Approach to Joint
Pain
Presenter – Dr Sourabh Soni
Junior Resident
Dept of Paediatrics
Moderator – Dr Gunjan Kela
Professor and HOD
Dept of Paediatrics
Overview
• Introduction
• Etiology
• History
• Growing pain
• Examination
• pGALS
• Investigation
Introduction
Arthralgia and Arthritis
Arthralgia : Joint Pain
Arthritis : Intrarticular swelling
Or
Two or more of the following signs:
1. Limitation in the range of motion
2. Tenderness or pain on motion
3. Warmth
4. Erythema
Etiology
Arthralgia Arthritis
• Infection: Rheumatic fever,Dengue • Rheumatic causes : Systemic lupus erythematosus(SLE)
• Trauma Juvenile dermatomyositis(JDM)
• Malignancy Vasculitis, Behcets disease ,Sarcoidosis,
• Rheumatic : Juvenile idiopathic arthritis Kawasaki disease, Henoch Schonlein
• SLE,Juvenile Dermatomyositis purpura(HSP)
• Scleroderma • Non Rheumatic causes:
• Hematological : Sickle cell disease 1> Malignancy
• Vascultitis : HSP,Kawasaki disease 2> Infective- Viral – Chikungunya, Rubella, Hepatits-B,
PAN,Wegener’s granulomatosis Parvovirus B, Ebstein Bar Virus(EBV)
Sarcidosis Bacterial- Osteomyelitis
• Reactive arthritis Tubercular
• Benign syndromes : Ehler danlos syndrome Lyme disease
• Pain syndromes : Fibromyalgia 4> Post-infectious : Acute rheumatic fever
• Nutritional : Rickets,Scurvy,Anaemia Reactive arthritis
• Psychogenic • Trauma
Number of Joints involved
What to ask?
• Age
• Sex
• Mode of onset and duration of joint involvement
• Single or Multiple joint
• Small or Large joint
• Axial or Appendicular
• Nature of pain :Migratory or additive
• Restriction of movement/Local erythema/Warmth
• H/o Trauma, illness or drug intake
• H/o Fever or other systemic manifestations
• Relationship of Pain to Activity
• H/o Bleeding diathesis
• Is the child suffering from any Blood disease
• Dietary history
• Polyarticular JIA
Age
• Kawasaki disease Early Childhood (2 - 5 years)
• HSP
• Psoriatic arthritis
• Juvenile Dermatomyositis Mid Childhood ( 6-11 years)
• Polyarteritis Nodosa
• Enthesitis Related Arthritis(ERA) Late childhood or
• Systemic Lupus Erythematosis(SLE) Early adolescence (12- 18 years)
Sex
• SLE Girls
• JIA
• Kawasaki disease
• Polyarteritis nodosa Boys
• Inflammatory bowel disease
• Enthesitis related arthritis
• Systemic onset Juvenile Idiopathic Arthritis = Equal distribution
Mode of onset and duration
Duration Examples
Acute : < 2 weeks Septic Arthritis,Trauma,Acute rheumatic fever,HSP
Subacute : 2 to 6 weeks Systemic lupus erythematosus,Reactive arthritis,
Polyarteritis Nodosa,Dermatomyositis,Leukemia
Sickle cell disease, hemarthrosis
Chronic : > 6 weeks Juvenile Idopathic Arthritis ,Tubercular, Psoriatic arthritis
Enthesitis related Arthritis(ERA)
History of preceeding events
Sore-throat or Scarlet fever – Acute Rheumatic Fever
GI symptoms- Reactive arthritis,Inflammatory bowel disease
GI infections – Salmonella
Urethritis –Reiter’s disease
Viral infections- Rubella,Mumps,chickenpox,Infectious mononucleosis,Hepatitis B
Recent immunization: Rubella
Trauma: Septic arthritis,Hemarthrosis,Effusion,strained ligaments,sprained muscles,
dislocation, fractures
Pyoderma : Septic arthritis
H/o drugs : Penicillin,Immunoglobulin, Antitoxin
H/o Koch contact
Site
• Distal interphalangeal joint : Psoriatic arthritis
• B/L Temporomandibular joint : RA factor Negative Polyarthritis
• Knee/Ankle joints : Reactive arthritis
Fever
• High grade fever with chills with joint swelling- Septic arthritis
• Long standing,low grade and continuous fever- Tuberculosis
• Prolonged high grade and irregular fever with remissions:
Idiopathic arthritis and SLE
• Prolonged fever with joint involvement : Leukemias
Deforming/Non- Deforming
Long standing/Aggressive disease :
Causes- Malalignment of articular structure
Soft tissue contracture
Fibrosis/Ankylosis
e.g.- RA factor +ve Polyarticular JIA
Pain
• Onset : Acute and related to specific trauma is commonly related to
Fractures
• Pain that worsens on activity: Destructive joint pain
• Pain with morning stiffness that improves on activity : JIA
• Pain that worsens on massage : Inflammatory joint pain
• Pain that improves on massage : Growing pains ( Usually occurs at
night and disappear in the morning
• Night pain : 1.) Malignancy( Osteiod osteoma)-Refractory or Unremitting pain
Persistant night waking
2.) Growing pains
• Pain in infectious cause has no diurnal variation
• Fleeting pain(Migratory): Acute Rheumatic Fever
Growing pains
• Benign nocturnal pains of childhood
• Peak age : 4-12 years
• M/C cause or reccurent musculoskeletal pain in children
• Intermittent and Bilateral
• Involves : Anterior Thigh, Shins and calf but not the joint
• In late afternoon or evening,wake the child from sleep
• Resolves quickly on massage/analgesics
• Disappear in the morning
• Treatment : Reassurance,Education,Massage during the episode, Muscle
stretching, NSAIDs may be used in frequent episodes
H/o Bleeding
• Bleeding from Gums : Scurvy
• Bleeding in joint on trivial injury : Hemophilia
• Bleeding P/R : HSP
H/o Hematological diseases :
• Sickle cell disease
• Leukemia
• Hemarthrosis in Hemophilia
Cardiac Symptoms:
• Exertional dypnea
• Palpitation
• Chest pain
Examination
• Local examination of joints
• Examination of spine
• Examination of muscles
• Presence of rash/subcutaneous nodules
• Lymphadenopathy/sinuses
• Eyes
• Oral cavity
• Desquamation of fingers
• Focus of infection
• Organomegaly
• Cardiovascular system
• Nails and Hair- Alopecia, Nail pitting,Onycholysis
• Gangrene and Stroke : SLE, Antiphospholipid Antibody syndrome(APLA)
• Renal system : Nephritis, nephrotic syndrome, hypertension in
JIA,SLE,PAN,KD,HSP
Inspection
• General body habitus including signs of cachexia, Pallor and Nutritional
deficiencies
• Balance,posture and gait pattern
• Skin-Rashes, Café-au-late spots,Hairy patches,Dimples,Cyst,Tuft of hair
or evidence of Spinal midline defects
• Spinal asymmetry,axial or appendicular deformities and evidence of
muscle spasm or contractures
• Muscle atrophy
• Range of motion of all joints,their stability and any evidence of
hyperlaxity
Palpation
• Local temperature
• Tenderness
• Swelling or mass
• Spasticity
• Contracture
• Bone or joint deformity
• Limb length
Examination of Joints
• Swelling,pain,tenderness and range of movements
• Arthralgia/Arthritis
• Single / Multiple
• Large joint affected in lower extremities i.e. Knee/Ankle : Oligoarticular JIA
• Small joints of upper or lower extremities : Polyarticular JIA
• Spindle shaped fingers : Rheumatoid arthritis
• Diffuse swelling of entire dorsum of hand and foot : Sickle cell disease
• Scorbutic beading of costochondral joint : Scury
• In TB hip joint : Limb is flexed,abducted and medially rotated
• Pseudoparalysis(Inability to move joint due to severe pain) : Septic
arthritis
• Examination of spine for kyphosis/scoliosis: TB spine
• Examination of muscles:
• Wasting above or below a joint is seen in idiopathic
arthritis or chronic involvement(Disuse atrophy)
• Tenderness of muscles : Dermatomyositis
Skin
• Erythema marginatum : Acute Rheumatic fever
• Salmon colored ( faint evanescent macular rash) : Systemic onset Juvenile
idiopathic arthritis(SJIA)
• Malar rash (butterfly shaped,sparing nasolabial fold) : SLE
• Palpable purpuric rash( extensor aspect-extremities) : HSP
• Heliotrope rash over upper eyelids and Gottron’s papules :
Dermatomyosistis
• Purpuric and ecchymotic patches :Leukemia
24
• Erythematous rashes with silvery white scales :
Psoriatic arthritis
• Subcutaneous nodules(extensor aspect of upper
extremities and suboccipital region) : Rheumatic fever
Eyes
• Pallor and Jaundice with symmetrical painful swelling of hand and
feet : Hand foot syndrome (Sickle cell disease)
• Uveitis: JIA
• Conjuctival redness : Kawasaki disease
Oral cavity
• Gum bleeding / spongy gums : Scurvy
• Swollen tongue(strawberry tongue and cracked lips)
- Kawasaki disease
- SLE
Organomegaly
• Hepatosplenomegaly : Collagen diseases
Leukemias
Disseminated TB
Splenomegaly : Sickle cell disease
Focus of infection : Boils
Abscess
E.g.- Septic Arthritis
CVS
• Hypertension : SLE
• Pericardial rub/Pericarditis: Rheumatoid arthritis
SLE
• Myocarditis : Rheumatoid arthritis and Kawasaki disease
pGALS
paediatric Gait,Arms,Legs and Spine
• Developed to detect inflammatory joint disease but can also detect
other Musculoskeletal disorders.
• Screening test for the assessment of school aged children based on
the adult GALS screen
• Consist of basic clinical maneuvers
Screening questions
• Ask for pain/stiffness in joint,muscle or back
• Ask for difficulty in getting dressed without any help
• Ask for difficulty in going up and downstairs
Gait
• Observing the child walking
• Asking the child to walk on tip-toes and heels
Arms
• Moving hands in different directions
• Making a fist
• Touching fingertips with thumb
• Squeezing metatarso-phalangeal joints
Legs
• Bending and straightening knees
• Passive flexion and extension of hip
• Feel for knee effusion
Spine :
Lateral flexion of cervical spine, bending forwards to
touch toes, observe spine from side and behind.
Investigations
• CBC
• ESR,CRP
• Coagulation factor
• Rheumatoid factor(RA)
• Liver function test
• Renal function test
• Antibodies – ANA,Anti-DNA
• ASO titre
• Culture-Throat swab,joint fluid,stool,urine
• Mantoux test
• Slit lamp examination of eyes
• Radiological investigations : Xray,USG,MRI
CBC
• Anemia – Sickle cell disease
Leukemia
• Leukocytosis(Polymorphonuclear predominance) – Septic arthritis
• Leucopenia with lymphopenia – SLE
• Reticulocytosis- Sickle cell disease
• Thrombocytopenia- Leukemia
• Thrombocytosis – Idiopathic arthritis
• Anemia of chronic disease- Collagen vascular disease,TB
• ESR – increased in Collagen diseases and Rheumatic fever.
• Clotting factors- Hemophilia
• Mantoux test – Tubercular
• Xray – Scurvy, TB, Idiopathic arthritis
• RA factor- Polyarticular JIA
• ANA seropositivity – increased in chronic uveitis in JIA
• Anti dsDNA – Highly specific for SLE
• ASO titre and Throat swab culture- Recent Streptococcal infection(Rising
titre-Rheumatic arthritis)
• CRP-Acute Rheumatic arthritis
• Urinalysis- Albumin and hematuria
• Synovial fluid aspiration – Microscopy and culture in Septic arthritis
• USG and MRI – Septic and tubercular arthritis and Hemarthrosis
• CRP-Acute Rheumatic arthritis
• Urinalysis- Albumin and hematuria
• Synovial fluid aspiration – Microscopy and culture in Septic arthritis
• USG and MRI – Septic and tubercular arthritis and Hemarthrosis
Case scenario
Case 1
A 6 year-old boy was brought with lower limb pain which happened
at [Link] was relieved with oil massage and paracetamol. Next day
morning the child woke up as if nothing happened over [Link]
following week he has a similar episode. This causes significant
anxiety in the family, and they immediately visit the primary
physician.
Diagnosis
Growing Pain
Case 2
• A 12-year-old boy was admitted to Hospital for multiple sites of arthralgia. He had
presented at the local clinic after experiencing fever, diarrhea, and abdominal
pain for 5 days, for which he had received successful [Link] week after
the onset of the enteritis, he developed generalized limb pain followed by large
joint involvement i.e. bilateral sacroiliac, wrist, and ankle [Link] had never
received a blood transfusion and had no history of sexual contact.
On admission-
Conscious
Temp -38℃(Febrile)
Pulse-115 beats/min
Blood pressure -110/70 mmHg
Physical examination-:
Swelling and tenderness of left ankle joint
Tenderness on motion
Pain over the bilateral wrist and left sacroiliac joints
Systemic examinations- Normal
A- Swelling of left ankle joint
B- Normal right ankle joint
• Laboratory studies showed
Hemoglobin-12.8 g/dL
WBC- 21,860/mm3
Platelets- 573,000/mm3,
ESR -74 mm/hr
CRP- 3.97 (0 to 0.5) mg/dL
Liver and renal function tests – Normal
VDRL – Negative
ANA – Negative
Urinalysis - Pyuria, but
Urine culture – Negative
HLA class I serotyping - Positive for B27
Synovial fluid(left ankle and left hip joint)- Severe inflammation but
Gram staining and Culture of this synovial fluid - Negative
Stool culture – Positive for Salmonella group D
Radiographs of the ankle joint - Soft tissue swelling, without erosive joint
damage
Diagnosis
Enthesitis related Arthritis
Thank You
