The Patient with

Joint Pain
Musculoskeletal 2 Module
Nancy Selfridge, MD
Department of Clinical Medicine
2017
Hang in there *Kiss*! (Can’t hug with fins!)
 Learning Objectives
• List key elements of a musculoskeletal pain history and a physical
examination
• Identify and discriminate between the following based on key history,
physical exam, lab and x-ray features in a clinical vignette:
o Osteoarthritis, RA, gout, septic arthritis, pseudogout, psoriatic
arthritis, polymyalgia rheumatica, ankylosing spondylitis, reactive
arthritis, gonococcal arthritis
• Correlate and integrate above clinical knowledge with associated
pathophysiology and pharmacology
• Apply knowledge and understanding of the descriptions of the above
conditions to decisions concerning evaluation and management
• Describe arthrocentesis and how to interpret synovial fluid analysis and
apply its use in the evaluation of a patient with joint problems
 Making a Diagnosis

Common Scary

Start with a knowledge of the common and serious causes.

Then let this list drive your history, physical exam and lab evaluations.
 Making a Diagnosis
For Non-traumatic Musculoskeletal Pain:

•History – 85%
•Physical and musculoskeletal
examination – 10%
•Lab and imaging – 5%
American College of Rheumatology - 1996
 DETERMINE FIRST

Inflammatory vs. Noninflammatory*?

Inflammatory Noninflammatory
• Infection • Acute trauma (e.g. fracture or
• Crystal-induced arthritis rotator cuff tear)
• RA • Overuse (tendinitis, bursitis)
• SLE • Degenerative (OA)
• Reactive arthrits • Neoplasm
• Rheumatic fever • Idiopathic (fibromyalgia)
• Ankylosing spondylitis
• Polymyalgia rheumatica

*Systemic inflammation
How can you tell if inflammation is present in a
joint or periarticular structure?

RUBOR, CALOR, DOLOR, TURGOR

“Have you had any redness, swelling or heat in or around the joint(s)?”
 NEXT DETERMINE
Extent & Distribution of Involvement
Using Semantic Qualifiers
• Joint (articular) disorders
oMonoarticular – just one joint
oOligo- or Pauciarticular – 2 or 3 joints
oPolyarticular – 4 or more joints
oSymmetric vs. asymmetric
oUpper vs. lower extremities; axial involvement
• Non-Joint (nonarticular) disorders
oFocal – clustered in one location
oWidespread – “all 4 quadrants”
How can you tell if pain is coming from
a joint or from a “periarticular”
structure?
If only active movement hurts = periarticular involvement

If active and passive movements hurt = joint space involvement

 NEXT DETERMINE

Chronology of the Joint Problem

Using More Semantic Qualifiers
• Onset
• Abrupt
• Indolent
• Evolution
• Chronic
• Intermittent
• Migratory
• Additive
• Duration
• Acute (less than 6 weeks)
• Chronic (more than 6 weeks)
 THEN COLLECT

Other Potential Clues from Medical History

• Precipitating events
• Trauma
• Medication
• Antecedent or inter-current illness
• Comorbidities*
• Inflammatory bowel disease
• Diabetes (Charcot or neuropathic arthritis)
• Sinusitis (Wegener’s)
• Associated symptoms*
• Eye problems
• Dry mouth *Pay close attention to Dr. Johnson’s
• Abdominal pain/diarrhea pathology lecture and make note of extra-
• Rash articular signs and symptoms for each
• Genital Symptoms joint disease!
 AND ALWAYS BE MINDFUL

Might this be a Fracture? Cancer?

•Fracture*
• History of antecedent injury
• Stress fractures-pain worse with weight bearing
• When in doubt, get an x-ray

•Cancer*
• Nocturnal pain
• Unrelenting pain-does not respond to change in position
• Fever or constitutional symptoms such as fatigue, malaise, weight loss

*Do NOT miss these!

 Commonest Causes of (Adult) Musculoskeletal Pain

Trauma, Fracture Low Back Pain

Fibromyalgia

Age < than 60 Age > than 60

Frequency
Tendinitis, Bursitis Osteoarthritis
Gout (males) Gout, Pseudogout
Rheumatoid Arthritis Polymyalgia rheumatica
Psoriatic, reactive arthritis,
IBD arthritis Osteoporotic fracture

Infectious arthritis: GC, viral, Infectious (bacterial,

bacterial, Lyme septic) arthritis
 Identifying and Differentiating
Musculoskeletal Joint Disorders in a
Clinical Vignette

Snapshots*

*Aka: Illness scripts

 Osteoarthritis
• Adults, older women predominate
• Oligoarticular, chronic & non-inflammatory
• Most commonly primary; less commonly associated with
DM, ochronosis, hemochromatosis
• Pain in DIP, CMC 1, knees, hips, spine
• Pain with movement; knee pain in obese women
• Pain correlates poorly with findings (x-ray and PE)**
• Stiffness (brief) after rest; limited ROM (advanced)
• Physical exam
• Heberden’s (DIP)** and Bouchard’s (PIP)** nodes
• Crepitus (unlike RA)**
 Osteoarthritis
• Evaluation
• X-rays (osteophytes, subchondral sclerosis, joint space
narrowing, subchondral cysts; NO ankyloses occur)**
• ESR/CRP low
• Treatment
• Analgesics
• NSAIDS
• PT, exercise more effective**
• Weight loss in obese women with
knee OA
• Complementary and alternative
medicine?
• Arthroplasty (advanced disease)
 Rheumatoid Arthritis
• Women aged 35 – 50 predominate
• Chronic & inflammatory: redness, heat,
swelling**
• Symmetrical, polyarticular, additive**
• First and commonly small joints of hands and
*Note the
feet (PIP, MCP, MTP)** organs/systems
• Large joints follow potentially involved in RA
• Morning stiffness > 1 hour** in Dr. Johnson’s lecture!
• Systemic*: Patients often complain of fatigue,
malaise, generalized pain
 Rheumatoid Arthritis
• Physical exam
oTenderness, redness heat, swelling**
oReduced ROM because of pain
oUlnar deviation* of fingers at MCP with
advanced disease
oSwan Neck deformity*
oBoutonniere deformity*
oRheumatoid nodules* (often in areas subjected
to pressure-elbows, ulnar forearm)
oAnkyloses (fused joints that cannot move)
Rheumatoid Arthritis

Synovitis of flexor tendon sheath-

pulls on flexor tendon at MP joint
causing hyperextension at PIP joint,
flexion at DIP joint

swan neck deformity

Rheumatoid Arthritis

destruction of central tendon slip

boutonniere deformity
 Rheumatoid Arthritis
Lab & X-ray
• Erythrocyte Sedimentation Rate (ESR) elevated
• C-reactive protein (CRP) elevated (But RA is negative in
• Rheumatoid factor (rheumatoid antibody - RA) 1/3 of patients and
5% of normal
elevated patients have
elevated RA)*

X-Ray findings: bony erosions;

joint space destruction and
ankyloses in advanced disease
 Rheumatoid Arthritis
• Acute treatment
• Analgesics: acetaminophen, narcotics
• Non-steroidal anti-inflammatory drugs
(NSAIDS)
• Steroids
• Joint protection
• Long term treatment Goldfinger
• Disease modifying antirheumatic drugs
(DMARDs)* like gold, etanercept,
infliximab, methotrexate
• Physical and occupational therapies; warm
water exercise; emotional support
 Gout
• Adults, men 35–50 years
• Often obese
• Red meat & alcohol consumption
• Monoarticular, very acute**
• Podagra common (big toe)**
• Also common in knees, ankles

(Renal failure and metabolic syndrome also risk factors)

 Gout

podagra
Think about a patient presenting with this toe. What is the differential diagnosis?
 Gout
• Physical exam
• Vitals: low-grade temp in bad flare
• Swollen, red, tender, hot joint**
• Tophi may be present (late disease)**
• Evaluation
• Uric acid elevated, but may be normal by the time you see the
patient
• ESR/CRP usually elevated
• Elevated white blood cell (WBC) count**
• Arthrocentesis may be necessary to diagnose**
 Gout
• Acute treatment
• Analgesics (including opioids)
• NSAIDS: indomethacin, others
• Colchicine: inhibits mitosis (microtubule inhibitor)
• Steroids
• Chronic treatment (will not help acutely!)
• Allopurinol: xanthine oxidase inhibitor
• Probenecid: uricosuric agent
• Febuxostat is a relatively new xanthine oxidase inhibitor
which also dissolves gouty tophi
 Pseudogout
• Older age, females predominate
• Joint trauma history, family history,
hemochromatosis*
• Acute, inflammatory; calcium pyrophosphate
dehydrate (CPPD) crystal deposition*
• KNEE, ankles, feet, shoulders, elbows, wrists,
hands
• Redness, heat, swelling*
• Arthrocentesis needed to diagnose*
• Treatment same as for osteoarthritis
 Polymyalgia Rheumatica
• Age > 50, women predominate
• Subacute or chronic
• Morning stiffness > 30 minutes*
• Generalized pain, widespread and diffuse, symmetrical*
• Systemic sx and signs: malaise, fatigue, anorexia, weight loss,
fever**
• May be associated with temporal arteritis§

§ causes fever, jaw pain with chewing (jaw claudication), unilateral

headache, temporal artery tenderness
 Polymyalgia Rheumatica
• Physical Examination
• Diffuse tenderness**
• Edema
• Tenosynovitis, bursitis
• Decreased ROM
• Lab and Imaging
• Very high ESR (> 40) and CRP*
• MRI – periarticular inflammation
• Rx – corticosteroids (work fast and well – this response is almost
diagnostic!)*
 Gonococcal Arthritis –
(Disseminated Gonococcal Infection)
• Young (< 40), more common in women than men
• Polyarthralgias, polyarthritis or oligoarthritis
• Symptomatic genital infection UNCOMMON
• Two typical presentations:
• Tenosynovitis + dermatitis + arthralgias (not arthritis)
• Often multiple tendons inflamed
• Fevers, chills, malaise
• Painless skin lesions, few in number
• OR purulent arthritis w/o skin lesions
• Patient afebrile
• Knees, wrists, ankles: asymmetrical
• Arthrocentesis helpful for diagnosis Quagmire
• Culture and treat with antibiotics
 Reactive Arthritis – aka Reiter’s Syndrome
• Young adults
• Previous infection*
• Salmonella, Shigella, Campylobacter, Yersinia, Chlamydia
• Episodic, waxing & waning over several weeks to 6 months
• Musculoskeletal
• Asymmetric mono- or oligoarthritis
• Enthesitis (feet)
• Dactylitis (sausage fingers)
• Extra-articular
• Urethritis*
• Conjunctivitis/uveitis*
• Balinitis
• Dermatitis* (keratoderma blenorrhagica) Classic triad: conjunctivitis, urethritis, arthritis
(“can’t see, can’t pee, can’t climb a tree”)
 Psoriatic Arthritis
• Men and women
• Pain, morning stiffness > 30 minutes
• Inflammatory*
• Distal (DIP) is classic*
• Asymmetric polyarthritis & oligoarthritis is more
common
• Axial skeleton may be affected
• Associated with: Nail pitting, onycholysis, psoriatic
skin lesions*
• Tenosynovitis, enthesitis, dactylitis*

Onycholysis and dactylitis

 Ankylosing Spondylitis
• Young adults (20-30 years), whites
• Symptoms start in teens/early 20s
• Men & women
• Low back pain** (almost all patients); buttock pain
• May affect other joints, enthuses (1/3 of patients)
• Insidious onset
• Rest does not help!*
• Nocturnal pain*
• Fatigue
 Ankylosing Spondylitis
• Physical exam
• May be limited spinal motion
• SI joint tenderness
• SI joint pain with provocative
testing
• Flexion deformity of hip
• Enthesitis (Achilles)
• Dactylitis
Eliciting SI Joint Pain/Tenderness
 Ankylosing Spondylitis
•Lab
•ESR, CRP elevated
•HLA-B27 + * (90% of
patients)
•SI imaging
• X-ray shows joint sclerosis in advanced disease
• MRI may show cartilage abnormalities and bone X-ray: SI Joint Sclerosis
marrow edema in early disease

•Rx
•NSAIDs, DMARDs
 Bacterial (Septic or Suppurative) Arthritis
• Young, 50% < age 20**
• Inflammatory: redness, swelling heat
• Monoarthritis, usually acute**
• Exquisite pain with minimal movement
• Fever, chills**
• Additional history
• Underlying joint disease
• IV drug use, alcoholic
• Recent penetrating trauma
A bizarre accident of penetrating trauma!
Thanks Amir Abdolmaleki!
 Bacterial (Septic) Arthritis
• Usually gram positive (S. aureus) in older children and
adults*
• Gram negatives, pseudomonas, in drug abusers
• Fungi, TB in immune compromised patients
• Evaluation
• High WBC count, with high PMNs (“left shift”)*
• High ESR/CRP*
• Arthrocentesis: WBCs increased, neutrophils
increased, no string forms, positive bacteria on gram
stain, positive culture **
 Bacterial (Septic) Arthritis
• Treatment: IV antibiotics - 2 weeks – with
repeated joint drainage, followed by oral
antibiotics for 2 weeks
STOP
• Even with rapid diagnosis and proper (Don’t Miss
therapy, joint destruction can occur This)
rapidly*
• MRSA is an emerging organism in this
infection!*
 Arthrocentesis
• Accessing synovial fluid to
help you diagnose an
inflamed joint
• Choose carefully – but do it if
you need to!
• Technique – must be ASEPTIC!
• Approach varies by joint
Normal Synovial Fluid
•Highly viscous
•Clear
•Essentially acellular
 Arthrocentesis – Synovial Fluid Analysis
• Gram stain and culture
• Positive in infection*
• The one test if only a small amount of fluid is
obtained**
• Appearance
• Turbid = cells = inflammation (nonspecific
finding)*
• Cell count and differential
• RBCs = trauma
• WBCs = inflammation OR infection**
 Arthrocentesis – Synovial Fluid Analysis
• Crystal search done with polarized light**
• Monosodium urate (MSU)
• Calcium pyrophosphate dihydrate (CPPD)
• Other MSU-needle shaped
with strongly negative
• String test birefringence*

• Proteolytic enzymes in inflammatory fluid break down

hyaluronate and decrease viscosity & fluid will NOT make
a string: “no string formed”*
CPPD-rhomboid shaped
with weakly positive
birefringence*
 String Test - see the string?
Normal healthy synovial fluid makes a string, inflamed fluid does not!
Arthrocentesis Technique
The End
References
• Harrison’s Online, Part 15, Chapter 331. “Approach to Articular and
Musculoskeletal Disorders”
• UpToDate, 2017. Multiple articles.