Joint Pain Explained in Simple Language

Joints could simply be painful (arthralgia) or inflamed (arthritis).  Sometimes what patients describe as joint pain can originate within the joint, or from outside the joint (such as tendons, ligaments, muscles). Joint pain can also be a manifestation of a systemic disease like systemic lupus or psoriasis.

Joint pain could be caused by:

1. Inflammation that is crystal-induced arthritis like gout, or systemic-induced like Rheumatoid arthritis or Juvenile idiopathic arthritis

2. A noninflammatory disorder like osteoarthritis

3. Inflammation of the thin membrane covering the joint, such as synovitis

Joint pain can affect one joint (mono articular) or multiple joints (poly articular). Joint pain may involve small joints like hands or feet, and larger joints like knees or hips. Axial joints like those in the back that affect the cervical spine can also ache with joint pain.

History is very important:

1. Trauma

2. Infection: Bacterial or viral

Bacterial (septic arthritis); more commonly mono articular

1. Acute rheumatic fever causes severe pain affecting mainly the large joints in the legs, elbows, and wrists associated with fever, heart murmur
2. Sexually transmitted disease with mostly mono articular joint pain. More common among young adults but can manifest at any age

Non inflammatory joint pain in adults is most often due to the following:

1. Osteoarthritis is by far the most common cause of arthritis in older people; if it  develops after the age of 60 or older cancer should be considered while Rheumatoid  arthritis most commonly begins between ages 30 and 40
2. Ankylosing spondylitis mostly with axial pain and stiffness, worse in the morning and relieved with activity  
3. Arthralgia  in Lyme-endemic area secondary to tick bite
4. Systemic lupus eryrhromatoses  is associated with Arthralgia more often than arthritis, more common  among women associated with systemic manifestations, such as rash (eg:,pleurisy, pericarditis, manifestations of pyelonephriti

History & characteristic of pain:

1 .Onset  of joint pain (eg, abrupt, gradual)

2. Persistent vs intermittent

3. Duration acute vs chronic, exacerbating and  pain at (eg, rest, activity)

Patients should specifically be asked about unprotected sexual contact (indicating risk of infectious bacterial arthritis with disseminated gonococcal infection)as well as tick bites in lyme endemic area.

Physical examination:

The patient is also evaluated for lymphadenopathy and Musculoskeletal and then proceeds to palpation for joint effusions, warmth, and point tenderness. Passive and active range of motion should be evaluated. Crepitus may be felt during joint flexion and/or extension. Comparison with the contralateral unaffected joint often helps detect more subtle changes. Examination should note the distribution of affected joints is symmetric or asymmetric. Painful joints can also be compressed without flexing or extending them.

 Structures  around joint also should be examined for involvement of tendons, bursae, or ligaments, such as discrete, soft swelling at the site of a bursa (bursitis) or point tenderness at the insertion of a tendon (tendinitis). Pain that is diffuse, vaguely described, and affects myofascial structures without signs of inflammation suggests fibromyalgia.

 Interpretation of findings:

Clinical findings of prolonged morning stiffness, stiffness after prolonged inactivity, non traumatic joint swelling, and fever or weight loss suggest a systemic inflammatory disorder. If the specific diagnosis cannot be established based on the history and examination, additional tests may be needed.

 ESR and C-reactive protein can be done to help determine whether the arthritis is inflammatory. Elevated ESR and C-reactive protein levels suggest inflammation also evaluates systemic involvement Synovial fluid (eg, WBC count of < 1000/µL) is more suggestive of osteoarthritis or trauma. Hemorrhagic fluid is consistent with hemarthrosis. Synovial fluid WBC counts can be very high (eg, > 50,000/µL) in both infectious and crystal-induced arthritis. Synovial fluid WBC counts in systemic inflammatory disorders causing poly arthritis.

Blood tests (ESR, C-reactive protein, and CBC but are nonspecific, particularly in older adults). Findings are more specific if values are high during inflammatory flare-ups and normal between flare-ups. ANA, anti-dsDNA, urinalysis, chemistry profile with renal and liver enzymes, immunoglobulin A, and x-ray. If arthritis is chronic, x-rays are typically done to look for signs. Sometimes MRI or CT scans are performed.

Treatment:

The underlying disorder is treated whenever possible.

 Joint inflammation is usually treated symptomatically with NSAIDs. Pain without inflammation is usually more safely treated with acetaminophen. Joint immobilization with a splint or sling can sometimes relieve pain. Heat or cold therapy may be analgesic in inflammatory joint diseases  surgery if advised.

 Systemic inflammatory diseases may require either immunosuppression or antibiotics as determined by the diagnosis.

 Because chronic poly arthritis can lead to inactivity and secondary muscle atrophy, continued physical activity physical therapy should be encouraged.