APPROACH TO A PATIENT

WITH JOINT PAIN

Hassan
Bin
Ajmal, MBBS
Intern at Medical
Unit-1

OBJECTIVES
Evaluation of a patient with joint pain.
Specific symptoms and signs of different pathologies.
Making a provisional diagnosis with respect to history,
examination and investigations.
Target audience: Young doctors and medical students.

EXCLUSIONS:
Detailed discussion of different pathologies and investigations.
Management part.

CASE

26-year-old woman with no prior medical history

presents with a 3-week history of joint pain,
swelling and stiffness. She informs you that she has
had stiffness for about 2 hours every morning
since these symptoms started and that the
symptoms improves as the day progresses. She
denies back stiffness or back pain. She has fatigue
and low-grade fever. On the examination the wrist,
MCPs and PIPs are red and swollen on both hands. The
DIPs are not involved. There is fluid in wrist joints.
Otherwise the examination is normal.

TERMS
ARTHRALGIA refers to joint pain. It is a
symptom.
ARTHRITIS refers to inflammation of the joints
and its a diagnosis. Signs of inflammation
include tenderness, redness, swelling, increase
in temperature and decrease/loss of function.

EVALUATION OF JOINT
PAIN/INFLAMMATION
1.
2.
3.
4.

Distribution
Acute v/s chronic
Systemic symptoms
Joint inflammation

Question 1

What
is
the
distribution of joint
involvement
and
how many joints

A.Polyarticular symmetric
B. Monoarticular
C. Migratory
D. Oligoarticular asymmetric

A. POLYARTICULAR SYMMETRIC
Rheumatoid Arthritis (RA)
Systemic lupus erythematosus (SLE)
Viral (Hepatitis B, EBV, Parvovirus B19)
Sjogren syndrome

B. MONOARTICULAR
Osteoarthritis (OA)
Crystal-induced arthritis (gout,
pseudogout)
Septic Arthritis (Gonococcus)
Trauma
Hemarthrosis

C. MIGRATORY
Rheumatic Fever
Disseminated gonococcal infection
Lyme disease

D. OLIGOARTICULAR
ASYMMETRIC
Spondyloarthropathies

(back pain +

peripheral arthritis)

-Ankylosing spondylitis
-Psoriatic arthritis
-Rieter Syndrome
-Enteropathic arthritis

Osteoarthritis (small joints of upper

extremities)

Examples
A 62-year-old man presents with right knee pain.
A 24-year-old woman presents with bilateral wrist,
MCP, PIP joint swelling, and pain.
A 32-year-old man presents with knee swelling after
you had seen him one week ago for left wrist pain and
swelling, which has now resolved.
A 29-year-old man has right knee pain and swelling
and left hip pain.

Question 2

Are the symptoms

acute or chronic?

 OA is a chronic disease; the patients

have symptoms for months to years.
Patients with septic arthritis or
crystal-induced arthropathies have
short-lived symptoms, commonly
only a few days.

Question 3

Does the patient

have
systemic
symptoms (beyond
arthritis)?

 SLE:

lungs involvement (pleural effusion), kidney (proteinuria

and renal failure), CNS (vasculitis, strokes, and change in
personality), skin (malar and photosensitivity rash), and
hematologic (immune-mediated anemia and thrombocytopenia).

Sjogren syndrome: keratoconjunctivitis sicca (dry eyes, dry

mouth) and parotid enlargement.

Wegener granulomatosis (overlaps with RA) presents with

upper respiratory (sinusitis and rhinitis), lower respiratory (lung
nodules and hemoptysis), and renal (necrotizing glomerulonephritis)
involvement.

OA, on the other hand, presents with absence of systemic symptoms.

Question 4

Is there evidence of
joint inflammation?

 Evidence of joint inflammation includes: joint

stiffness in the morning >1 hour, joint
erythema and warmth, and elevated
erythrocyte sedimentation rate (ESR) and
C-reactive protein e.g. Rheumatoid arthritis.

OA is typically noninflammatory.

Reaching to a diagnosis
History answer all the four questions and ask
for systemic symptoms.
Examination look for signs of inflammation
and systemic examination for specific signs.
Investigations blood tests, radiology and
joint aspiration.

TESTS IN RHEUMATOLOGIC
DISEASES
Joint Aspiration
If there is fluid in
the joint, it needs
analysis
immediately.
The basic tests to
run on the
synovial fluid are
the 3 Cs (cell
count, crystals,
and cultures) and
the Gram stain.

TESTS IN RHEUMATOLOGIC
DISEASES
CBC
UCE
PT
ESR, CRP
RA, Anti-CCP
ANA
ANCA

TESTS IN RHEUMATOLOGIC
DISEASES

TESTS IN RHEUMATOLOGIC
DISEASES

DISCUSS
ION

 26-year-old woman with no prior medical history

presents with a 3-week history of joint pain,
swelling and stiffness. She informs you that she
has had stiffness for about 2 hours every
morning since these symptoms started and that the
symptoms improves as the day progresses. She
denies back stiffness or back pain. She has
fatigue and low-grade fever. On the examination the
wrist, MCPs and PIPs are red and swollen on both
hands. The DIPs are not involved. There is fluid in
wrist joints. Otherwise the examination is normal.

RHEUMATOID ARTHRITIS
RA is a chronic inflammatory multisystemic disease
with the main target being the synovium. The
hallmark of RA is inflammatory synovitis that
presents in a symmetric distribution. The intense
joint inflammation that occurs has the potential to
destroy cartilage and cause bone erosions and
eventually deform the joint.
Anti-CCP (cyclic citrullinated peptide) is also positive
in RA and carries a very high specificity.

Presentation: Diagnostic criterianeed 4 of the following diagnostic

criteria.
Morning stiffness (>1 h) for 6 weeks
Swelling of wrists, MCPs, PIPs for 6 weeks
Swelling of 3 joints for 6 weeks
Symmetric joint swelling for 6 weeks
RF positive or anti-cyclic citrullinated peptide
CRP or ESR raised
X-ray abnormalities and nodules are not necessary for the diagnosis of RA.

Criteria. RA is a chronic inflammatory symmetric arthropathy. There needs to

be involvement of multiple joints, but some joints are never involved in RA:
DIPs
Joints of the lower back
Because RA is a systemic disease, two-thirds of patients present with
constitutional symptoms fatigue, anorexia, weight loss, generalized weakness
before the onset of the arthritis.

Extraarticular Manifestations
Damage to the ligaments and tendons
Radial deviation of the wrist with ulnar deviation of the
digits
Boutonnire deformity
Swan-neck deformity
Rheumatoid nodules
Initial event caused by focal vasculitis
2030% of patients with RA; usually occur in areas of
mechanical stress (olecranon, occiput, Achilles tendon)
Methotrexate may flare this process

 Felty syndrome (RA + splenomegaly + neutropenia)

Caplan syndrome (RA + pneumoconiosis)
Still disease (Juvenile RA + Fever + Rash
+Hepatospleenomegaly)

LABORATORY FINDINGS

RF or anti-CCP
Anemia
ESR or C-reactive protein (CRP)
X-rays
Synovial fluid analysis

The End
Thank You!