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Primary care approach to joint pain
1. Primary Care Approach
to
Joint Pain
Bayalpata Hospital CME
Last updated:-16th September 2019
Edited by: Dr. Pawan KB Agrawal, MBBS, MD, DFID
Associate Medical Director & Senior Consultant (GP & ER)
Contributor: Dr. Alina Khadka, MBBS
2. Objectives
After this session, participants should be able to
1) Acknowledge common causes of acute & chronic
joint pain.
2) Describe and treat septic arthritis
3) Describe and treat gout
4) Describe and treat osteoarthritis
5) Describe and treat rheumatoid arthritis
6) Describe concerns for bone cancer
3. Brainstorming
• A 10 years child was brought with sudden onset
knee pain with swelling and restriction of
movement.
• A 54yrs old obese woman complaints of recurrent
pain in the both knee joints. On examination of
knee joint there is presence of joint tenderness and
coarse crepitations.
5. Clinical Case
A 54yrs old obese woman complaints of recurrent
pain in the both knee joints. On examination of knee
joint there is presence of joint tenderness and coarse
crepitation. What may be the diagnosis? How will
you proceed to manage this case?
Vital signs: Temperature:-98*F, Pulse:-80 b/min
BP:-130/90 mm of Hg
6.
7.
8. Typical OA
• Patient over age 45 (often>60yrs)
• Insidious onset of pain over months or years.
• Variable or intermittent pain over time.
• Morning stiffness <15min
• Usually only one or a few joints painful not multiple
regional pain.
• Mainly worsen during movement and weight-
bearing, and relieved by rest.
9.
10.
11.
12. Treatment
• Non-Pharmacological :-
>Exercise
>weight loss if obese
>Shock-absorbing footwear
>Pacing of activities
>Use of a walking-stick for painful knee or hip OA
>provision of built-up shoes to equalize leg lenghts
• Pharmacological:-
>Initial trial with Paracetamol
>Consider the addition of topical NSAIDS
>If required, consider oral NSAIDS
• Surgery:-
>Osteotomy
>Joint replacement
13. Physical therapy is key!
• Use this :
http://orthoinfo.aaos.org/PDFs/Rehab_Knee_6.pdf
14. Key Point #1
Structural changes are permanent so we should
focus on general measures to treat osteoarthritis.
15. Clinical Case
A 30yrs old lady presented to the OPD with 4 months
history of multiple, painful swollen proximal
interphalangeal joint associated with early morning
stiffness, malaise and lethargy. What is the
diagnosis?
16. Question for HA and CMAs
What are the main differences in signs and symptoms
of osteoarthritis and rheumatoid arthritis?
17.
18.
19. • What major joints do each affect?
• What are the criteria for diagnosing rheumatoid
arthritis?
31. Key Point #2
• Start DMARDs at the day of confirmation of disease
to prevent the deformities.
32. Clinical Case
A 30 yrs old male presented with sudden severe pain
and swelling of first MTP joint of right foot at mid-
night in ER. He has history of similar attack 6weeks
ago. What will be your probable diagnosis and
management of this case??
MNEMONIC: STArK
33. Gout
• Typical findings:-
> Extremely rapid onset, severe pain
> Marked swelling with redness, shiny skin
>It usually affects 1st MTP joints. Other joints
may be involved like ankle, knee, small joints of
feets and hand, wrist ,elbow.
>Onset is usually preceded by high protein
intake.
34. Investigations
• Aspirate from joint, bursa or tophus:-
> Identification of MSUM crystals
• Serum uric acid level:
Acute gout :-usually normal
Chronic gout:-high level
• CBC- neutrophilia, ESR raised in tophus gout
• X-rays
35.
36.
37.
38.
39.
40. Treatment
1)Non-pharmacological treatment:-
>Avoid alcohol and lifestyle alteration to correct
obesity
>Avoid protein diet:-red meat, seafood
2)Pharmacological treatment :-
a) Acute attack - Oral NSAIDs
• Oral colchicine:- 1mg loading dose ,then 0.5mg 6hrly until
symptoms become less intense.
• Aspiration of the joint
• An intra-articular corticosteriod injection
b)Long-term management:-
• Diuretics should be stopped
• Allopurinol 100-300mg once daily .
42. Clinical Case
A 30 yrs old patient presented with pain and
swelling of the right knee joint for 2 days in our
Bayalpata Emergency.
Vitals:-
Temperature-101*F, Pulse-90b/pm
What will be the probable diagnosis? How will
you proceed to manage this case?
43. Septic arthritis
>Usual presentation with acute or sub-acute
monoarthritis
>Any joint can be affected, lower limbs joint, such
a knee and hip joint are commonly targeted.
>The joint is usually swollen, hot and red and is
held in loose-pack position with an effusion, rest
pain and stress pain on movement
44. Investigations
• Joint aspiration- Synovial fluid is sent for culture
• CBC- Leucocytosis >20,000 or neutrophil >50% with
raised ESR and CRP
45.
46.
47. • Causative organism
• In adults-Staphylococcus aureus
• In kids-Haemophilus influenza,streptococcus
and staphylococcus
48. TREATMENT
• Immediate hospitalization
• Analgesics:-oral or IV analgesic
• IV antibiotics:- Inj Ceftriaxone 1gm BD
• Adequate drainage of joint effusion
• Early passive movement to progression to active
movement once pain controlled.
49. Key Point #4
Septic arthritis is medical emergency so IV antibiotics
should be started while waiting for culture and
sensitivity.
50. Clinical Case
A male patient of 60yrs old presented with painless
hard swelling in the right thigh. On further evaluation
patient complaints of weight loss, and no any history
of trauma. On general examination patient was
anaemic.
On examination of the mass it is fixed to
underlying structure, irregular margin and hard in
consistency.
What might be the probable diagnosis? How would
you proceed to manage this case?
56. Key Point #5
As soon as you suspect malignancy refer patient to
higher center for confirmation of malignancy.
57. Summary of Key Points
1) Structural changes are permanent so we should
focus on general measures to treat osteoarthritis.
2)Start DMARDs at the day of confirmation of RA to
prevent the deformities.
3)Limit protein containing diet and alcohol to prevent
gout.
4)Septic arthritis is medical emergency so IV antibiotics
should be started while waiting for culture and
sensitivity.
5)As soon as you suspect malignancy refer patient to
higher center for confirmation of malignancy.
If you contribute to improving these slides, add your name here!
Describe a typical case of osteoarthritis
Describe a typical case of rheumatoid arthritis
Asking questions at two different levels can help keep more people engaged. Doctors stop paying attention if everything is too basic. And mid-level providers stop paying attention if everything is too advanced.
