Rheumatology: Approach to a Patient with Joint Pain

1. Rheumatology: Approach to a Patient with Joint Pain

2. Objectives • To distinguish between articular (joint) vs periarticular (around a joint) pain • To differentiate arthralgia from arthritis • To distinguish between inflammatory and non-inflammatory joint complaints • To develop differential diagnoses of inflammatory , non-inflammatory arthritides, acute monoarthritis and polyarthritis

3. A 65-year-old female comes to the clinic for evaluation of right elbow pain. On examination, there is no swelling or tenderness of the elbow joint, but the olecranon bursa is noted to be swollen and tender. This is an example of: • Artricular pain • Periartricular pain • Referred pain • Neuropathic pain

4. Is the process articular or periarticular? • Artricular pain is true joint pain • Periarticular pain is defined as pain in structures around a joint eg. Tendinitis , bursitis , enthesitis • Referred pain is defined as pain that is referred to a location distant from the site of origin of pathology • Patients with pain in structures around a joint, (i.e., periarticular pain), can also present to you with the chief complaint of 'joint pain • Differential diagnosis of true articular process is very different from that of a periarticular process. '

5. Diagrammatic illustration of a joint and periarticular structures

6. Periartricular pain

9. Articular, periarticular and referred pain

10. Hip pain

11. A 25-year-old female is seen in your clinic for evaluation of fatigue and diffuse joint pains. She reports pain in bilateral wrists, shoulders, MCPs and PIP joints. To diagnose this patient with arthralgia, she must have: • Heat in joints • Swelling in joints • Tenderness in joints • Redness in joints

12. Arthralgia vs. Arthritis

13. Causes of Arthralgia

14. Distinguishing Arthralgia from Arthritis

15. Inflammatory from non-inflammatory arthritis • Distinguishing inflammatory from non-inflammatory arthritis is a key branching point in evaluation of any patient with arthritis because it helps us • Formulate a differential diagnosis • Define further diagnostic workup • Decide whether your patient needs to be referred to rheumatology, orthopedics or can be managed in the primary care setting

16. Differentiating inflammatory from non-inflammatory arthritis

17. Causes of inflammatory arthritis

18. Causes of non- inflammatory arthritis

19. So far ..

20. Using the history to diagnose a patient with a joint complaint Questions to ask : • Q1: Exact location of pain ? • Q2: When is the pain/swelling/stiffness in the joints worst? • Q3: Do the joint symptoms improve with activity? • Q4: Do you have morning stiffness (i.e., joints are stiff in the mornings)? Does it last for less than or greater than 60 minutes?

21. Specific questions

22. Specific questions

23. The physical exam: Arthralgia vs. arthritis • LOOK – For redness, swelling or deformity • TOUCH - For heat or warmth • PALPATE - For tenderness or effusion/swelling • MOVE – To assess tenderness and limitation of range of motion in the joint • The presence of any one of these-swelling, warmth or erythema is diagnostic of arthritis, but the absence of all of these is diagnostic of arthralgia

24. Likely diagnosis by physical exam of joints

27. Patterns of joint complaints

28. Summary of diagnosis by pattern of presentation

29. Thank you