Download Evaluation of Joint Pain

Evaluation of Joint Pain
Sarah Lewis MHS, PA-C
Classifications and Different
Strategies
1.
2.
Anatomically
Rule-out critical conditions first
“Joint Emergencies”
3.
4.
Mono vs Poly articular
Inflammatory vs non inflammatory
ANATOMICALLY
Anatomy
Anatomic Sources of Pain?
Source
Dermis
Soft Tissue
Muscle
Bone
Vascular
Nervous
Synovial
Other
Rheumatologic
Examples
Clues
JOINT EMERGENCIES
Red Flags

Acute Onset
◦ Pain
◦ Weakness
◦ Numbness
Fever?
 Red Hot Swollen Joint?
 History of Cancer?
 Weight Loss?
 Underlying Bleeding Disorder?

Fever

Fever 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)
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Rheumatoid arthritis and Still's disease
Systemic rheumatic illness (vasculitis, SLE)
Crystal-induced arthritis (gout and
pseudogout)
Other diseases such as cancer, sarcoidosis,
and mucocutaneous disorders
Joint emergencies
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 bone
5. Avascular necrosis: bone necrosis due to
vascular injury
6. Cancer-Usually Mets
1.
Septic Joints
MONOARTICULAR VS.
POLYARTICULAR
Mono Articular
DJD
 Crystalline Arthropathies
 Hemarthrosis
 Avascular Necrosis
 Osteomyelitis
 Tendonitis/ Synovitis/ Epicondylitis
 Septic Arthritis
 Trauma
 Tumor

Case
65 year old man with left great toe pain
X2 days
 Had this before, he thinks
 Meds: HCTZ, ASA, simvastatin; NKDA
 Questions?

◦ HPI
◦ ROS
◦ PE
Poly Articular
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Polyarthritis (table 1- slide 20)
Viral arthritis (table 2- slide 22)
Postinfectious or active arthritis
Fibromyalgia
Multiple sites of bursitis or tendinitis
Soft tissue abnormalities
Hypothyroidism
Neuropathic pain
Metabolic bone disease
Depression
Case
21 year old male with left elbow and right
ankle pain, no fever
 Yesterday discharged from hospital for
“STDs”
 PE: L elbow and right ankle appear slightly
swollen, more pink. Active or passive
ROM
 Any questions?

Case
27 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
History
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General/Constitutional
ENT-Sore Throat, Oral Ulcers, Dysgeusia
GI-Critical!!! Abdominal
Pain/Diarrhea/Hematochezia/IBS symptoms
GU- Hematuria/Dysuria/Discharge
Soft Tissue Symptoms
PMH- Sickle Cell, RA, RF,DJD, LE, Gout Etc
Fam Hx- Sickle Cell, RA, RF,DJD, LE, Gout Etc
Medications-Diuretics, Procainamide, Statins,
Others
Allergies
Physical Examination
Eyes-Conjunctivitis/Uveitis?
 Mouth-Oral Ulcers?
 Chest-Pulmonary Findings?
 Abdomen- Organomegaly?
 Rectal-Mets from Prostate Disease?

Physical Examination- cont.
MS- All Joints, Soft Tissues
 Don’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
CBC
 ESR, CRP
 Blood Cultures
 Antibody tests (and autoantibodies)
 Uric acid

Diagnostic Summary

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“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-Ray
Standardized imaging protocols are used for
most joints
 Densities that can be distinguished on
radiographs are calcium, soft tissue, fat, and
air.
 Detect:
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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 Scan
Detects:
 radionuclide activity in all three phases: blood
flow phase, blood pool phase, and uptake at the
area in question
 Disease examples:
◦
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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
Disease
Chronolo Inflammati
gy
on
Pattern
Axial
Symmet involveme Extra-articular
ry
nt
manifestations
Human
Acute Yes
parvovirus B19
infection
Rheumatoid Chronic Yes
arthritis
Small joints
Yes
No
Small and
large joints
Yes
Systemic lupus Chronic Yes
erythematosus
Small joints
Yes
Cervical Subcutaneous
nodules, carpal
tunnel syndrome
No
Malar rash, oral
ulcers, serositis
(pleuritis or
pericarditis)
Female-tomale ratio
Lacy rash, malar rash3:1 to 4:1
3:1 to 4:1
9:01
Disease
Inflam
Chronology mationPattern
Axial
Symmet involve Extra-articular
ry
ment manifestations
Osteoarthritis Chronic
No
Lower
Yes/No Cervic None
extremity joints,
al and
proximal and
lumbar
distal
interphalangeal
joints, first
carpometacarp
al joint
Fibromyalgia Chronic
No
Diffuse
Yes
Yes
Ankylosing
spondylitis
Chronic
Yes
Large joints
Yes
Yes
Psoriatic
arthritis
Chronic
Yes
Large and
small joints
Yes/No Yes/No Psoriasis, dactylitis
(“sausage digits”),
tendonitis,
onychodystrophy
Female-tomale ratio
1:1 to 2:1
Myalgias, tender points, 9:01
irritable bowel syndrome
Iritis, tendonitis, aortic
1:1 to 1:5
insufficiency
1:01
DIFFERENTIAL DIAGNOSIS OF POLYARTICULAR JOINT PAIN
•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