Evaluation of Joint Pain Sarah Lewis MHS, PA-C.
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Evaluation of Joint PainSarah Lewis MHS, PA-C
Classifications and Different Strategies1. Anatomically2. Rule-out critical conditions first
“Joint Emergencies”
3. Mono vs Poly articular4. Inflammatory vs non
inflammatory
ANATOMICALLY
Anatomy
Anatomic Sources of Pain?Source Examples Clues
Dermis
Soft Tissue
Muscle
Bone
Vascular
Nervous
Synovial
Other
Rheumatologic
JOINT EMERGENCIES
Red FlagsAcute Onset
◦Pain ◦Weakness◦Numbness
Fever?Red Hot Swollen Joint?History of Cancer?Weight Loss?Underlying Bleeding Disorder?
FeverFever 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 diseaseSystemic rheumatic illness (vasculitis, SLE)Crystal-induced arthritis (gout and
pseudogout)Other diseases such as cancer, sarcoidosis,
and mucocutaneous disorders
Joint emergencies1. Septic Joint: infection of the joint requires
immediate surgical wash out 2. Compartment syndrome: fasciotomy to
prevent neuromuscular, and vascular damage
3. Acute myelopathy- cord impingement/nerve impingement motor dysfunction
4. Osteomyelitis: infection of bone5. Avascular necrosis: bone necrosis due to
vascular injury6. Cancer-Usually Mets
Septic Joints
MONOARTICULAR VS. POLYARTICULAR
Mono ArticularDJDCrystalline ArthropathiesHemarthrosisAvascular NecrosisOsteomyelitisTendonitis/ Synovitis/ EpicondylitisSeptic ArthritisTraumaTumor
Case65 year old man with left great
toe pain X2 daysHad this before, he thinksMeds: HCTZ, ASA, simvastatin;
NKDAQuestions?
◦HPI◦ROS◦PE
Poly ArticularPolyarthritis (table 1- slide 20)Viral arthritis (table 2- slide 22)Postinfectious or active arthritisFibromyalgiaMultiple sites of bursitis or tendinitisSoft tissue abnormalitiesHypothyroidismNeuropathic painMetabolic bone diseaseDepression
Case21 year old male with left elbow
and right ankle pain, no feverYesterday discharged from
hospital for “STDs”PE: L elbow and right ankle
appear slightly swollen, more pink. Active or passive ROM
Any questions?
Case27 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
HistoryGeneral/ConstitutionalENT-Sore Throat, Oral Ulcers, DysgeusiaGI-Critical!!! Abdominal
Pain/Diarrhea/Hematochezia/IBS symptomsGU- Hematuria/Dysuria/DischargeSoft Tissue SymptomsPMH- Sickle Cell, RA, RF,DJD, LE, Gout EtcFam Hx- Sickle Cell, RA, RF,DJD, LE, Gout EtcMedications-Diuretics, Procainamide,
Statins, OthersAllergies
Physical ExaminationEyes-Conjunctivitis/Uveitis?Mouth-Oral Ulcers?Chest-Pulmonary Findings?Abdomen- Organomegaly?Rectal-Mets from Prostate
Disease?
Physical Examination- cont.MS- All Joints, Soft TissuesDon’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
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 CBCESR, CRPBlood CulturesAntibody 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-RayStandardized imaging protocols are used
for most jointsDensities 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.
Bone ScanDetects: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
DiseaseChronology
Inflammation Pattern
Symmetry
Axial involvement
Extra-articular manifestations
Female-to-male ratio
Human parvovirus B19 infection
Acute Yes Small joints Yes No Lacy rash, malar rash3:1 to 4:1
Rheumatoid arthritis
Chronic Yes Small and large joints
Yes Cervical Subcutaneous nodules, carpal tunnel syndrome
3:1 to 4:1
Systemic lupus erythematosus
Chronic Yes Small joints Yes No Malar rash, oral ulcers, serositis (pleuritis or pericarditis)
9:01
Disease ChronologyInflammationPattern
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 Chronic No Diffuse Yes Yes Myalgias, tender points, irritable bowel syndrome
9:01
Ankylosing spondylitis
Chronic Yes Large joints Yes Yes Iritis, tendonitis, aortic insufficiency
1:1 to 1:5
Psoriatic arthritis
Chronic Yes Large and small joints
Yes/No Yes/No Psoriasis, dactylitis (“sausage digits”), tendonitis, onychodystrophy
1:01
•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
TABLE 1DIFFERENTIAL DIAGNOSIS OF POLYARTICULAR JOINT PAIN
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