gout)
Heliotropic eyelid rash: (Dermatomyositis, SLE)
Rheumatoid nodule: (Rheumatoid arthritis)
Finger tip atrophy or ulcers, calcinosis and telangiectasia
(scleroderma)
Hyperkeratotic lesions on the palms and soles (keratoderma
blenorrhagia), blanitis circinate painless ulcer on the penis:
(Reiter’s syndrome).

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Head: Hair loss, scar: SLE, Drug side effects

Eyes: Conjunctivitis, uveitis: (Inflammatory bowel disease,drug

side effects)

Respiratory system:
effusion, pleuritis (Rheumatoid arthritis, SLE)
Cardiovascular system: Pericarditis

Abdomen:
Spleenomegaly: Rheumatoid arthritis, SLE
Joint:
Signs of inflammation: - Swelling
- Redness
- Warmth
- Tenderness
Range of Motion
Range of Deformity
Irregular bony enlargements
- Osteoarthritis
- Bouchard’s node
- Heberden’s node
Bony mass: (Tumor)
Periarticular tissues: - Tendonitis
- Bursitis
- Myositis

Management
Clarification: Depends on the underlying diagnosis. However it
should include:
- Nature of the problem
- Magnitude of the problem in
Thecommunity
- Prognosis
Reassurance: Benign diagnosis: reassurance about the
nature

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Serious diagnosis: reassure the patient

that he will be given
appropriate care.
Advice:
RICE: most of the common injuries are treated with the RICE
recommendations
- Rest
- Ice
- Compression
- Elevation
Protection:Splinting
Physical therapy:
Usually useful regardless of the diagnosis

Prescribing - Septic arthritis: Antibiotics

- Osteoarthritis: Paracetamol (1st choice)
- Rheumatoid arthritis: Non-steroidal anti
inf lammatory
(NSAIDs)
- Disease modifying drugs:
- Methotrexate
- Sulfasalazine
- Hydroxychloroquine
- Gold
- Penicillamine
- Azathioprine
- Corticosteroids
- SLE:
- NSAIDs
- Corticosteroids
- Antimalarials
- Azathioprine
- Gout
- NSAIDs
- Cholchicine
- Allopurinol
- Probencid

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Referral:
- Rheumatologist: if patient need disease modifying drugs
- Orthopedic: If there is a need for joint drainage
- Ophthalmologist: basic fundus examination and follow up
check for any complications. e.g. retinopathy in patient on
hydroxychloroquine.
- Nephrologist: e.g. protinuria and glomerular toxicity in
patient on gold therapy

Investigations
Arthrocentesis:
1. Appearance
- Cloudy – infection
- Bloody – Trauma
2. Leucocyte count:
< 2000/cu mm, Non-inflammatory e.g. osteoarthritis
2000-50,000/cu mm,Mild inflammatory e.g. arthritis,
gout
50,000-100,000/cu mm Severe inflammatory e.g. sepsis,
gout
> 100,000/cu mm, Sepsis
3. Gram stain
4. Culture
5. Glucose
6. Crystals

X-ray:
Normal (Early arthritis)
Osteoarthritis
- Joint space narrowing
- Change in subchondral bone
- Osteophyte
Bony erosions
- Rheumatoid arthritis
- Septic arthritis
- Gout
Prearticular osteopenia: Inflammatory disease
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MRI: Periarticular soft tissue injury

ESR: Non-specific (increases in infections, infarction,
malignancies, collagen vascular diseases, and
physiologic stress)

Leukocytosis: Septic arthritis

Rheumatic factor (RF): Positive in 75% of patient with

Rheumatoid arthritis.It can be
found in vasculitis. it is IgM
antibody directed against the Fc
protein of IgG.

Antinuclear antibodies (ANA):

SLE: Sensitive, Non-specific
Rheumatoid arthritis
Scleroderma
Polymyositis
Dermatomyositis.

Duble-stranded DNA (dsDNA):

Specific for SLE (found in 70% of SLE patients)

Anti-Smith antibody:
Specific for SLE (found in only 30% of SLE patients)

Complement levels: Drop when thre is decreased production in

the liver or increased loss – either through
the formation of immune complexes or
from glomular diseases.It can help in
1. liver diseases(viral hepatitis)
2. SLE nephritis
3. Glomerulonephritis
4. Rheumatoid arthritis with vasculitis

Chemistry: (Renal function)

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(Uric acid)
Urinalysis: (Glomerular problems)
(Connective tissue disease)

Follow-up: According to the conditions

Prevention:
- Prevent further damage by splinting
- Regular screening for complication of condition and
drug
- Regular follow-up with ophthalmologist to screen for
side effects of drug.
- Regular essential investigation to screen for the effect of
drug on kidneys.

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