APPROACH TO ACUTE JOINT PAIN

• DR MOLLYZA MOHD ZAIN

• HOSPITAL SELAYANG
Outline
• Practical approach to joint pain
• Causes of acute joint pain
• Investigation
• Take Home message
1,074 patients surveyed in 2 Klinik Kesihatan in N9
- 18.8% had musculoskeletal (MSK) complaints.
- The knee was the most common site of MSK pain
(52.2%),
- 20.3% requiring referral for specialist assessment.
Public and private clinics
handled 27% versus 50%
acute cases and 20.0%
versus 3.1% chronic cases

Malays fam Physician. Feb 2021

 PRACTICAL APPROACH TO JOINT PAIN
Know your anatomy

periarticular
- tendon articular
- bursa - synovium
- ligament - capsule
- muscle - cartilage
- bone

referred pain
PRACTICAL APPROACH TO JOINT PAIN
Know the pathophysiology

? inflammation

? infection
? crystal deposition

? structural or mechanical joint derangement

? trauma related
 Thorough history taking and examination

1.Why do rheumatologists
make great detectives? They’re always
investigating pain points.

2.It’s not easy being a rheumatologist… you

have to juggle multiple joint pains at once!
6 STEPS
step 1 ? articular or non-articular

step 2 ? inflammatory or non inflammatory

step 3 ?acute or chronic

step 4 numbers and pattern of joint involvement

step 5 extra-skeletal manifestations

step 6 investigations
 Step 1 - periarticular vs articular

periarticular ROM
Periarticular pain
 Articular pain

Is it Arthritis or Arthralgia

arthritis arthralgia

swelling + -

erythema + -

local warmth + -

tenderness + ±

Loss of function + -
 Step 2 Inflammatory vs non inflammatory
arthritis
  step 3 ?acute or chronic

 step 4 numbers and pattern of joint involvement

 Step 5: Extra skeletal manifestation
Rash:
•Salmon pink evanescent rash: Adult onset Still’s disease
•Malar rash: SLE
•Plaques: Psoriasis
•Heliotrope rash: Dermatomyositis
•Erythema marginatum: Rheumatic fever Palpable purpura

•Erythema nodosum: Sarcoidosis, Crohn's disease Erythema nodosum

•Pyoderma gangrenosum: IBD, RA, SLE, ankylosing spondylitis,

•Palpable purpura: Hypersensitivity vasculitis, Schönlein-Henoch
purpura, PAN

Erythema marginatum
Pyoderma gangrenosum

Richie, A. M., & Francis, M. L. (2003, September 15). Diagnostic approach to polyarticular joint pain. AAFP. Heliotrope rash
https://www.aafp.org/pubs/afp/issues/2003/0915/p1151.html
Extra skeletal manifestation
Lesions
•Keratoderma blennorrhagicum: Reactive arthritis,
psoriatic arthritis
•Discoid lesions: Discoid lupus erythematosus, SLE,
sarcoidosis
•Gottron's papules: Dermatomyositis
Keratoderma blennorrhagicum

Gottron's papules Discoid lesions

Extra skeletal manifestation

Eyes
•Iritis/Uveitis: Spondyloarthropathies, sarcoidosis
•Conjunctivitis: Spondyloarthropathies, SLE
•Scleritis: RA, relapsing polychondritis
•Ischemic optic neuritis: Giant cell arteritis,
Wegener's granulomatosis
•Hypopion: Behcet Ischemic optic neuritis

Conjunctivitis Hypopions Scleritis

Iritis
Extra skeletal manifestation
Ears, Nose, and Throat
•Lymphadenopathy: AOSD
•Oral ulcers: SLE, Behçet's syndrome
•Parotid enlargement: Sjögren's syndrome, sarcoidosis
•Scalp tenderness: Giant cell arteritis
•Sinusitis: Wegener's granulomatosis
•Inflammation of ear: Relapsing polychondritis
•Tophi at pinna: Gout
Relapsing polychondritis.

Temporal arteritis
Oral ulcers Parotid enlargement
Tophi
Extra skeletal manifestation

Nails
•Onycholysis: Psoriatic arthritis,
hyperthyroidism
•Pitting: Psoriatic arthritis
•Nodules: RA, gout, Whipple's disease,
amyloidosis, sarcoidosis
•Tophi: Gout
•Thickened skin: Scleroderma,
amyloidosis
•Hair thinning: Hypothyroidism, SLE

Enthsitis
Extra skeletal manifestation

Cardiovascular System
•Mitral /Aortic regurgitation: Rheumatic fever
Genitourinary System
•Cardiomyopathies: Viral infection, amyloidosis
•Urethritis/Cervicitis: Reactive arthritis
•New murmur with fever: Bacterial endocarditis
•Ulcers: Behçet's syndrome
•Diminished peripheral pulses: Giant cell arteritis

Gastrointestinal System
•Splenomegaly: AOSD
•Hepatomegaly: AOSD, Whipple's
disease, hemochromatosis

Genital ulcer Cervicitis

• constitutional - fevers, weight loss;

• oral/nasal ulcers; lymphadenopathy; serositis; dysphagia;

dysuria, hematuria, frothy urine; diarrhea, bloody stool;
rashes, photosensitivity; Raynaud’s phenomenon
The university of arizona health science. (n.d.). Approach to joint pain . https://arthritis.arizona.edu/sites/default/files/arthritisgridupdate.pdf
 CLINICAL PEARL 1

Most of the diseases of the connective tissues in

particular arthritis can be identified clinically

 CLINICAL PEARL 2

Arthralgia suspicious for progression to Rheumatoid Arthritis

(EULAR definition)
History parameters :
-Joint symptoms of recent onset (duration
< 1 year) Physical examination parameters:
-Symptoms located in MCP joints -Difficulty with making a fist
-Duration of morning stiffness ≥60 min -Positive squeeze test of MCP
-Most severe symptoms present in the joints
early morning
-A first-degree relative with RA

A sensitivity > 90% was obtained in the presence of ≥3 parameters

and a specificity > 90% in the presence of ≥4 parameters.
 CLINICAL PEARL 3

A joint may be affected by more than a single process ;

eg septic arthritis and gout or pseudogout may coexist
in the same joint
  Step 6 Investigations

Principle
• should help further narrow the differential diagnosis

• should be aligned with your pre-test clinical diagnosis

– to either confirm or rule out suspected diagnostic possibilities
– guide your decision regarding next steps in management
  Step 6 Investigations
• Laboratory tests which include the autoantibodies

• Radiology investigations such as plain X-ray, musculoskeletal ultrasound ,

MRI.

• Others:

Ø Polarised microscope

Ø Capillaroscopy

Ø Arthrocentesis
 CLINICAL PEARL 4

SEPTIC ARTHRITIS MUST BE CONSIDERED IN PATIENTS WITH

MONOARTHRITIS (ACUTE/CHRONIC)
ALL PATIENTS WITH INFLAMMATORY MONOARTHRITIS SHOULD HAVE
AN ARTHROCENTESIS IF POSSIBLE
• The two most important indications for diagnostic arthrocentesis are:
• Suspected septic arthritis
• Suspected crystalline arthropathy
Investigations
investigations type

Basic blood investigation FBC RP LFT UFEME Uric acid

Inflammatory markers ESR,CRP, ferritin

Infection screen Hep B, C HIV

autoantibodies Rheumatoid factors (RF), ACPA, ANA, DsDNA, ENA (if

indicated)
Synovial fluid analysis Examination under polarized microscopy, FEME,
Culture and sensitivity
Radiology / imaging Plain radiographs, musculoskeletal ultrasound, CT scan,
MRI
Screening tests for inflammatory arthritis
Screening tests
ESR/CRP Inflammatory markers

ANA Non-specific
High titers present in lupus,
SS, scleroderma, CTD

Rheumatoid Factor Non-specific

High titers present in RA
Anti-CCP antibodies Highly specific for RA

Research in Progress
Mmp-3 As A Potential Predictor Of Inflammatory Arthritis Among New Patients Referred To
Rheumatology Clinic For Arthralgia
Diagnostic tests for specific rheumatic diseases
Disease Investigation
Septic arthritis Gram stain and culture of synovial fluid

Gout or pseudogout Serum uric acid (gout)

Synovial fluid for urate crystals (gout) or
calcium pyrophosphate dihydrate crystals
(pseudogout) under polarized light
microscopy
Double contour sign on ultrasound
Ankylosing spondylitis Sacroiliac joint radiography to demonstrate
bilateral sacroiliitis
Osteoarthritis Radiography of the affected joint
 Specific Serology - driven by clinical suspicion
Specific Serologies Clinical symptoms Present in..

dsDNA antibodies Oral ulcers, malar rash, Lupus

photosensitivity, hair loss,
serositis, hematuria,
proteinura
Anti- Smith As above Lupus
antibodies
Anti-Ro / anti-La As above Lupus, Sjogren’s
antibodies Dry eyes, dry mouth, RP syndrome
Anti-RNP antibodies Arthritis, rash, muscle Overlap syndrome
weakness, RP
Complements Above lupus symptoms Lupus
C3/C4
ANCA serologies Petechial rashes, chronic ANCA vasculitis
sinusitis, pulmonary nodules
• Rule out common causes of inflammatory arthritis
– Thyroid function test
– Hepatitis B, hepatitis C, HIV
Others such as chickungunya

General Labs
– CBC
– LFTs
– Serum creatinine
– Ferritin

Vit D level in generalised arthralgia

 CLINICAL PEARL 5

Positive ANA ≠ SYSTEMIC LUPUS ERYTHEMATOSUS

Positive Rh FACTOR ≠ RHEUMATOID ARTHRITIS

Radiographic Workup of Inflammatory
Arthritis
X-rays
• Usually normal in early inflammatory disease.
• chondrocalcinosis in CPPD X. ray characteristics of
inflammatory arthritis:
• Erosion
• Joint space narrowing

lunotriquetral
ligament
trapezioscaphoid

triangular
fibrocartilage
Radiology in osteoarthritis

X. ray characteristics of
osteoarthritis:
• Osteophytes
• Bony sclerosis (extra
bone formation)
• Joint space narrowing
 Role of musculoskeletal ultrasound
• may assist in diagnosis

• ultrasound guided intervention

double contour sign @ intracartilaginous CPPD @

suprapatellar knee joint. lateral femoral condyle s
When to Refer to Rheumatology
Ø Inflammatory arthritis
Ø Involvement of MCPs/MTPs
Ø High markers of inflammation
Ø Any patient with inflammatory back
pain
Ø Any patient with non-infectious
dactylitis
TAKE HOME MESSAGE
Thorough history and examination to come up with an accurate
differential diagnosis

Think beyond the joint - extra-skeletal manifestations

Order targeted investigations based on clinical suspicion.

Early Rheumatology referral for inflammatory arthritis