Approach to joint pain

1. APPROACH TO JOINT PAIN
Dr Anoop R Prasad

2. INTRODUCTION
• 15% of patients in general practice presents with
musculo-skeletal complaints
• Most common cause of long term pain and disability
• Joint diseases account for half of all chronic conditions in
people aged 60 and over
• Osteoarthritis accounts for half of all chronic conditions
in persons aged over 65. 25 % of people over the age of
60 have significant pain and disability from osteoarthritis

3. • Low back pain is the most frequent cause of limitation of
activity in the young and middle aged, one of commonest
reasons for medical consultation, and the most frequent
occupational injury. Back pain is the second leading
cause of sick leave.

4. • In children
• JRA : 58%
• Childhood SLE : 14%
• Rheumatic Fever : 12%
• Vasculitis : 7%
• Juvenile Dermatomyositis : 2%
Best Practice & Research Clinical
Rheumatology
Vol. 22, No. 4, pp. 583–604, 2008

5. NORMAL JOINT

6. • Is it Arthritis or Arthralgia?
• Presence of swelling of joint (synovial fluid , bony)
• Local warmth
• Tenderness along the joint line
• Redness (e.g. septic arthritis. acute gout .etc.)
• Range of motion (often reduced)
• Any deformity
• ( Rubor, Calor, Dolor, Tumor, Functio laesa )

7. INFLAMMATORY
• Rubor, calor, dolor, tumor,
Functio laesa
• Decreases with activity,
increase with rest
• EMS > 1 hour
• Systemic symptoms like
fever, weight loss, LOA
• ESR, CRP
NONINFLAMMATORY
• No classical signs
• Increases with activity,
decrease with rest
• EMS < 1 hour
• No systemic symptoms

8. ARTHRALGIA
• Fibromyalgia
• Bursitis
• Tendinitis
• Hypothyroidism
• Neuropathic pain
• Metabolic bone disease
• Depression
• Drugs

9. ARTHRITIS
• MONOARTHRITIS:
• Trauma
• Infection:
• DGI ± Skin lesion.
• Nongonococcal bacterial infections: large joints.
• Mycobacterial and fungal infection.
• Crystal induced arthritis
• Monosodium Urate crystals (MPJ)
• Ca pyrophosphate dihydrate crystals (knee)
• Lyme disease
• Systemic Rheumatoid diseases:
• Seronegative spondyloarthropathy (Reactive arthritis,
psoriatic arthritis, Inflammatory BD..)
• Sarcoid periarthritis
• RA
• Osteoarthritis

10. • POLYARTHRITIS:
• Rheumatoid Arthritis
• Systemic lupus Erythrematosus
• Viral arthritis
• Reiter’s disease (Reactive arthritis)
• Psoriatic arthritis

11. Articular Vs. Periarticular
Clinical feature Articular Periarticular
Anatomic
structure
Painful site
Pain on
movement
Swelling
Synovium,
cartilage,
capsule
Diffuse, deep
Active/passive,
all planes
Common
Tendon, bursa,
ligament,
muscle, bone
Focal “point”
Active, in few
planes
Uncommon

12. HISTORY
• Duration of complaints (acute<6wk versus chronic>6wk).
• Number of Joints involved (mono, oligo or
polyarthritis).
• Distribution of joints involved (peripheral, axial,
sparing some joints)
• Pattern of involvement (recurrent, additive, migratory
etc.)
• History of joint swelling
• Duration of early morning stiffness (prolonged in
Inflammatory arthritis)

13. • Extra-articular complaints (e.g. fever, rash, alopecia,
oral ulcers, photosensitivity etc.)
• Associated medical illness (e.g. psoriasis.
hypothyroidism, tuberculosis, IBD)
• Significant past history (similar episode of arthritis.
drug allergy. peptic ulcer)
• Family history of rheumatic disease (e.g. gout.
spondarthritis)

14. • Acute mono articular :
• Septic arthritis – orthopedic and medical emergency
• Crystal induced – gout , pseudogout
• Hemarthrosis - as in Hemophilia
• Chronic mono articular :
• Osteoarthritis
• Monoarticular presentation of RA or psoriatic arthritis

15. • Acute polyarticular:
• Reactive arthritis
• Viral arthritis
• Post viral arthritis
• Drug-induced arthritis
• Poncet's arthritis
• Sarcoidosis

16. • Chronic polyarticular:
• Rheumatoid arthritis
• Spondarthritis {AS, Reiter's, lBD-associated, uSpA
Juvenile spondylitis. Ps A)
• Psoriatic arthritis
• Juvenile Idiopathic Arthritis

17. • Distribution:
• Symmetrical- upper and lower limb eg. RA, SLE
• Asymmetric - psoriatic, gout, spondyloarthritidis
• Fist metatarsal – gout
• Hand joints with sparing of DIP – RA
• Axial joints – OA, AS, Spondyloarthritis, RA ( only
cervical spine)
• DIP : OA, Ps A

18. • Pattern:
• Fleeting / migratory :
• Rheumatic fever
• Gonococcemia
• Meningococcemia
• Viral Arthritis
• Acute Leukemia
• Additive:
• SLE
• RA

19. Age
• <30= SLE, Ankylosing spondylitis, Reactive Arthritis.
• 30-50= RA, Systemic sclerosis, Gout.
• >50= OA, Pseudogout, PMR
• Any Age group= Psoriatic arthritis, Enteropathic arthritis

20. • Extra articular manifestations :

22. EXAMINATION
• JOINT:
• Swelling, warmth, effusion – inflammatory
• Deformity
• Synovial thickening
• Active and passive movements – both restricted-
arthritis, passive normal & active restricted- enthesitis
• Number of joints involved

28. Extra articular manifestations

32. INVESTIGATIONS
• CBC – thrombocytosis, leukocytosis in inflammatory
• Acute phase reactants – ESR, CRP
• Urine analysis – pus cells in reactive arthritis, active
sediments( 2-5 rbc, rbc cast, wbc cast) in SLE, vasculitis
• Viral serologies – HBsAg, HCV, EBV,
Chikungunya,Parvo
• Serologies –
• RF -

33. Rheumatoid Arthritis Factor
• Antibody against the Fc portion of IgG.
• above 20 IU/mL, 1:40, or over the 95th percentile
• 75-80% sensitivity, 85-90% specificity, 60% PPV,
92% NPV
• 80% pts with RA, 70% with Sjogrens
• Epstein-Barr virus or Parvovirus infection
• 5-10% of healthy persons
• chronic hepatitis

34. • primary biliary cirrhosis,
• any chronic viral infection,
• Bacterial endocarditis,
• leukemia,
• dermatomyositis,
• infectious mononucleosis,
• systemic sclerosis,
• systemic lupus erythematosus (SLE)(20-30%)

35. • Anti ccp (cyclic citrullinated peptide):
• Sensitivity – 80%
• Specificity – 85- 98%
• ANA - Systemic lupus erythematosus (lupus or SLE) -
over 95%
• Progressive systemic sclerosis (scleroderma) - 60-
90%
• Rheumatoid Arthritis - 25-30%
• Sjogrens syndrome - 40-70%
• Felty's syndrome - 100%
• Juvenile arthritis - 15-30%
• Anti dsDNA -- SLE

36. • Serum uric acid - >7mg/dl to be significant
• 0.1% develop gout if <7, 0.5% if 7-8.9, 5% if >9
• Synovial fluid analysis:
• Monoarthritis
• Suspicion of infection
• Suspicion of crystal-induced arthritis
• Suspicion of hemarthrosis
• Differentiating inflammatory from noninflammatory
arthritis

38. RADIOLOGY

43. • 12 OCTOBER- WORLD ARTHRITIS DAY
16 OCTOBER - WORLD SPINE DAY
17 OCTOBER- WORLD TRAUMA DAY
20 OCTOBER - WORLD OSTEOPOROSIS DAY