Approach to Joint Pain¶

Tina Arkee

Background¶

MSK complaints account for >20% of all outpatient visits in the US
The goal is to formulate a ddx based on good history taking and thorough physical exam that leads to accurate diagnosis and timely therapy while avoiding excessive diagnostic testing and unnecessary treatment

Articular (within the joint) vs. extra-articular (involving muscles, tendons, bursae, bones)
Articular: pain with passive and active ROM, swelling, crepitus, joint instability, joint deformity
Extra-articular: pain with active ROM only, may have focal tenderness near the joint, typically no crepitus, instability, or deformity
Chronology
- Acute: < 6 weeks
- Chronic: >12 weeks
Inflammatory vs. noninflammatory
- Inflammatory: swelling, warmth, erythema, worse with rest, morning stiffness > 30 min - 1 hr
- Noninflammatory: worse with activity, morning stiffness < 30 min - 1 hr
Localized (monoarticular) vs diffuse (oligo/polyarticular)
- Monoarticular: 1 joint
- Oligoarticular: 2-4 joints
- Polyarticular: >4 joints
Symmetric vs asymmetric
Size of joints involved (small vs large)
Presence of signs and symptoms of systemic inflammation

Visually inspect the affected joint. Inflamed joints may look red, swollen, or deformed.
Palpate the joint for warmth, effusion, focal tenderness (inflammatory) or bony enlargement (non-inflammatory)
Perform passive and active ROM exam. Articular joint pain is elicited by passive and active ROM, and may also have crepitus. Extra-articular joint pain is only elicited by active ROM.
Look for signs of systemic inflammation, including rashes, mucosal ulcers, hair and nail changes.
For polyarticular complaints, the goal is to determine inflammatory vs non-inflammatory
- Inflammatory: joint swelling, warmth, visible deformities. More common in MCP and wrist
- Non-inflammatory: bony enlargement, Heberden’s nodes (DIP), Bouchard’s nodes (PIP), CMC squaring, prominence of the medial tibial plateau, absence of joint effusions (except the knees with severe OA). More common in DIP and weight bearing joints.

X-ray: may be normal in early disease; can be used to monitor disease progression
- Inflammatory arthritis: early on, may see soft tissue swelling and periarticular demineralization; later in disease, may see erosions, uniform joint space narrowing, and joint subluxation
- Non-inflammatory arthritis (i.e. osteoarthritis): non-uniform joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts
Ultrasound: Useful for detecting synovial hypertrophy, tissue vascularity (use doppler), and visualization of joint effusions and tendons to guide arthrocentesis
MRI: more sensitive than xray and MRI, but not necessarily more specific