JOINT PAIN

CASE SCENARIOS

• 15-year-old male with 2-week history swelling and pain of left knee joint.
Patient also had fever and redness over the joint was seen.

• 45-year-old male with 2-4 wk. similar history of knee joint pain, previous
history of similar attacks in MTP joints.
 CASE SCENARIOS

• 25 yr. old male had knee joint pain, had an episode of diarrhea 4 weeks ago
which was treated with antibiotics o/e red eye is present.

• 35 yr. old female presented with ankle pain and redness. Pain more in plantar
and dorsiflexion but less in inversion and eversion o/e red nodule on shin was
present.

HOW TO APPROACH ??
APPROACH TO JOINT PAIN

Presenter Dr Shubham
SR Moderator Dr. Samia
Faculty Preceptor Dr. Priyanka (Medicine) and Dr. Rudra (Rheumatology)
 PAIN

Character - Aching, joint disorder and burning or numbness, neuropathic

Localisation – Pain diffuse in articular structures, but small joint – often focal.

Severity – VAS

Referred pain – Shoulder in case of diaphragmatic irritation

 STIFFNESS

• “Gel” phenomenon occurs usually after an hour or more of inactivity.

• Early feature of inflammatory arthropathies ex RA and PMR, may last for

several hours.

• Morning stiffness not specific for inflammatory arthropathies may be seen in

patients with fibromyalgia or chronic idiopathic pain syndromes, neurologic
disorders, such as Parkinson’s disease.
 SWELLING

• Diffuse soft tissue swelling - venous or lymphatic obstruction, soft tissue

injury, or obesity - not in a distribution of particular joints, bursae, or tendons.

• In contrast, patients with inflammatory arthritis - swelling of joints present in a

distribution typical of a specific disease—swelling of the metacarpophalangeal
joints and wrists in RA, or several toes and a knee in psoriatic arthritis.
 LIMITATION OF MOVEMENT

• Extent of disability resulting from restriction in joint movement.

• Not only the range of motion but duration of limitation of movement is

important since it predicts response to treatment.
 CARDINALS QUESTIONS

1. Is it articular
2. Is it acute or chronic
3. Is inflammation present
4. How many/which joints are involved
 ARTICULAR VS NON ARTICULAR
ARTICULAR
Anatomic Structures – Synovium,
synovial fluid, articular cartilage, intra-
articular ligaments, joint capsule and
juxta-articular bone
Diffuse pain and deep tenderness
Active and passive movement pain,
all planes
Swelling, crepitus and deformity -
Common
NON ARTICULAR
Non Articular – Supportive ligaments,
tendons, bursae, fascia, bone, nerve.
Point tenderness
Active only, few planes
Swelling, crepitus, deformity -
Uncommon
 ARTICULAR VS NON ARTICULAR

OLECRANON BURSITIS GOUTY ARTHRITIS

TUCK SIGN
 INFLAMMATORY VS NON
INFLAMMATORY

History Examination
- Inflamed joints (Presence of dolor,
- Morning stiffness, improving rubor and calor +/- loss of fn).
with activity
- Spontaneous fluctuation in Lab
disease activity. - High CRP
- Constitutional symptoms (ex - Hight ESR
fatigue, loss of apatite)
EXAMINATION OF ENTHESIS
 EXAMINATION OF DACTYLITIS

Clinical diagnosis
ALGORITHM FOR MUSCULOSKELETAL
COMPLAINTS

Musculoskeletal complaints

Initial history and physical examination

1. Is it articular
2. Is it acute or chronic
3. is inflammation present
4.How many/which joints are involved

Is it articular
 Is it articular

no
yes

Is complaint > 6 wk?

no
yes

acute

chronic
 NON ARTICULAR

• Trauma/fracture
• Fibromyalgia
• Polymyalgia rheumatica
• Bursitis
• Tendinitis
 PRESENTATION

• A 34-year-old woman with widespread pain, fatigue and sleep disturbances.

• Multiple visits to numerous specialists, including rheumatologists,
neurologists, urologists, pain specialists, and gastroenterologists.
 FIBROMYALGIA

• Fibromyalgia is a pain amplification disorder unified by sleep disturbance,

exaggerated pain and sensitivity.
• Age – 30 – 50
• Female: male – 9:1
• Characteristic - tender “trigger points” may be elicited.
• A/s with numerous comorbidities including IBS, dysmenorrhea, migraine,
depression, anxiety, memory loss etc
FIBROMYALGIA
 Articular

acute chronic

Consider

•Acute arthritis
•Infectious arthritis Is inflammation present?
•Gout/Pseudogout Is there prolonged morning stiffness
•Reactive arthritis Is there soft tissue swelling
•Initial presentation of chronic arthritis Are there systemic symptoms
Is the ESR or CRP elevated
 ACUTE ARTICULAR

ACUTE INFLAMMATORY ACUTE NON INFLAMMATORY

• GOUT • TRAUMA
• PSEUDOGOUT
• SEPTIC ARTHRITIS
• REACTIVE ARTHRITIS
• SARCOIDOSIS
• INITIAL PRESENTATION OF
CHRONIC ARTHRITIS OR
FLARE
 ACUTE ARTICULAR

ACUTE ACUTE ACUTE

MONARTICULAR OLIGOARTICULAR POLYARTICULAR
• GOUT • REACTIVE • GOUT
• PSEUDOGOUT ARTHRITIS • CPPD
• SEPTIC ARTHRITIS • INITIAL
• TUMORS PRESENTATION OF
• SARCOIDOSIS CHRONIC DISEASE
OR FLARE
• VIRAL ARTHRITIS
ACUTE MONOARTICULAR
 PRESENTATION

• Ram a 60 year-old male who presented with abrupt onset pain in left great toe
in morning. He states he had a similar episode of sudden onset pain upon
waking in the morning, but thought he stubbed his toe.
 D/D
ACUTE MONOARTHRITIS OF MTP

INFLAMMATORY
• Gout
• Osteomyelitis

NON INFLAMMATORY
• Morton’s neuroma
• Stress fracture
• Freiberg disease
 GOUT

• Age of presentation 30-50 years. Women after menopause.

• Women represent 5-20% of all patient.

• Most common joint – First metatarsophalangeal joint.

• Characteristic - Typically flare subside spontaneously within 1-2 week and

without treatment develops subcutaneous tophi, deformity, and bony destruction.
 GOUT PRECIPITANTS

Triggers of gout flares

• purine-rich food
• alcohol
• diuretic use
• initial introduction of urate-lowering therapy,
• local trauma, and medical illnesses such as congestive heart failure and
respiratory hypoxic conditions.
CHRONIC INFLAMMATIO
N

no yes

Chronic non-inflammatory arthritis Chronic inflammatory arthritis

Are DIP, CMC-1,Hip or Knee joint

involved

no yes

Unlikely to be osteoarthritis consider osteoarthritis

• Osteonecrosis
• Charcot arthritis
• Hemochromatosis
 CHRONIC, NON INFLAMMATORY

MONOARTICLUAR
• Monoarticular osteoarthritis
• Osteonecrosis
• Neuropathic arthropathy ex
Charcot's
• Pigmented villonodular synovitis
OLIGO/POLYARTICULAR
• OA
• Stickler Syndrome
• Handigodu Syndrome
 PRESENTATION

Ram, a 65-year-old male. Presented with bilateral pain in knee joint

especially during activities like climbing stairs. He has a BMI of 32 kg/m 2,
has hypertension and type 2 diabetes mellitus.
 OSTEOARTHRITIS

• After age of 40 in females and 50 in males.

• Female predominance

• Early in disease, pain is episodic, triggered often by overactive use of a

diseased joint. As disease progresses, the pain becomes continuous.

• Mechanical symptoms, such as buckling, catching, or locking, may occur in

OA without history of trauma.
OSTEOARTHRIS
 Chronic inflammatory arthritis

How many joints involved

1-3
>3

Chronic inflammatory mono/oligoarthritic

consider Chronic inflammatory
• Indolent infection polyarthritis
• Psoriatic arthritis
• SpA and IBD related
• Reactive arthritis
• Pauciarticular JIA
 PRESENTATION

• A 35-year-old man presented to us with painful swelling of multiple

fingers. History of itchy scaly patch on elbow and scalp area also present.
Physical assessment revealed tender, fusiform, swollen soft tissues in the
affected fingertips. Pitting of the nails was also seen.
 PSORIATIC ARTHRITIS

• Male = Female, typically begins in the fourth or fifth decade.

• Joint involvement tends to follow a “ray” distribution.

• Dactylitis occurs in >30%; enthesitis and tenosynovitis present in most.

• Accompanying nail changes mostly in all cases with arthritis.

RAY VS ROW DISTRIBUTION
 Chronic inflammatory polyarthritis

Is involvement symmetric ?

no
yes

Consider
• Psoriatic arthritis
• Reactive arthritis Are PIP, MCP or MTP joints involved?

no yes

Unlikely to be rheumatoid arthritis consider

• SLE Rheumatoid arthritis
• Scleroderma (Arthralgia)
• Polymyositis (Arthralgia)
CAUSES OF POLYARTHRITIS
 PATTERN RECOGNITION IN JOINT
INVOLVEMENT IN INFLAMMATORY
ARTHRITIDES

• Symmetry
• Number
• Clusters of joints
 PATTERN EXAMPLES

• Bilaterally symmetric inflammatory chronic erosive small joint polyarthritis =

RA

• Bilaterally symmetric inflammatory chronic non erosive small joint

polyarthritis = SLE

• Asymmetric lower limb inflammatory oligoarthritis = SpA (arthritis +

enthesitis +/- .Other features uveitis, dactylitis, IBD, psoriatic rash, HLA B27,
MRI or X Ray - Sacroiliitis)
EROSION PATTERN
 CLUSTER EXAMPLES

• B/L MCPs = RA

• B/L DIPs without bony nodule = PsA

• B/L DIPs with bony nodules = OA

• B/L Hip = OA ~ SpA

Caveat: Gout can involve any joint.

 PRESENTATION

• Bharti is a 48-year old married mother, works as hair dresser in nearby saloon.
• Seven months ago, she began noticing pain and stiffness in both hands in the
morning that lasted longer and longer included hands, wrists and ankles.
• She began taking ibuprofen 800 mg 3 times daily and found it helped her get
through her day with less pain and stiffness.
 RHEUMATOID ARTHRITS

• The incidence of RA increases between 25 and 55 years of age.

• Female predominance (2-3 times)

• The earliest involved joints are the small joints of the hands (wrist, PIP and MCP)
and feet.

• Intital pattern may be monoarticular, oligoarticular (≤4 joints), or polyarticular (>5

joints), usually in a symmetric distribution.
 EXTRA ARTICULAR POINTERS

Fever with arthritis Enthesitis

1. Viral Arthritis 1. SpA

2. Rheumatic fever 2. Sarcoidosis
3. AOSD
4. Enteropathic
5. Sarcoidosis
 EXTRA ARTICULAR POINTERS

Raynaud’s Phenomenon Ulcers

1. Scleroderma 1. SLE
2. MCTD 2. Reactive arthritis
3. IIM 3. Enteropathic
4. Anti synthetase syndrome 4. Behcet
5. Other CTDS (uncommon
and without DU)
 EXTRA ARTICULAR POINTERS

Pulmonary
Neuropathy - AAV (nodule, cavity, DAH, UIP (MPO+))
- SLE - Polymyositis (ILD)
- Sjogren - SLE (pleuritis)
- Lymes - MCTD (PAH, ILD-NSIP)
- Amyloidosis - Scleroderma (ILD-NSIP, PAH)
- Cryoglobulinemia - Sarcoid (well described, from nodes to
DPLD)
- RA (obstructive airway disease, nodule,
Caplan, BOOP, UIP-ILD, pleural effusion,
PAH)
- AS (upper lobe fibrosis – not documented
now a days with improved therapy)
 EXTRA ARTICULAR POINTERS

Renal involvement GI Involvement

- Crescentic GN – AAV - Scleroderma (GERD, diarrhea,

- Pulmonary renal syndrome – pseudo-obstruction)
AAV - SLE (mesenteric vasculitis, lupus
- GN – SLE, AAV, IgAV enteritis, PLE)
- TI – SLE, AAV, Gout - Enteropathic (IBD)
- IgAN – IgAV, SpA
- Amyloid – any, untreated,
especially SpA.
 CASE SCENARIOS

• 15-year-old male with 2-week history swelling and pain of left knee joint.
Patient also had fever and redness over the joint was seen.
ACUTE INFLAMMATORY MONARTHRITIS

• 45-year-old male with 2-4 wk. similar history of knee joint pain, previous
history of similar attacks in MTP joints.
ACUTE INFLAMMATURY MONOARTHRITIS (with flare)
 CASE SCENARIOS

• 25 yr. old male had bilateral knee joint pain and ankle pain with high ESR and
CRP, had an episode of diarrhea 4 weeks ago which was treated with
antibiotics o/e red eye is present.
ACUTE INFLAMMATORY OLIGO ARTHRITIS

• 35 yr. old female presented with ankle pain and redness. Pain more in plantar
and dorsiflexion but less in inversion and eversion o/e red nodule on shin was
present.
NON ARTICULAR
 SIMPLIFIED APPROACH CAUSES

Because trauma, fracture, overuse

syndromes, and fibromyalgia are
among the most common causes
of musculoskeletal pain, these
should be considered with each
new encounter.
THANK YOU
ANY QUES? PLEASE ASK

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GMAIL shubhamh96@gmail.com