Dr. Sami S. Eid Consultant Family Medicine Approach to Joint Pain Dr. Sami S. Eid Consultant Family Medicine

Objectives At the end of this session, the trainees should be able: To know the pathophysiology of joint pain . To list common causes of joint pain To examine major joints (knee, ankle, hip, elbow, shoulder) To provide a systematic approach to the investigation and differential diagnosis of patients presenting with joint pain. To describe diagnosis and treatment of the important joint problems Romatoid arthritis Osteoarthritis Gout arthritis Septic arthritis Tendonitis To describe referral criteria for common joint problems

Pathophysiology There may be : There may be: The pain may occur : Pain (arthralgia). Inflammation (arthritis) - redness, warmth, and swelling There may be: Only a single joint involved (mono-articular). Multiple joints involved. The pain may occur : Only with use, suggesting a mechanical problem (eg, osteoarthritis, tendinitis). At rest, suggesting inflammation (eg, crystal disease, septic arthritis). There may or may not be fluid within the joint (effusion).

Pathophysiology Joint pain may arise from: Structures within the joint (intra-articular): 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 Inflammatory. Infectious arthritis Rheumatoid arthritis Crystal deposition arthritis Non-inflammatory Osteoarthritis. internal mechanical derangement

Joint pain may arise from (cont..) Pathophysiology Joint pain may arise from (cont..) Structures adjacent or a round to the joint (peri-articular) Bursitis Tendinitis Extra-articular disorders (eg, polymyalgia rheumatica, fibromyalgia). Referred Pain from more distant sites

Basic principles Is the problem acute or chronic? Is it an articular or extra-articular problem? Is it a mono or oligo/poly arthritis? Are there features of joint inflammation? Are there extra-articular features? Is the arthritis part of a more generalised complaint?

Aetiology of Joint Pain Mono-articular Pain Trauma : ( overuse – fractures – hemarthrosis). Most common – to all ages Internal derangement or intra-articular trauma (Meniscus injury – ligament tear) Infectious or Septic arthritis (eg, bacterial, fungal, viral, mycobacterial, spirochetal, parasitic). Most important to rule out. Reactive arthritis (Aseptic inflammatory arthritis). Crystal-induced disease (gout or pseudogout) Periarticular syndromes (eg, bursitis, epicondylitis, fasciitis, tendinitis, tenosynovitis)

Aetiology of Joint Pain Mono-articular Pain Uncommon Causes : Avascular necrosis (H/O corticosteriod use or sickle cell anaemia) Neuropathy (Charcot ‘s Joint). Osteoarthritis Osteomyelitis. Lyme disease. Paget’s disease (Osteitis deformans) Tumor

Aetiology of Joint Pain Poly-articular Joint Pain Acute polyarticular arthritis is most often due to the following: Infection (usually viral) Flare of a rheumatic disease Chronic polyarticular arthritis in adults is most often due to the following: RA (inflammatory) Osteoarthritis (noninflammatory) Chronic polyarticular arthritis in children is most often due to the following: Juvenile idiopathic arthritis

Poly-articular disorders Cause Suggestive Findings Diagnostic Approach* Cause Suggestive Findings Diagnostic Approach Acute rheumatic fever Fever, cardiac symptoms and signs, and migrating inflammation of the large joints, Specific clinical criteria (Jones criteria), antistreptolysin O titers, group A streptococcal antigen testing Hemoglobinopathies (eg, sickle cell disease or trait, thalassemias) Symmetric pain in joints of hands and feet -Bone pain, avascular necrosis Young patients of African or Mediterranean , often with known diagnosis Hb electrophoresis Juvenile idiopathic arthritis Oligoarticular symmetric arthritis during childhood,. ANA and RF testing Lyme disease arthritis Erythema migrans, fever, malaise, headache, and myalgias in days to weeks after tick bite Serologic testing for antibodies against Borrelia burgdorferi Other rheumatic diseases (eg, polymyositis/dermatomyositis, scleroderma, Sjögren's syndrome, polymyalgia rheumatica) Depends on specific rheumatic disease and can include specific dermatologic manifestations, dysphagia, muscle soreness, or dry eyes and dry mouth X-ray and various serologies (eg, ANA, RF testing, anti-SS-A, anti-SS-B, anti-Scl-70) Sometimes skin or muscle biopsy Psoriatic arthritis Psoriasis, dactylitis (sausage digits), tendinitis, onychodystrophy Clinical evaluation Sometimes x-ray RA Symmetric involvement of small and large joints More prevalent among women Specific clinical criteria, x-ray, anti-CCP, and RF testing Septic arthritis (particularly that caused by Neisseria gonorrhea) Acute, severe pain; redness; swelling Higher index of suspicion in patients with risk factors for STDs Arthrocentesis Serum sickness Fever, arthralgia, lymphadenopathy, and skin eruption 1–21 days after treatment with a biologic compound (eg, blood products, vaccines, protein concentrates) SLE Malar rash, oral ulcers, alopecia, history of serositis (eg, pleuritis pericarditis), RA-like polyarthralgia Usually women Serologic testing (eg, ANA, RF, anti-dsDNA) Systemic vasculitis (eg, giant cell arteritis, Henoch-Schönlein purpura, hypersensitivity vasculitis, polyarteritis nodosa, Wegener's granulomatosis) Various and sometimes vague extra-articular symptoms, including abdominal pain, renal failure, sinonasal pathology, and dermatologic lesions (eg rash, ulcers, purpura, nodules) ESR Biopsy of any suspected affected area (eg, kidney, skin) Viral arthritis (particularly parvovirus but also enterovirus, adenovirus, Epstein-Barr, coxsackievirus, cytomegalovirus, rubella, mumps, hepatitis B, hepatitis C, varicella, HIV) Less severe than septic arthritis Malaise, lacy red malar rash, concomitant anemia in patients with parvovirus infection Jaundice with hepatitis B Systemic lymphadenopathy with HIV Sometimes parvovirus serologies or other virologic testing based on clinical suspicion

Oligo-articular disorders Ankylosing spondylitis‡ Back pain and symmetric involvement of the large joints, iritis, tendinitis, aortic insufficiency More common among young adult males X-ray HLA-B27 Behçet's syndrome Oral and genital ulcers, sometimes eye pain Begins in the 20s Specific clinical criteria Crystal-induced arthritis§ (eg, uric acid, Ca pyrophosphate, Ca hydroxyapatite) Acute onset of severe pain, redness, swelling (particularly in the great toe or knee for uric acid deposition) Arthrocentesis Fibromyalgia Diffuse myalgias, tender muscular points not involving joints, fatigue, sometimes irritable bowel syndrome Usually women Specific clinical criteria (see Fig. 1: Bursa, Muscle, and Tendon Disorders: Diagnosing fibromyalgia ) Infective endocarditis Fever, malaise, weight loss, heart murmur, embolic phenomena Blood cultures ESR Transesophageal echocardiography Osteoarthritis‡ Chronic pain usually in lower extremity joints, PIP and DIP joints, 1st carpometacarpal joint Heberden's nodes, Bouchard's nodes Reactive and enteropathic arthritis‡ Acute, asymmetric joint pain predominantly involving the lower extremities 1–3 wk after GI or GU infection (chlamydial urethritis) Clinical evaluation Sometimes X-ray, STD testing, stool cultures

Evaluation I - History Symptoms of joint disease Pain Inflammatory joint disease present both at rest and with motion. It is worse at the beginning than at the end of usage. Non-inflammatory joint disease(ie, degenerative, traumatic, or mechanical) Occurs mainly or only during motion Improves quickly with rest. Patients with advanced degenerative disease of the hips, spine, or knees may also have pain at rest and at night. Pain that arises from small peripheral joints tends to be more accurately localized than pain arising from larger proximal joints. For example, pain arising from the hip joint may be felt in the groin or buttocks, in the anterior portion of the thigh, or in the knee.

I - History Symptoms of joint disease Stiffness Stiffness is a perceived sensation of tightness when attempting to move joints after a period of inactivity. It typically subsides over time. Its duration may serve to distinguish inflammatory from non-inflammatory forms of joint disease. With inflammatory arthritis, the stiffness is present upon waking and typically lasts 30-60 minutes or longer. With noninflammatory arthritis, stiffness is experienced briefly (eg, 15 min) upon waking in the morning or following periods of inactivity.

I - History Symptoms of joint disease Swelling With inflammatory arthritis, joint swelling is related to synovial hypertrophy, synovial effusion, and/or inflammation of periarticular structures. The degree of swelling often varies over time. With noninflammatory arthritis, the formation of osteophytes leads to bony swelling. Patients may report gnarled fingers or knobby knees. Mild degrees of soft tissue swelling do occur and are related to synovial cysts, thickening, or effusions.

Symptoms of joint disease History Symptoms of joint disease Limitation of motion Loss of joint motion may be due to structural damage, inflammation, or contracture of surrounding soft tissues. Patients may report restrictions on their activities of daily living, such as fastening a bra, cutting toenails, climbing stairs, or combing hair. Weakness Muscle strength is often diminished around an arthritic joint as a result of disuse atrophy. Weakness with pain suggests a musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause. Manifestations include decreased grip strength, difficulty rising from a chair or climbing stairs, and the sensation that a leg is "giving way."

Symptoms of joint disease History Symptoms of joint disease Fatigue Fatigue is usually synonymous with exhaustion and depletion of energy in patients with arthritis. With inflammatory polyarthritis, the fatigue is usually noted in the afternoon or early evening. With psychogenic disorders, the fatigue is often noted upon arising in the morning and is related to anxiety, muscle tension, and poor sleep.

Temporal pattern of arthritis History Temporal pattern of arthritis The onset of symptoms can be abrupt or insidious. With an abrupt onset, joint symptoms develop over minutes to hours. This may occur in: trauma crystalline synovitis infection. With an insidious pattern, joint symptoms develop over weeks to months. It is typical of most forms of arthritis, including rheumatoid arthritis (RA) and osteoarthritis. Duration of symptoms is considered either acute or chronic. Acute is less than 6 weeks in duration chronic is 6 or more weeks in duration.

Temporal pattern of arthritis History Temporal pattern of arthritis The temporal patterns of joint involvement are migratory, additive or simultaneous, and intermittent. With a migratory pattern, inflammation persists for only a few days in each joint (eg, acute rheumatic fever, disseminated gonococcal infection). With an additive or simultaneous pattern, inflammation persists in involved joints as new ones become affected. With an intermittent pattern, episodic involvement occurs, with intervening periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis).

History Number of involved joints Symmetry of joint involvement Monoarthritis is the involvement of one joint. Oligoarthritis is the involvement of 2-4 joints. Polyarthritis is the involvement of 5 or more joints. Symmetry of joint involvement Symmetric arthritis is characterized by involvement of the same joints on each side of the body. This symmetry is typical of RA and SLE. Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

History Distribution of affected joints The distal interphalangeal joints of the fingers are usually involved in psoriatic arthritis, gout, or osteoarthritis but are usually spared in RA. Joints of the lumbar spine are typically involved in ankylosing spondylitis but are spared in RA. Distinctive types of musculoskeletal involvement Spondyloarthropathy involves entheses, leading to heel pain (inflammation at the insertions of the Achilles tendon and/or plantar fascia), dactylitis (sausage digits), tendonitis, and back pain (sacroiliitis and vertebral disc insertions). Gout commonly involves tendon sheaths and bursae, resulting in superficial inflammation.

History Extra-articular manifestations Constitutional symptoms suggest an underlying systemic disorder and are not expected in patients with degenerative joint disease. These may include fatigue, malaise, and weight loss. Skin lesions may be present. Physical examination of the skin, but not the joints, may indicate the specific diagnosis of a number of rheumatic diseases. Examples include SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum. Ocular symptoms or signs are also possible. Episcleritis and scleritis may be associated with RA or Wegener granulomatosis, anterior uveitis with ankylosing spondylitis, and iridocyclitis with juvenile RA. Conjunctivitis may be caused by reactive arthritis.

Common Causes of Acute Monoarthritis Bacterial Infection of the Joint Space I Non-gonococcal : S. aureus, BHSC, S. pneumonia, G-ve. II Gonococcal : precided by migratory tenosynovitis + Skin lesions Crystal-induced Arthritis Gout (monosodium urate crystals) Pseudogout (calcium pyrophosphate dihydrate crystals) Trauma Current Rheumatology Diagnosis & treatment - 2004

Differential Diagnosis of Chronic Monoarthritis Ch. Inflammatory MA Ch. Non-inflammatory MA Infection Non-gonococcal septic arthritis Gonococcal Chronic Lyme disease Mycobacterial Fungal Viral Crystl-induced arthritis Gout Peudogout Calcium apatite crystals Monoarticular presentation of oligoarthritis or polyathritis Spodyloarthropathy Rheumatoid arthritis Lupus & other systemic autoimmune diseases Sarcoidosis Uncommon or Rare Familial Mediterranean fever Amyloidosis Foreign-body (due to plant thorn, wood fragments, etc) Pigmented villonodular synovitis Osteoarthritis Internal derangments (e.g. torn meniscus) Chondromalacia patellae Osteonecrosis Uncommon or rare Neuropathic (Charcot) arthropathy Sarcoidosis Amyloidosis Current Rheumatology Diagnosis & treatment - 2004

Evaluation II – Physical Examination The musculoskeletal examination helps distinguish joint inflammation (eg, RA) from joint damage (eg, degenerative joint disease). It can also help elucidate the site of musculoskeletal involvement (eg, synovitis, enthesitis, tenosynovitis, bursitis) and the distribution of joint involvement.

I – Physical Examination General general condition, fever, pulse, BP Articular or extra-articular Joint Inflammation swollen, red, , tender, hot Functional impairment passive and active movement Crepitus during active or passive range of motion Instability Joint Deformity (flexion, subluxation, dislocation)

II – Physical Examination Other joints (including spine) Extra-articular features nails (pitting, ridging, hyperkeratosis) enthesitis, dactylitis and tenosynovitis nodules (elbows/ears) skin (local infection, psoriasis, keratoderma blenorrhagicum, balanitis) eyes (conjunctivitis, uveitis) mouth ulcers

Differential Diagnosis of Oligoathritis Acute Oligoarthritis Chronic Oligoarthritis Inflammatory Causes Common Spondylarthropathy Reactive arthritis Anklosing Spondylitis Psoriatic arthritis Inflammatory bowel disease Atypical presentation of rheumatoid arthritis Gout Uncommon or rare Subacute bacterial endocarditis Sarcoidosis Behcet disease Relapsing polychondritis Celiac disease Non-inflammatory Causes Osteoarthritis Hypothyroidism Amyloidosis Infection Dissaminated gonococcal infection Non-gonococcal septic arthritis Bacterial endocarditis Viral Postinfection Reactive arthritis Rheumatic fever Spondyloarthropathy Anklosing spondylitis Psoriatic arthritis Inflammatory bowel disease Oligoarticular presentation of rheumatoid arthritis, SLE, adult Still disease or other polyarthritis Gout and pseudogout Current Rheumatology Diagnosis & treatment - 2004

Differential Diagnosis of Polyathritis Acute Polyarthritis Chronic Polyarthritis Common Acute viral infections Early disseminated Lyme disease Rheumatoid disease Systemic lupus erythematosus Uncommon or rare Paraneoplastic polyarthritis Remitting seronegative symmetric polyarthritis with pitting edema (RS3PE) Acute Sarcoidosis Adult onset Still disease Secondary Syphilis Systemic autoimmune diseases & vasculitides Whipple disease Inflammatory Causes Common Rheumatoid arthritis Systemic lupus erythematosus Spondylarthropathy (esp. psoriatic arthritis) Chronic hepatitis C infection Gout Drug-induced lupus syndromes Uncommon or rare Paraneoplastic polyarthritis Remitting seronegative symmetric polyarthritis with pitting edema (RS3PE) Adult onset Still disease Systemic autoimmune diseases & vasculitides Sjogren syndrome Viral inections other than hepatitis C Whipple disease Non-inflammatory Causes Primary generalised osteoarthritis Hemochromatosis Calcium pyrophosphate deposition disease Current Rheumatology Diagnosis & treatment - 2004

Some Suggestive Findings in Polyarticular Joint Pain Possible Cause General findings Bone tenderness or chest pain Sickle cell crisis Coexisting tendinitis Gonococcal or rheumatoid disease Conjunctivitis, abdominal pain, and diarrhea Reactive arthritis Fever and malaise Infection, gout, rheumatic disorders, vasculitis Malaise and lymphadenopathy Acute HIV infection Oral and genital ulcer Behçet's syndrome Raised silver plaques Psoriatic arthritis Recent pharyngitis and migrating joint pain Rheumatic fever Recent vaccination or blood product Serum sickness Skin ulcerations, rash, and abdominal pain Vasculitis Tick bites Lyme arthritis Urethritis Gonococcal or reactive arthritis Merck Manual Minute - 2009

Investigations Urinalysis Haematology - FBC, ESR, clotting Biochemistry - U&E, LFTs, urate, CRP Immunology Microbiology blood/urine/stool/urethral/sputum cultures serology

Investigations Synovial fluid Imaging volume/viscosity/cellularity polarised light microscopy (crystals) gram stain/culture Imaging plain films loss of joint space, osteophytes, subchondral cysts, osteosclerosis, erosions, chondrocalcinosis arthrogram, MRI, bone scan

Categorization of Synovial Fluid White blood cell count Polymorphonuclear neutrophilic leukocytes Examples Normal 0 to 200 per mm3 (0 to 0.2 3 109 per L) <25% (0.25) -- Non-inflammatory <2,000 per mm3 (2 X 109 per L) Osteoarthritis, internal derangement, myxedema Inflammatory 2,000 to 50,000 per mm3 (2 to 50 3 109 per L) >75% (0.75) Rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, Neisseria gonorrhoeae infection Septic >50,000 per mm3 (50 X 109 per L); usually >100,000 per mm3 (100 X 109 per L) Usually >90% (0.90) Septic arthritis (primary concern); occasionally, gout, pseudogout, reactive arthritis, Lyme disease

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Management General Infection Haemarthrosis education, Physiotherapy analgesics and/or anti-inflammatory drugs Infection (if in doubt, treat until culture result) Gram +ve flucloxacillin, benzylpenicillin, Gram -ve 3rd generation cephalosporin 6 weeks in total (2 iv, 4 po) Haemarthrosis joint aspiration

Management Reactive arthritis Crystal arthritis joint injection (steroid and local anaesthetic) ophthalmology review screen partner (?) DMARD (Disease Modifying Anti-Rheumatic Drugs) (sulphasalazine/MTX) if chronic Crystal arthritis NSAID/colchicine/joint injection (steroid/LA) lifestyle review Allopurinol if recurrent, tophaceous or erosive

Management Sero-negative spondyloarthritis Osteoarthritis joint injection (steroid and LA) DMARD if chronic surgery (synovectomy, replacement) Osteoarthritis education, wt loss, physio joint injection (steroid/LA or hyuralonate) surgery

Thanks Dr. Sami eid