Precise anatomic localization of pain is the first task of the physician caring for a patient presenting with joint pain, while also evaluating stiffness, redness, warmth, or swelling in the absence of trauma. It is important to distinguish pain that is truly articular from periarticular pain. Causes of localized periarticular pain include bursitis, tendonitis, and carpal tunnel syndrome, whereas fibromyalgia, polymyalgia rheumat-ica, and polymyositis all can cause diffuse periarticular pain.
The number of involved joints and presence or absence of symmetry are criteria for further diagnosis of articular pain (Figs. 32-1 and 32-2). Monoarticular (one joint) or oligoarticular (several joints) arthritides can be caused by conditions such as osteoarthritis (OA), gout, pseudogout, or septic arthritis. Asymmetric polyarthritis occurs in ankylosing spondylitis, psoriatic arthritis, Reiter's disease, and spondyloarthropathies. Symmetric arthritis, meaning that the same joint is affected on the contralateral side but not necessarily to the same degree, is characteristic of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren's syndrome, polymyositis, and scleroderma. Fibromyalgia, reflex sympathetic dystrophy, and predominantly psychological
MONOSODIUM URATE (gout)
CALCIUM PYROPHOSPHATE DIHYDRATE (pseudogout)
'Synovial fluid culture as well as cervical, urethral, pharyngeal, and/or rectal evaluations for Gonococcus and Chlamydia when suspected.
Check: CBC, ESR, RF Consider: LFTs, HLA-B27, ANA, Lyme serologies, and pelvis radiographs
Suspect: RA, JRA, VIRAL, SLE, LYME, SARCOIDOSIS, or SPONDYLOARTHROPATHY
Figure 32-1 Evaluation of monoarticular or pauciarticular symptoms. ANA, Antinuclear antibodies; CBC, complete blood cell count; ESR, erythrocyte sedimentation rate; JRA, juvenile rheumatoid arthritis; LFTs, liver function tests; PMNs, polymorphonuclear (leukocyte) neutrophils; PT, prothrombin time; PTT, partial thromboplastin time; RA, rheumatoid arthritis; RF, rheumatoid factor; SLE, systemic lupus erythematosus; WBCs, white blood cells. (From American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. Arthritis Rheum i996;39:i.)
factors must be considered when pain is diffuse, not relat-able to specific anatomic structures, or described in vague terms. (See also Chapter 30.)
Other differentiating criteria include the correlation with activity or rest and the character of the pain. Mechanical causes tend to be more directly related to the joint's activity than inflammatory conditions. Neuropathies tend to cause burning or prickling sensations, whereas arthritides often cause an aching pain. The presence of joint stiffness after a period of inactivity might also aid in diagnosis; RA is characterized by morning stiffness lasting 30 to 60 minutes or longer, whereas OA-related morning stiffness lasts a shorter period, typically less than 30 minutes, but stiffness might also occur during the day. In neurologic conditions such as Parkinson's disease, stiffness might be relatively constant. Vascular pain, such as intermittent claudication, is felt with activity, relieved quickly by rest, and described as a "deep, aching" sensation.
Constitutional symptoms such as fatigue, weakness, malaise, and weight changes are common chief complaints heard in a primary care office practice and often associated symptoms of specific rheumatic diseases. The patient's recording the maximal grip force in millimeters of mercury. Signs of systemic disease include fever; weight loss; oral or nasal ulcerations; liver, spleen, or lymph node enlargement; neurologic abnormalities; rashes; subcutaneous nodules; eye iritis; conjunctivitis or scleritis; and pericardial or pulmonary rubs. Because of circadian changes in patients with RA, serial comparisons of the physical examination are more accurate if the time of day is also recorded. Using skeleton diagrams of joint involvement facilitates the recording of a comprehensive joint examination (Fig. 32-3).
Myalgias can be caused by localized trauma or overuse, systemic infection, metabolic disorder, or primary muscle disease. Multiple tender sites in an otherwise healthy patient suggest fibromyalgia. An elevated creatine kinase (CK) level with proximal weakness may be caused by an inflammatory myopathy.
Rheumatic and other musculoskeletal problems are properly diagnosed by careful history and physical examination rather than by just ordering many laboratory tests, the results of which might actually confuse diagnosis. Laboratory tests and radiologic imaging help confirm a presumptive clinical diagnosis made from a careful history and physical examination.
Was this article helpful?