Definition
A.Joint pain can be discomfort, pain, or inflammation arising from any part of a joint including cartilage, bone, ligaments, tendons, or muscles.
B.Acute joint pain is defined as pain resolving within 6 weeks of onset.
C.Chronic joint pain extends past 6 weeks from onset of symptoms.
D.Many joint pain complaints stem from self-limiting conditions, but there are many causes that require immediate and ongoing care.
E.Osteoarthritis (OA) or degenerative joint disease (DJD), which presents with pain and swelling resulting in decreased joint mobility, is the most common form of joint disease. It may affect any joint in the body, notably the hips and knees.
F.OA can affect the cartilage that cushions the ends of bones and allows for easy movement of joints.
Incidence
A.It is estimated that approximately 5% of primary care office visits are for joint pain with OA being the most common diagnosis.
Pathogenesis
A.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.
B.The basic pathophysiologic types of joint disease and pain stem from synovitis, enthesopathy, crystal deposition, infection, and structural or mechanical derangements.
Predisposing Factors
A.A combination of clinical, laboratory, and imaging data can help to differentiate patients likely to have self-limited disease from those likely to have persistent arthritis.
B.Prediction models based upon patients with early arthritis have identified a number of features associated with persistent and/or erosive disease, including:
1.Duration of symptoms prior to presentation.
2.Older age.
3.Male gender.
4.High body mass index (BMI).
5.Duration of morning stiffness.
6.Number of tender or swollen joints.
7.Involvement of lower extremities.
8.Elevated acute phase reactants.
9.Rheumatoid factor.
10.Anti-cyclic citrullinated peptide (anti-CCP) antibody.
11.Erosive change on baseline radiograph.
12.Human leukocyte antigen (HLA)-DRB1 shared epitope alleles.
Subjective Data
A.Common complaints/symptoms.
1.Knee pain.
2.Shoulder pain.
3.Hip pain.
4.Hand pain.
5.Ankle and foot pain.
6.Soft tissue swelling or effusion.
7.Joint erythema and warmth.
8.Joint tenderness.
9.Joint contractures or deformity.
10.Joint stiffness.
11.Myalgias and muscle spasms.
12.Muscle weakness.
B.Common/typical scenario.
1.Rash.
2.Fever.
3.Crepitus.
C.Family and social history.
1.Family history may have a role in joint pain. Specific questions inquiring about autoimmune diseases in the family should be addressed.
2.Patient’s daily routine may provide insight into causes of repetitive injuries.
3.Smoking can also contribute to joint pain.
D.Review of systems.
1.Specific symptoms to ask patients with joint pain.
a.Fever.
b.Weight loss.
c.Night sweats.
d.Rash.
e.Nodules.
f.Neuropathy.
g.Joint swelling.
h.Joint erythema.
i.Tenderness.
j.Warmth around joint.
k.Inability to use joint.
l.Eye pain.
m.Eye dryness.
n.Recent infection.
o.Recent tick bite.
p.Recent exposure to sexually transmitted infection (STI).
q.Recent joint injection or surgery.
r.History of immunosuppression.
2.Joint pain may represent a vast number of problems. The following questions can help direct
clinical decision making and narrow down differential diagnosis.
a.Is one joint affected or many joints affected?
i.One joint = monoarticular.
ii.Two to four joints = oligoarticular.
iii.Greater than five joints = polyarticular.
E.Is inflammation present or absent?
F.What joints are involved?
G.Are there systemic symptoms?
Physical Examination
A.A complete history and physical examination is appropriate for all patients presenting with joint pain, since this symptom may be the initial manifestation of a systemic illness.
B.The following findings on physical examination could indicate a more serious pathogenesis of joint pain.
1.General survey: Level of patient’s pain, ability to carry out activities of daily living (ADL).
2.Vital signs: Fever.
3.Eye: Keratoconjunctivitis sicca, uveitis, conjunctivitis, episcleritis.
4.Neck: Lymphadenopathy.
5.Mouth: Parotid enlargement, oral ulcerations.
6.Cardiovascular (CV): Murmur, pericardial, or pleural friction rubs.
7.Lungs: Fine inspiratory rales (secondary to interstitial lung disease).
8.Skin: Skin lesions may suggest that the joint symptoms are due to psoriatic arthritis, systemic lupus erythematosus (SLE), viral infection, or Still’s disease.
9.Musculoskeletal: Swollen, erythematous, warm joints, joint deformities, range of motion of joints.
10.Neurovascular: Muscle tone, muscle strength, sensory perceptions, gait.
Diagnostic Tests
A.Arthrocentesis and examination of synovial fluid to include a cell count, gram stain, crystal analysis, and culture.
B.Laboratory tests.
a.Complete blood count (CBC).
b.Basic metabolic panel (BMP).
c.Liver function test (LFTs).
d.Erythrocyte sedimentation rate (ESR).
e.C-reactive protein (CRP).
f.Uric acid.
g.Antinuclear antibody (ANA).
h.Rheumatoid factor.
i.Anti-CCP antibody.
C.Radiologic imaging of affected joint(s).
a.X-rays.
b.CT scan.
c.MRI.
D.Tissue biopsy.
Differential Diagnosis
A.Adult Still’s disease.
B.Ankylosing spondylitis.
C.Avascular necrosis.
D.Bone cancer.
E.Certain types of arthritis.
1.OA.
2.Juvenile rheumatoid arthritis.
3.Psoriatic arthritis.
4.Reactive arthritis.
5.Rheumatoid arthritis.
6.Septic arthritis.
F.Fractured bone.
G.Bursitis.
H.Complex regional pain syndrome.
I.Dislocation.
J.Gonococcal arthritis.
K.Gout.
L.Hypothyroidism.
M.Leukemia.
N.Lupus.
O.Lyme disease.
P.Osteomyelitis.
Q.Paget’s disease of bone.
R.Polymyalgia rheumatica.
S.Pseudogout.
T.Rickets.
U.Sarcoidosis.
V.Sprains and strains.
W.Tendinitis.
Evaluation and Management Plan
A.General plan.
1.Avoid using affected joint if doing so causes pain.
2.Use ice to area 15 to 20 minutes of each hour.
3.Specific treatment targeted to each individual diagnosis that may include but not be limited to:
a.Physical therapy.
b.Surgical management.
c.Pharmacologic intervention (noted in the following section).
B.Patient/family teaching points.
1.Exercise and weight loss are highly effective in relieving joint pain.
2.Start with low-impact exercises that don’t irritate the joint such as swimming or cycling.