Evaluation of Joint Pain Sarah Lewis MHS, PA-C.

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