Joints Pain Approach for

Primary care
Dr. Hasan AlAidarous MD, GerFA.
Associated Consultant
Ass. Professor, College of Medicine
Albaha University
Consultant orthopedic Oncology & Arthroscopic Surgeries
 INTRODUCTION

• Joint pain is discomfort that arises from any joint

• It is sometimes called arthritis, arthralgia and rheumatism1
• Arthritis: an inflammatory conditions of the joints
• Arthralgia: joint pain of non inflammatory conditions
• Rheumatism: pain at or around a joint which is not due to joint2

• Chronic pain is defined as a pain that lasts longer than 3 months.

 SIGNS AND SYMPTOMS OF JOINTPAIN
• Pain • Inflammatory joint disease : pain occur
• Stiffness at rest and with motion, worse at the
beginning of usage than at the end.
• Swelling
• Limitation of motion
• Non-inflammatory joint disease (ie,
• Weakness traumatic, or mechanical): pain occurs
during movement, improves quickly
with rest
SHOULDER PAIN
 CAUSES OF SHOULDER PAIN
Pain origin Differential diagnosis
• Rotator cuff disorders: rotator cuff tendinopathy,
Pain arising impingement, subacromial bursitis, rotator cuff tears
from the
shoulder • Glenohumeral disorders: capsulitis (“frozen shoulder”),
arthritis

• Acromioclavicular disease

• Traumatic dislocation

Pain arising • Referred pain: neck pain, myocardial ischaemia, referred

from elsewhere diaphragmatic pain

• Polymyalgia rheumatic

• Malignancy: apical lung cancers, metastases

 HISTORY AND PHYSICAL EXAMINATION
HISTORY
• Onset and characteristics
• Functional impact
• Pain at rest /movement
• Night pain
• Any neck thoracic or upper limb
pain?
• History of acute trauma, shoulder
pain, or instability during certain
movement?
• Systemic symptoms of illness
• Significant comorbidity (diabetes,
stroke, cancer)
EXAMINATION
• Examine neck, axilla and chest wall
• Assess range of movement of cervical
spine
• Inspect shoulder for swelling,
wasting and deformity
• Palpate sternoclavicular,
acromioclavicular and glenohumeral
joints for tenderness, warm, swelling
and crepitus
• Assesss stability and range of
movement (active, passive, resisted)
• Specific diagnostic tests
• Neurological examination of both
upper limbs
SPECIFIC DIAGNOSTIC TESTING
Specific tests Diagnosis
Drop arm test Rotator Cuff Tear

Apprehension test Test For Anterior

Instability Positive In
Recurent Shoulder
Dislocation.

Impingement test Impingement

Syndrome
 RED FLAGS IN SHOULDER PAIN
Features Possible diagnosis

History of cancer, symptoms and signs of cancer, Tumor

unexplained deformity, mass or swelling

Red skin, fever systemically unwell Infection

Trauma, epileptic fit, electric shock, loss of rotation Shoulder Dislocation

and normal shape

Trauma, acute disabling pain, significant weakness, Acute Rotator Cuff

positive drop arm test Tear

Unexplained wasting, significant sensory or motor Neurological Lesion

deficit
 TREATMENT REFERRAL CRITERIA
• A holistic approach: • Pain lasting more than 6
pharmacological & non- months with functional
pharmacological disability

• Adequate analgesia (paracetamol,

NSAIDs drugs - regular / PRN • Diagnostic uncertainty
basis)

• Positive Red flags.

• Self-motivation

• Encourage activity

• Give written patient information

sheet.
SHOULDER PAIN EXERCISES
HIP PAIN
 CAUSES OF HIP PAIN

Anterior hip Lateral Posterior

Osteoarthritis Osteoarthritis Sciatic nerve irritation
secondary to
spondyloarthritis /
Differential lumbar disc herniation
diagnosis Avascular Necrosis Bone tumor Muscle strain

Hip fracture Radiating lumbar

disease
Hip flexor muscle
strains or tendonitis,
and iliopsoas
bursitis
 Integrating the history and physical examination to diagnose hip pain
Disorder Presentation and exam findings

Osteoarthritis • Gradual onset anterior thigh/groin pain worsening with

weight-bearing.
• Limited range of motion with pain, especially internal rotation
Hip flexor muscle • History of overuse or sports injury.
strain/tendonitis • Tenderness over specific muscle or tendon

Iliopsoas bursitis • Anterior pain and associated snapping sensation.

• Tenderness with deep palpation over femoral triangle.
• Etiology from overuse, acute trauma, or rheumatoid arthritis
Anterior
pain
Hip fracture • Fall or trauma followed by inability to walk.
• Limb externally rotated, abducted, and shortened.
(proximal femur) • Pain with any movement

Inflammatory • Morning stiffness or associated systemic symptoms.

arthritis • Previous history of inflammatory arthritis.
• Limited range of motion and pain with passive motion

Avascular • Dull ache in groin, thigh, and buttock usually with risk factors
necrosis of (corticosteroid exposure, alcohol abuse).
femoral head • Limited range of movement with pain.
 RED FLAGS OF HIP PAIN
• Fever, malaise
• Night sweats, night pain, weight loss
• Previous history of cancer
• Trauma/assault (fall, blow, lifting)
• Intravenous drug abuse
• Long term use of immunosuppressants
• Pain that is not relieved with rest and continues through the night

** An accumulation of multiple red flags requires

immediate medical referral
HIP EXERCISES
KNEE PAIN
 CAUSES OF KNEE PAIN
• The knee joint is prone to injury because of its complexity
and weight bearing function.

• The most common knee problem in primary care are:

• Ligament injuries
• Meniscus injuries
• Osteoarthritis
PHYSICAL EXAMINATION & DIAGNOSIS
Examination: Description:

Inspection • Attitude of the lower limbs ( genu varus / genu valgus)

• Skin changes ( scar/sinus/swelling/inflammation)
• Wasting of muscles

Walking ( gait) • Normal, antalgic, shuffling, short limb, and high stepping

Palpation • Temperature of the knee

• Patella tap to assess intraarticular fluid collection

Range of • Lift both feet up ( with hips flexed and knee extended)

movement • Patient to flex the knee and hip actively & passively to
assess the posible range of movement
KNEE LIGAMENTAL INJURIES

SIGNS AND SYMPTOMS

• Ligaments injuries involve high energy injuries

• Patients may present with knee swelling within an hour or two and
associated with ‘clunk’ or ‘popping’ sensation at the time of injury

• Once pain subsides patients would feel instability

SPECIFIC TESTS FOR LIGAMENT INJURIES

Specific tests Diagnosis

Ø Valgus stress Medial collateral ligament

Ø Varus stress Lateral collateral ligament

Ø Lachman test: Anterior cruciate ligament injury

Ø Anterior drawer test Anterior cruciate ligament injury

Ø Posterior drawer test posterior cruciate ligament injury

 LIGAMENTAL INJURIES:TREATMENT
OPTIONS
• In general, torn collateral ligaments heal without surgery whilst
torn cruciate ligaments require surgery.

• Non pharmacology treatment: ACL performance brace

• Surgery: ligaments replacement with a graft.

 MENISCUS INJURIES

Signs and symptoms: Physical examination &

diagnosis:
• Presented with pain
associated with trauma, • Joint line tenderness &
mechanical symptoms and joint line pain with deep
joints swelling. flexion associated with
swelling / effusion over the
point tenderness
• History of locking
episodes.
 SPECIFIC TESTS FOR MENISCUS INJURY

Specific How to perform the test Diagnosis

tests
MC • Physicians flexing the patient hip & • Assess medial / lateral
MURRAY’S knee and palpating for a pop or click as meniscus tear
TEST the tibia is externally or internally
rotated.

APLEY / • Test was performed with patient in • Medial knee join line
GRINDING prone position by rotating the tibia on tenderness indicates medial
TEST the femur and applying compression to meniscus tear & lateral knee
reproduce join line pain. join line pain tenderness
indicates lateral meniscus
tear.
 MENISCUS INJURY: TREATMENT OPTIONS

• Surgery: in general meniscus tear require arthroscopy surgery

to maximize the shock absorption in the joint.

• Removal: if repair can’t be done, removal of the torn meniscus

will be done and the particular cartilage will now take over the
role of absorber.
 KNEE OSTEOARTHRITIS

Signs and symptoms Physical examination &

dignosis
• joint pain, stiffness and
reduced range of motions. • joint line tenderness, effusion
& reduce range of movement
KNEE ARTHRITIS: TREATMENT OPTIONS
Non surgical treatment: Surgical treatment:

• Anti- inflammatory medicines • Unicompartmental knee

• Supplements replacement
• Braces
• Corticosteroids shots / therapeutics • Total knee replacement
injections
• Viscosupplementation shots
• Weight loss
• Cane, crutches, walker
• Physiotherapy
 KNEE ARTHRITIS
Red flags in knee pain:
• Systemic Complaints –
fever, weight loss, pain at
rest, night pain
When to refer
• Inability to bear weight
• Extreme of age
• Locking
• Bilateral knee pain
• Other joint involvement –
e.g: Hip
SPECIFIC EXERCISES
FOR KNEE
ARTHRITIS