• Clinical Skills
  • Clinical Skills

How To Approach a Patient with Painful Joints

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  • Revised on: 2020-08-20

Painful joints are one of the common presentations that you may encounter in your career. The following is a guide on how to  approach a patient with painful joints:

Good History Taking

Evaluate the Pain
Nature of onset of joint pain and frequency

With inflammatory joint disease, the pain is present both at rest and with motion. It is worse at the beginning of usage as opposed to at the end of usage.

With noninflammatory (ie, degenerative, traumatic, or mechanical) joint disease, the pain occurs mainly or only during motion and improves quickly with rest.

Localization of pain within the joint or associated myalgia or bone pain

deep joint pain(synovitis) or superficial joint pain(soft tissue injuries, tendon injuries)

Referral of pain to other joints.

Number of joints that are painful.

Associations

Fever indicates infective-septic arthritis or restive arthritis
 1.Stiffness

Stiffness is a perceived sensation of tightness when attempting to move joints after a period of inactivity

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.

Prolonged morning stiffness that does not involve the hands and feet should prompt consideration of a diagnosis other than RA.

2.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 does occur and are related to synovial cysts, thickening, or effusions.

3.Limitation of motion

Loss of joint motion may be due to structural damage, inflammation, or contracture of surrounding soft tissues. Patients usually report loss of joint motion indirectly by noting restrictions on activities of daily living (eg, fastening a bra, cutting toenails, climbing stairs, combing hair).

4.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."

5.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, muscular tension, and poor sleep.
 

 Historical features important to the differential diagnosis

 Temporal pattern of arthritis

The onset of symptoms can be abrupt or insidious. An abrupt onset is when joint symptoms develop over minutes to hours. This may be related to trauma, crystalline synovitis, or infection. With an insidious pattern, joint symptoms develop over weeks to months. This onset is typical of most forms of arthritis, including RA and osteoarthritis.

Duration of symptoms is considered either acute or chronic. Acute is less than 6 weeks in duration. Chronic is 6 weeks or more in duration.

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).

Number of involved painful joints

Monoarthritis is the involvement of one joint.
Oligoarthritis is the involvement of 2-4 joints.
Polyarthritis is the involvement of 5 or more joints.

The symmetry of joint involvement

Symmetric arthritis is characterized by the involvement of the same joints on each side of the body. This symmetry is typical of RA, SLE, other connective-tissue diseases, and many other arthritides.

Asymmetric arthritis is characteristic of psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis.

 Distribution of affected joints

The distal interphalangeal joints of the fingers are usually involved in patients with psoriatic arthritis, gout, or osteoarthritis but are usually spared in patients with RA.

Joints of the lumbar spine are typically involved in patients with ankylosing spondylitis but are spared in patients with RA.

Distinctive types of musculoskeletal involvement

Spondyloarthropathy involves joints and entheses. Resulting problems include heel pain, dactylitis (sausage digits), tendonitis and back pain.

Gout and infection may involve joints, tendon sheaths, and bursae.

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 caused by RA or Wegener granulomatosis. Anterior uveitis may be related to ankylosing spondylitis. Iridocyclitis is characteristic of juvenile RA. Conjunctivitis may be caused by reactive arthritis.