Lecture Slides Presented at SIMS by Medical Unit SIMS Hospital

1. Approach to
Joint Pain
Dr. Tahir BashirDr. Tahir Bashir
Assistant Professor Medical Unit-IVAssistant Professor Medical Unit-IV
SIMSSIMS

2.  There may be :
o Pain (arthralgia).
o Inflammation (arthritis) - redness, warmth, and
swelling
 There may be:
o Only a single joint involved (mono-articular).
o Multiple joints involved.
 The pain may occur :
o Only with use, suggesting a mechanical problem
(eg, osteoarthritis, tendinitis).
o At rest, suggesting inflammation (eg, crystal
disease, septic arthritis).
 There may or may not be fluid within the joint
(effusion).
Pathophysiology

3. Joint pain may arise from:
 Structures within the joint (intra-articular):
o Sources of pain within the joint include the
joint capsule, periosteum, ligaments,
subchondral bone, and synovium, but not the
articular cartilage, which lacks nerve endings
o Inflammatory.
 Infectious arthritis
 Rheumatoid arthritis
 Crystal deposition arthritis
o Non-inflammatory
 Osteoarthritis.
 internal mechanical derangement
Pathophysiology

4. Joint pain may arise from (cont..)
 Structures adjacent or a round to the joint (peri-
articular)
o Bursitis
o Tendinitis
o Extra-articular disorders (eg, polymyalgia rheumatica,
fibromyalgia).
 Referred Pain from more distant sites
Pathophysiology

5. • Is the problem acute or chronic?
• Is it an articular or extra-articular problem?
• Is it a mono or oligo/poly arthritis?
• Are there features of joint inflammation?
• Are there extra-articular features?
• Is the arthritis part of a more generalised
complaint?
Basic principles

6. Aetiology of Joint Pain
Mono-articular Pain
• Trauma : ( overuse – fractures – hemarthrosis).
Most common – to all ages
• Internal derangement or intra-articular trauma
(Meniscus injury – ligament tear)
• Infectious or Septic arthritis (eg, bacterial, fungal,
viral, mycobacterial, spirochetal, parasitic). Most
important to rule out.
• Reactive arthritis (Aseptic inflammatory arthritis).
• Crystal-induced disease (gout or pseudogout)
• Periarticular syndromes (eg, bursitis,
epicondylitis, fasciitis, tendinitis, tenosynovitis)

7. Aetiology of Joint Pain
Mono-articular Pain
• Uncommon Causes :
– Avascular necrosis (H/O corticosteriod use or sickle
cell anaemia)
– Neuropathy (Charcot ‘s Joint).
– Osteoarthritis
– Osteomyelitis.
– Lyme disease.
– Paget’s disease (Osteitis deformans)
– Tumor

8.  Stiffness
– Stiffness is a perceived sensation of tightness
when attempting to move joints after a
period of inactivity. It typically subsides over
time. Its duration may serve to distinguish
inflammatory from non-inflammatory forms
of joint disease.
– With inflammatory arthritis, the stiffness is
present upon waking and typically lasts 30-60
minutes or longer.
– With noninflammatory arthritis, stiffness is
experienced briefly (eg, 15 min) upon waking
in the morning or following periods of
inactivity.
I - History
Symptoms of joint disease

9.  Swelling
– With inflammatory arthritis, joint swelling is
related to synovial hypertrophy, synovial
effusion, and/or inflammation of periarticular
structures. The degree of swelling often varies
over time.
– With noninflammatory arthritis, the
formation of osteophytes leads to bony
swelling. Patients may report gnarled fingers
or knobby knees. Mild degrees of soft tissue
swelling do occur and are related to synovial
cysts, thickening, or effusions.
I - History
Symptoms of joint disease

10. Symptoms of joint disease
 Limitation of motion
• Loss of joint motion may be due to structural
damage, inflammation, or contracture of
surrounding soft tissues.
• Patients may report restrictions on their
activities of daily living, such as fastening a bra,
cutting toenails, climbing stairs, or combing hair.
 Weakness
• Muscle strength is often diminished around an
arthritic joint as a result of disuse atrophy.
• Weakness with pain suggests a musculoskeletal
cause (eg, arthritis, tendonitis) rather than a
pure myopathic or neurogenic cause.
• Manifestations include decreased grip strength,
difficulty rising from a chair or climbing stairs,
and the sensation that a leg is "giving way."
History

11. Symptoms of joint disease
 Fatigue
• Fatigue is usually synonymous with
exhaustion and depletion of energy in
patients with arthritis.
• With inflammatory polyarthritis, the
fatigue is usually noted in the afternoon
or early evening.
• With psychogenic disorders, the fatigue
is often noted upon arising in the
morning and is related to anxiety,
muscle tension, and poor sleep.
History

12.  Number of involved joints
o Monoarthritis is the involvement of one joint.
o Oligoarthritis is the involvement of 2-4 joints.
o Polyarthritis is the involvement of 5 or more
joints.
 Symmetry of joint involvement
o Symmetric arthritis is characterized by
involvement of the same joints on each side of
the body. This symmetry is typical of RA and
SLE.
o Asymmetric arthritis is characteristic of psoriatic
arthritis, reactive arthritis (Reiter syndrome),
and Lyme arthritis.
History

13. Common Causes of Acute Monoarthritis

14. Evaluation
II – Physical Examination
The musculoskeletal examination helps
distinguish joint inflammation (eg, RA)
from joint damage (eg, degenerative joint
disease). It can also help elucidate the site
of musculoskeletal involvement (eg,
synovitis, enthesitis, tenosynovitis,
bursitis) and the distribution of joint
involvement.

15. I – Physical Examination
 General
 general condition, fever, pulse, BP
 Articular or extra-articular
 Joint Inflammation
 swollen, red, , tender, hot
 Functional impairment
 passive and active movement
 Crepitus during active or passive range of
motion
 Instability
 Joint Deformity (flexion, subluxation,
dislocation)

16. II – Physical Examination
 Other joints (including spine)
 Extra-articular features
 nails (pitting, ridging, hyperkeratosis)
 enthesitis, dactylitis and tenosynovitis
 nodules (elbows/ears)
 skin (local infection, psoriasis,
keratoderma blenorrhagicum,
balanitis)
 eyes (conjunctivitis, uveitis)
 mouth ulcers

17. Differential Diagnosis of Polyarthritis
Acute Polyarthritis
• Common
 Acute viral infections
 Early disseminated Lyme disease
 Rheumatoid disease
 Systemic lupus erythematosus
• Uncommon or rare
 Paraneoplastic polyarthritis
 Remitting seronegative symmetric
polyarthritis with pitting edema (RS3PE)
 Acute Sarcoidosis
 Adult onset Still disease
 Secondary Syphilis
 Systemic autoimmune diseases &
vasculitides
 Whipple disease
Chronic Polyarthritis
• Inflammatory Causes
• Common
 Rheumatoid arthritis
 Systemic lupus erythematosus
 Spondylarthropathy (esp. psoriatic arthritis)
 Chronic hepatitis C infection
 Gout
 Drug-induced lupus syndromes
• Uncommon or rare
 Paraneoplastic polyarthritis
 Remitting seronegative symmetric polyarthritis
with pitting edema (RS3PE)
 Adult onset Still disease
 Systemic autoimmune diseases & vasculitides
 Sjogren syndrome
 Viral inections other than hepatitis C
 Whipple disease
• Non-inflammatory Causes
 Primary generalised osteoarthritis
 Hemochromatosis
 Calcium pyrophosphate deposition disease

18. Investigations
• Urinalysis
• Haematology - FBC, ESR, clotting
• Biochemistry - U&E, LFTs, urate, CRP
• Immunology
• Microbiology
– blood/urine/stool/urethral/sputum
cultures
– serology

19. Investigations
• Synovial fluid
 volume/viscosity/cellularity
 polarised light microscopy (crystals)
 gram stain/culture
• Imaging
 plain films
loss of joint space, osteophytes, subchondral
cysts, osteosclerosis, erosions,
chondrocalcinosis
 arthrogram, MRI, bone scan

20. Evaluation

21. Management
• General
 education, Physiotherapy
 analgesics and/or anti-inflammatory drugs
• Infection
 (if in doubt, treat until culture result)
 Gram +ve flucloxacillin, benzylpenicillin,
 Gram -ve 3rd generation cephalosporin
 6 weeks in total (2 iv, 4 po)
• Haemarthrosis
 joint aspiration

22. Management
• Reactive arthritis
 joint injection (steroid and local anaesthetic)
 ophthalmology review
 screen partner (?)
 DMARD (Disease Modifying Anti-Rheumatic Drugs)
(sulphasalazine/MTX) if chronic
• Crystal arthritis
 NSAID/colchicine/joint injection (steroid/LA)
 lifestyle review
 Allopurinol if recurrent, tophaceous or erosive

23. Management
• Sero-negative spondyloarthritis
 joint injection (steroid and LA)
 DMARD if chronic
 surgery (synovectomy, replacement)
• Osteoarthritis
 education, wt loss, physio
 joint injection (steroid/LA or
hyuralonate)
 surgery