This document provides an overview of how to approach a patient presenting with joint pain. It discusses how the pain may occur only at rest or only with activity. The physical exam aims to localize the source and understand the pathophysiology by assessing for signs of inflammation, functional impairment, swelling, range of motion, and tendon issues. Taking a thorough history is important to generate differential diagnoses and evaluate features like onset, duration, joint involvement, and extra-articular manifestations that may indicate underlying conditions like rheumatoid arthritis or lupus.

1. Approach to patient with
joint pain
HAMMAD KHALIL

2. overview
 Joint pain can have multiple causes,
 It is a reflection of diverse joint diseases, arises from
inflammation, infection, cartilage degeneration, crystal
deposition and trauma
 Initial aim is to localize the source and to understand the
pathophysiology
 Differential diagnosis are generated in large part from history
and clinical examination
 Laboratory tests serves primarily to confirm the diagnosis

3.  The pain may occur:
only during rest suggesting inflammation. eg, crystal disease,
septic arthritis
only during activity suggesting mechanical problem. Eg. OA,
tendinitis
 There may or may not be fluid in joint cavity(effusion)
 There may be:
single joint involvement(mono-articular)
oligo or pauci-articular involvement(2-4 joints)
polyarthritis( involvement of 5 or more joints)

4. ARTHRITIS VS ARTHRALGIA
ARTHRITIS
DIAGNOSIS
JOINT PAIN
INFLAMMATORY SIGNS
MOTION LIMITATION
STIFFNESS
ARTHRALGIA
SYMPTOM
JOINT PAIN
NON-INFLAMMATORY
NO SWELLING

5. PATHOPHYSIOLOGY
JOINT PAIN MAY ARISE ANATOMICALLY FROM
Structures within the joint (intra-articular);
joint capsule
Periosteum
Ligaments
Subchondral bone
Synovium
Eg. Synovitis, capsulitis

6. pathophysiology
Structures adjacent or around the joint(peri-articular);
Bursa- bursitis
Tendon sheath-tenosynovitis
Tendon- tendonitis
Insertion of tendon, ligament- enthesitis
Extra-articular disorders e.g, fibromyalgia, polymyalgia rheumatica
Referred pain from more distant site

7. Crystal deposition
 The deposition of crystals in articular structures may lead to symptomatic disease.
 The responsible crystals are:
Monosodium urate; gout
Calcium pyrophosphate; pseudo-gout
Calcium oxalate

8. Structural or mechanical joint deralement
 Degeneration of articular cartilage is the principal pathologic event of OA. It occurs
in response to both local and host factors
 Host factors are: genetic traits, obesity, profession
 Local factors are: previous trauma (meniscal tear)
congenital or developmental joint alterations(congenital hip dysplasia)
alterations of subchondral bone (osteopetrosis, avascular necrosis)
alterations of supporting structures (hypermobility)
cartilage derangement (crystal deposition)

9. ETIOLOGY OF JOINT PAIN
 MONO-ARTICULAR PAIN
Trauma
Infectious or septic arthritis
Reactive arthritis
Crystal induced arthritis
Periarticular syndromes (e.g bursitis, epicondylitis, tendinitis)
Avascular necrosis
Osteomyelitis
Lyme disease
Paget’s disease
tumor

10. Etiology
Poly-articular pain:
 Acute poly-articular arthritis is most often due to following:
Infections (mostly viral)
Flare of rheumatic disease
 Chronic poly-articular arthritis in adults is most often due to:
RA (inflammatory)
OA (non-inflammatory)
 Chronic poly-articular arthritis in children is due to
Juvenile idiopathic arthritis

11. APPROACH
 HISTORY
 SYMPTOMS OF JOINT DISEASE;
 PAIN:
 Inflammatory joint disease:
Present both at rest and during activity
It is worse at start of movement
 Non inflammatory joint disease;
occurs mainly or only during motion
Improves quickly with rest

12. Symptoms of joint disease
 Stiffness;
Sensation of tightness when attempting to move joints after inactivity
Typically subsides over time
In inflammatory arthritis, the stiffness is present with early morning that last about 1
Hour
With non- inflammatory arthritis, tend to occur after resting and stiffness last only a
few minutes

13.  Swelling:
With inflammatory arthritis, joint swelling is related to synovial hypertrophy, synovial
effusion and or peri articular involvement.
With non-inflammatory arthritis, formation of osteophytes lead to bony swelling. Mild
degrees of soft tissue swelling may occur and are due to synovial thickening, cyst
formation.

14.  Limitation of motion:
May be due to structural damage, inflammation or contracture development
Patient may tell about restriction in daily activities.
 Weakness:
Due to disuse atrophy, muscle strength is often reduced around the joint.
Weakness with pain suggests a musculoskeletal cause (eg, arthritis, tendonitis) rather
than a pure myogenic or neurogenic cause.
Manifestation include decreased grip strength, difficult to rise from chair

15.  Fatigue;
Synonymous with exhaustion and lack of energy
With inflammatory poly-arthritis fatigue is usually noted in late afternoon or early
evening
While in psychogenic disorders, fatigue is noted upon arising in morning.

16. HISTORY
 Historical features important to the differentials diagnosis are following:
 Onset, duration and temporal pattern of joint involvement
 Number of joint involved
 Symmetry of involvement
 Distribution of affected joints
 Distinctive type of musculoskeletal involvement
 Extra-articular manifestations

17.  TEMPORAL PATTERN OF ARTHRITIS
 ONSET OF SYMPTOMS:
 With abrupt onset- developed over minutes to hours. Occur in;
 Trauma
 Crystal induced
 synovitis
 With insidious onset- developed over weeks to months. Typical of most types of arthritis
o Rheunmatoid arthritis
o osteoarthritis
 DURATION OF SYMPTOMS if considered either:
Acute: less than 6 week duration
Chronic: more than 6 week duration

18.  MIGRATORY, ADDITIVE OR SIMULTANEOUS, INTERMITTENT:
 With migratory pattern, inflammation persists for only a few days in each joint
 With additive pattern, inflammation persists in involved joints as a new joints
become affected
 With intermittent pattern, episodic involvement occurs, with symptom free periods

19.  Number of joints involved;
 Mono-articular involvement
 Oligo or pauci-articular involvement
 Poly-articular involvement
 Symmetry of joint involvement:
 Same joints involved in both sides of body; typical of RA and SLE
 Asymmetric involvement is characteristic of psoriatic arthritis, reactive arthritis and
lyme arthritis

20.  Distribution of affected joints:
Distal interphalangeal joints of fingers are usually involved in psoriatic arthritis, gout or
OA but rarely involve in RA
Joints of lumbar spine are typically involved in ankylosing spondylitis but are spared in
RA
 Distinctive type of musculoskeletal involvement
gout commonly involves tendon sheaths and bursae resulting in superficial
inflammation
Spondyloarthropathy involves areas of Achilles tendon, planter fascia; leading to
tendonitis, heal pain, back pain

21. Extra-articular manifestations
 Skin involvement;
May indicate specific diagnosis
SLE, scleroderma, psoriasis
 Ocular involvement
Episcleritis and scleritis- RA
Anterior uveitis- ankylosing spondylitis
Iridiocyclitis with JRA
Conjunctivitis with reactive arthritis
 Constitutional symptoms
May suggest underlying systemic disease

22. PHYSICAL EXAMINATION
 It helps to distinguish joint inflammation (RA) from joint damage (degenerative
joint disease)
 It also helps to identify site of involvement
Synovitis
Tendonitis
Bursitis
 Distribution of joint involvement

23.  General condition; GPE, VITALS
 JOINT EXAMINATIOIN (ASK, LOOK, FEEL, MOVE)
 Articular and extra-articular examination
 Signs of inflammation
 Functional impairment
Passive and active movement
Instability
Crepitus
Joint deformity

24.  Swelling and ecchymosis
 Laxity(hypermobility)
 Gross deformity
 Range of motion
 Tendon or muscle dysfunction