Evaluation of Joint Pain Sarah Lewis MHS, PA-C

Classifications and Different Strategies Anatomically Rule-out critical conditions first “Joint Emergencies” Mono vs Poly articular Inflammatory vs non inflammatory myelopathy /my·elop·a·thy/ (mi″ĕ-lop´ah-the) 1. any functional disturbance and/or pathological change in the spinal cord; often used to denote nonspecific lesions, as opposed to myelitis.

Anatomically

Anatomy

Anatomic Sources of Pain? Examples Clues Dermis Soft Tissue Muscle Bone Vascular Nervous Synovial Other Rheumatologic

Joint emergencies

Red Flags Acute Onset Fever? Red Hot Swollen Joint? History of Cancer? Pain Weakness Numbness Fever? Red Hot Swollen Joint? History of Cancer? Weight Loss? Underlying Bleeding Disorder?

Fever Fever suggests a subset of infectious and rheumatic illnesses including : Infectious arthritis (bacterial or viral) Postinfectious or reactive arthritis (enteric infection, rheumatic fever, inflammatory bowel disease) Rheumatoid arthritis and Still's disease Systemic rheumatic illness (vasculitis, SLE) Crystal-induced arthritis (gout and pseudogout) Other diseases such as cancer, sarcoidosis, and mucocutaneous disorders “Adult Still's disease is an inflammatory disorder characterized by quotidian (daily) fevers, arthritis, and an evanescent rash. First described in children by George Still in 1896, "Still's disease" has become the eponymous term for what is now called systemic onset juvenile inflammatory arthritis .” uptodate.com

Joint emergencies Septic Joint: infection of the joint requires immediate surgical wash out Compartment syndrome: fasciotomy to prevent neuromuscular, and vascular damage Acute myelopathy- cord impingement/nerve impingement motor dysfunction Osteomyelitis: infection of bone Avascular necrosis: bone necrosis due to vascular injury Cancer-Usually Mets Avascular necrosis: Cause: metabolic factors, local factors affecting blood supply such as vascular damage, increased intraosseous pressure, and mechanical stresses hyperemicdemineralization, trabecular thinning, and if stressed, collapse Risk factors: Glucocorticoid use and excessive alcohol intake (90%) Osteomyelitis can occur as a result of hematogenous seeding, contiguous spread of infection to bone from adjacent soft tissues and joints, or direct inoculation of infection into the bone as a result of trauma or surgery. Hematogenous osteomyelitis is usually monomicrobial, while osteomyelitis due to contiguous spread or direct inoculation is usually polymicrobial.

Septic Joints Bottom right 2 pictures are bursitis (not septic joints)

Monoarticular vs. polyarticular

Mono Articular DJD Crystalline Arthropathies Hemarthrosis Avascular Necrosis Osteomyelitis Tendonitis/ Synovitis/ Epicondylitis Septic Arthritis Trauma Tumor

Case 65 year old man with left great toe pain X2 days Had this before, he thinks Meds: HCTZ, ASA, simvastatin; NKDA Questions? HPI ROS PE

Poly Articular Polyarthritis (table 1- slide 20) Viral arthritis (table 2- slide 22) Postinfectious or active arthritis Fibromyalgia Multiple sites of bursitis or tendinitis Soft tissue abnormalities Hypothyroidism Neuropathic pain Metabolic bone disease Depression

Case 21 year old male with left elbow and right ankle pain, no fever Yesterday discharged from hospital for “STDs” PE: L elbow and right ankle appear slightly swollen, more pink. Active or passive ROM Any questions?

Case 27 year old female comes in complaining of multiple joint and “neck” pain Son recently sick with “slapped checks” rash PE: low fever, faint lacy rash, no focal MSK findings . . .

Thorough H&P

History General/Constitutional ENT-Sore Throat, Oral Ulcers, Dysgeusia GI-Critical!!! Abdominal Pain/Diarrhea/Hematochezia/IBS symptoms GU- Hematuria/Dysuria/Discharge Soft Tissue Symptoms PMH- Sickle Cell, RA, RF,DJD, LE, Gout Etc Fam Hx- Sickle Cell, RA, RF,DJD, LE, Gout Etc Medications-Diuretics, Procainamide, Statins, Others Allergies

Physical Examination Eyes-Conjunctivitis/Uveitis? Mouth-Oral Ulcers? Chest-Pulmonary Findings? Abdomen- Organomegaly? Rectal-Mets from Prostate Disease?

Physical Examination- cont. MS- All Joints, Soft Tissues Don’t forget the back !! Inspect for: Redness, swelling or rash Symmetry/ tone ROM Palpate for: Heat Crepitus Tenderness Strength Pain articular or juxta-articular

Evaluation of oligoarthralgia Uptodate.com

Lab Studies - Arthrocentesis/ Joint Fluid Analysis Arthrocentesis/ Joint Fluid Analysis for Cell Count Crystals Culture A positive synovial fluid culture establishes the diagnosis of infectious arthritis. A bloody effusion should lead to consideration of a coagulopathy, pseudogout, tumor, trauma, or a Charcot joint; subsequent evaluation includes a PT, PTT, platelet count, and bleeding time. Bone marrow elements = intraarticular fracture. A noninflammatory synovial fluid (eg, <2000 WBCs or <75 percent neutrophils) should lead to consideration of osteoarthritis, soft tissue injury, or viral infection. Inflammatory joint fluid with crystals = gout or pseudogout. A sterile inflammatory joint fluid raises the suspicion of systemic rheumatic disorders

Lab Studies CBC ESR, CRP Blood Cultures Antibody tests (and autoantibodies) Uric acid

Diagnostic Summary “Patients with a history of significant trauma or focal bone pain should have plain radiographs of the affected joint to rule out fracture, tumor, or metabolic bone disease. In the absence of a history of trauma or following a radiograph that excludes fracture or dislocation, an effusion or other signs of inflammation are markers of infection until proven otherwise. Thus, joint aspiration is the next diagnostic step .” uptodate.com

Radiologic Studies X-ray next slide Fluoroscopy- simultaneous image Movement Procedures CT (computed tomography) Air-filled spaces, fatty tissue, muscle, and cortical and cancellous bone Occult fractures MRI (magnetic resonance imaging) Soft tissue images Contraindications: metallic implants or pacemakers or the use of life support equipment (eg, ventilators) Bone Scan in 2 slides PET scanning (Positron emission tomography) FDG is a radiopharmaceutical analog of glucose that is taken up by metabolically active cells such as tumor cells Ultrasound Pediatric joint effusions, soft tissue, procedures

X-Ray Standardized imaging protocols are used for most joints Densities that can be distinguished on radiographs are calcium, soft tissue, fat, and air. Detect: Fractures Periosteal reaction Faint soft tissue calcification or ossification Localized lesions of bone Failure or complication of orthopedic hardware Bone dysplasias and other skeletal deformities. Uptodate.com

Bone Scan Detects: radionuclide activity in all three phases: blood flow phase, blood pool phase, and uptake at the area in question Disease examples: Acute fracture Osteoid osteoma Paget disease, fibrous dysplasia, and melorheostosis Osteomyelitis Hypertrophic pulmonary osteoarthropathy shin splints Complex regional pain syndrome

Common Causes of Polyarticular Joint Pain   Distribution Disease Chronology Inflammation Pattern Symmetry Axial involvement Extra-articular manifestations Female-to-male ratio Human parvovirus B19 infection Acute Yes Small joints No Lacy rash, malar rash 3:1 to 4:1 Rheumatoid arthritis Chronic Small and large joints Cervical Subcutaneous nodules, carpal tunnel syndrome Systemic lupus erythematosus Malar rash, oral ulcers, serositis (pleuritis or pericarditis) 9:01

Myalgias, tender points, irritable bowel syndrome 9:01 Disease Chronology Inflammation Pattern Symmetry Axial involvement Extra-articular manifestations Female-to-male ratio Osteoarthritis Chronic No Lower extremity joints, proximal and distal interphalangeal joints, first carpometacarpal joint Yes/No Cervical and lumbar None 1:1 to 2:1 Fibromyalgia Diffuse Yes Myalgias, tender points, irritable bowel syndrome 9:01 Ankylosing spondylitis Large joints Iritis, tendonitis, aortic insufficiency 1:1 to 1:5 Psoriatic arthritis Large and small joints Psoriasis, dactylitis (“sausage digits”), tendonitis, onychodystrophy 1:01

Malignancy: metastatic cancer, multiple myeloma TABLE 1 DIFFERENTIAL DIAGNOSIS OF POLYARTICULAR JOINT PAIN Viral infection: human parvovirus (especially B19), enterovirus, adenovirus, Epstein-Barr, coxsackievirus (A9, B2, B3, B4, B6), cytomegalovirus, rubella, mumps, hepatitis B, varicella-zoster virus (human herpes virus 3), human immunodeficiency virus Indirect bacterial infection (reactive arthritis): Neisseria gonorrhoeae (gonorrhea), bacterial endocarditis, Campylobacter species, Chlamydia species, Salmonella species, Shigella species, Yersinia species, Tropheryma whippelii (Whipple's disease), group A streptococci (rheumatic fever) Direct bacterial infection: N. gonorrhoeae, Staphylococcus aureus, gram-negative bacilli, bacterial endocarditis Other infections: Borrelia burgdorferi (Lyme disease), Mycobacterium tuberculosis (tuberculosis), fungi Crystal-induced synovitis: gout, pseudogout (calcium pyrophosphate deposition disease), hydroxyapatite Systemic rheumatic disease: rheumatoid arthritis, systemic lupus erythematosus, polymyositis/dermatomyositis, juvenile rheumatoid arthritis, scleroderma, Sjögren's syndrome, Behçet's syndrome, polymyalgia rheumatica Systemic vasculitis disease: Schönlein-Henoch purpura, hypersensitivity vasculitis, polyarteritis nodosa, Wegener's granulomatosis, giant cell arteritis Spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, reactive arthritis (Reiter's syndrome) Endocrine disorders: hyperparathyroidism, hyperthyroidism, hypothyroidism Malignancy: metastatic cancer, multiple myeloma Others: osteoarthritis, hypermobility syndromes, sarcoidosis, fibromyalgia, osteomalacia, Sweet's syndrome, serum sickness