1. Joint pain: A family Medicine Approach
Eric Wooltorton MD Staff Physician TOH Civic Campus
September 2015

2. Objectives today: Diagnosis
1) List the most frequent causes (acute and chronic) of monoarthritis and polyarthritis.
2) Distinguish between osteoarthritis (OA), rheumatoid arthritis (RA), septic arthritis and gout from the physical exam.
3) List causes of low back pain
4) Identify risk factors and red flags from history and physical exam for LBP
5) List indications for diagnostic imaging for LBP

3. Objectives today: Management
6) Discuss the management of degenerative arthritis.
7) List the various indications, contraindications and side effects of medication used to treat arthritis.

4. Acknowledgements Dr Gary Viner for use of his many of his slides
uOttawa Medical students, clerkship program, and Department of Family Medicine for use of the “Problem Assisted Learning” cases
Figures from many references listed at end of this presentation

5. What does the CFPC (99 priority topics) specify?

6. 99 Priority topics continued…

7. Family Medicine approach: Illness & Illness experience
FIFE – the core of the Pt centred approach
Pain: OPQRST
Feelings
Ideas (and fears)
Function
Expectations
Onset
Precipitate/Relief
Quality
Radiation
Severty
Timing

8. Theme: The “Family Medicine Approach”
How does being a Family Physician potentially help when approaching a patient with ... Joint pain?
Relationship, trust – understand coping style/ illness behaviours
Awareness of “whole person”, illness experience (Pt and family), functional impact incl financial, drug plan?
Family: context/impact on function, collateral history, family history
Following patients over time: progression
Awareness of co-morbidities, medications
Care for pt with pretense of looking after other problems; time to approach Dx over weeks

9. Joint pain presents an inpact on function: ADLS, IADLS
ADL: grooming, toileting, bathing, dressing, transferring, continence, and eating
IADL: telephone use, shopping, transportation, budget management, adhering to medication regimens, cooking, housekeeping, and laundry

10. Approach to arthritis
DDx: ***Think about this – it focusses your history, exam and testing
*****consider serious Dx (red flags) and most common/likely
Red Flags:
Hx:
PE:
Investigations:

11. Initial characterization of arthritis
Duration: acute (hrs to days) vs chronic (wks or longer)
# joints (Mono, oligo (2-4); polyarticular (>=5)
Symmetric or asymmetric, additive or migratory
Accurate delineation of involved joints
Inflammatory or non inflammatory
Constitutional sxs
Extra articular disease
Comorbid conditions
P 33 Lange Current Diagnosis and Treatment: Rheumatology, 2nd Ed. Ed Imboden et al.

12. Initial characterization of arthritis
Duration:
acute (hrs to days) eg gout or septic
vs chronic (wks or longer) egRA vs spondyloarthropathies
Eg OA, IBD, psoriatic, torn meniscus, chondromalacia patellae, osteonecrosis, celiac, hep C, hemochromatosis
# joints:
Mono –bacterial incl gonococcal, crystals, trauma
oligo (2-4); Gonorr. , septic arthr, viral, bact endocarditis, reactive arthritis, Rheumatic fever (eg poststrep), spondyloarthropathy (reactive, ankylosing spondylitis, psoriatic, IBD, gout, pseudogout, )
polyarticular (>=5) –viral eg fifths, SLE, RA, paraneoplastic, sarcoid, secondary syphilis, vasculitis
P 33 Lange Current Diagnosis and Treatment: Rheumatology, 2nd Ed. Ed Imboden et al.

13. Initial characterizations of arthritis
Symmetric or asymmetric (asym – reactive arthritis)
additive or migratory
Accurate delineation of involved joints
Eg OA DIP, PIP, 1st MCP
RA PIPs, MCPs, MCPs. & wrists
Inflamm. vs non inflamm.
Psoriatic, RA, Septic, crystal vs OA
Constitutional sxs
eg fever
Extra articular disease
Eg IBD, psoriatic arthritis, gastroenteritis (reactive arthritis),urethritis, conjunctivitis (along with reactive arthritis)
Comorbid conditions

14. Approach to arthritis
Red Flags: temperature, previous history of cancer, trauma and infection signs.
Hx: trauma, swelling, morning stiffness, sexually transmitted diseases, osteoporosis, recent surgery, infiltration, stability of the joints
PE: general appearance; obesity; presence or absence of heat, redness, swelling and pain; amplitude of movements, test for ligaments, test for meniscus and test to determine the presence of effusion in the joints; approach to patient with low back pain

15. Approach to arthritis
DDX: ligament or meniscus problems, osteoarthritis vs. rheumatoid arthritis, monoarthritis vs. polyarthritis, gout, multiple myeloma, metastasis, scoliosis, ankylosing spondylitis. 
Investigations: blood tests, uric acid, radiography, knee aspiration

16. Separate into 4 groups
Start with your case – as a group you will present the answers to the others
Then move to the next case
Work together, move quickly through the cases
THINK LIKE A FAMILY PHYSICIAN!
Use the DDx to guide your Hx and PE
(be organized, red flags first, then most likely to least - don’t give a laundry list)
FIFE, OPQRST

17. Case 1: What else would you like to know about her pain?
What physical examination would you do?
What is your differential diagnosis for knee pain?
Is there a role for diagnostic imaging at this point? Any other tests?
What would you recommend to manage her pain
Red Flags:
Hx:
PE:
DDx: incl meniscal tear, OA, less likely inflammatory, #
Investigations

18. 2) Distinguish between how OA, RA, septic arthritis and gout will present (Hx and PE)
Non-inflammatory arthritis
Inflammatory arthritis
Stiffness generally mild, usually not a prominent symptom
Pain tends to worsen with activity, improve with rest
Usually N ESR and CRP
Stiffness worse in am or after inactivity “gel phenomenon”
Pain tends to improve with mild/mod activity
Warm large joints, erythema
WBC incr in synovial fluid
ESR, CRP incr

19. Case 2:
What else would you like to know about his pain? Why is family history important to ask?
What physical examination would you do? What is Shober’s manoeuvre? Why would you check his eyes?
What is your differential diagnosis for his back pain?
Is there a role for diagnostic imaging at this point? Any other suggestions?
What would you recommend to manage his pain?
Red Flags:
Hx:
PE:
DDx:
Investigations

20. 3) Causes of Acute LBP

21. 3) Causes of acute LBP cont

22. Alberta “LBP” guidelines

23. Acute LBP Red flags

24. Ankylosing spondylitis
Prototype of spondyloarthropathies
Reactive arthritis, psoriatic arthritis, IBD
Often includes enthesitis (insertion points of tendons, ligaments)
Inflammatory back pain in young adults
Pos FHx
Radiographs: Sacroilitis
Anterior uveitis
Incr HLA-B27
Eventual fusion of L spine causes straightening of spine
P175 Gorman and Imboden, Current Diagnosis & Treatment: Rheumatology 2nd Ed.

25. 4) LBP exam Non spine – abd exam. Strength -legs
Reflexes –knees, ankles
Palpation spine, incl SI joints
Spine ROM
Shober’s Manoever for ankylosing spondylitis

26. 5) Indication for LBP imaging
Imaging not warranted for most pts w. acute LBP
W/o signs and sxs indicating a serious underlying condition, imaging does not improve clinical outcomes in these pts.
Even with a few weaker red flags, 4-6 wks Tx is appropriate before consideration of imaging studies.
If serious condition suspected, MRI is usually best
CT is an alternative if MRI is CI or unavailable.
likelihood of false-positive results increases with age
Radiography may be helpful to screen for serious conditions, BUT low sensitivity and specificity.

27. Case 3: What else would you like to know about his pain?
What physical examination would you do?
What is your differential diagnosis for his foot pain?
Is there a role for diagnostic imaging at this point? Other investigations?
What would you recommend to manage his pain?
Red Flags:
Hx:
PE:
DDx:
Investigations

28. Gout Triggers – thiazides, CRF, cancer
Inflammatory often mono-arthritis
“Bed sheet tenderness”
Often 1st MTP –distal cool joints
Tophi
Incr urate – eg purine rich diet (meat, seafood, EtOH)
Crystals on aspirate
Acute Txs incl NSAIDs, colchicine, prednisone
Purine lowering Tx eg allopurinol – in acute phase, adjust in renal failure

29. Case 4: What else would you like to know about her pain?
What physical examination would you do?
What is your differential diagnosis for her shoulder pain?
Is there a role for diagnostic imaging at this point? Other investigations?
What would you recommend to manage her pain?
Red Flags:
Hx:
PE:
DDx: incl bursitis, rotator cuff tear, #, mets, OA, referred (eg liver mets)
Investigations

30. 6) Discuss the management of degenerative arthritis.
Treatments:
Non pharmacological:
weight loss, exercise, aqua fit, diet, stop alcohol, physiotherapy, prosthesis, glucosamine.
Pharmacological:
Tylenol, NSAIDs.
Side effects and complications of the NSAID such as gastro, renal, cardiac, HTN, allergy.
Orthopedic surgeon for arthroscopy and knee replacement.
For RA, early Dx and refer promptly to a rheumatologist.
Discuss role of oral cortisone, and other disease modifying medications (DMARD’s)

31. References
Lange Current Diagnosis & Treatment: Rheumatology 2nd Ed. [Editors John Imboden, David Hellman, John Stone] 2007, McGraw Hill. Toronto, ON
Casazza BA. Diagnosis and Treatment of Acute Low Back Pain. American Family Physician 2012; 85(4):
Top Doctors Alberta, Low Back Pain guidelines (2011) Available: ARYnov24.pdf?_