Symptom Finder - Joint Pain
JOINT PAIN
Because most joints may be affected by the same etiologic processes, a general discussion of the differential diagnosis of joint pain will be undertaken, followed by a discussion of exceptions that apply to certain joints.
Anatomic and histologic breakdown of the joint is not of much value in the differential diagnosis. It is sufficient to say that extrinsic lesions around the joint, such as cellulitis, bursitis, and tendonitis, must be considered in the differential diagnosis. Nonarticular rheumatism or fibromyositis comes to mind here also. To develop a differential list of intrinsic conditions of the joints, the mnemonic VINDICATE is useful.
V—Vascular suggests hemophilia and scurvy as well as aseptic bone necrosis (Osgood–Schlatter disease and so forth).
I—Inflammatory suggests several infectious lesions, but gonorrhea, Lyme disease, Staphylococcus, Streptococcus organisms, tuberculosis, and syphilis are most likely. Although uncommon, viral infections such as rubella, herpes simplex, human immunodeficiency virus (HIV), and cytomegalovirus may cause arthritis.
N—Neoplastic disorders to be ruled out are osteogenic sarcoma and giant
cell tumors.
D—Degenerative disorders bring to mind degenerative joint disease or osteoarthritis, which is so common that it is often the first condition to be considered in joint pain.
I—Intoxication suggests gout (uric acid) and pseudogout (calcium pyrophosphate). Drugs infrequently initiate joint disease, but the lupus syndrome of hydralazine (Apresoline) and procainamide and the “gout syndrome” of diuretics should be kept in mind.
C—Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.
A—Autoimmune indicates another commonly encountered group of diseases. RA is the most prevalent of these, but serum sickness, lupus erythematosus, rheumatic fever, Reiter syndrome, ulcerative colitis, regional ileitis, and psoriatic arthritis must be also considered. Do not forget polymyalgia rheumatica in elderly persons.
T—Trauma suggests numerous disorders. In addition to traumatic synovitis, one must consider tear or rupture of the collateral or cruciate ligaments, subluxation or laceration of the meniscus (semilunar cartilage), dislocation of the joint or patella, a sprain of the joint, and fracture of the bones of the joint.
E—Endocrine disorders that affect the joints include acromegaly, menopause, and diabetes mellitus (pseudogout).
Now it is useful to consider individual joints where special etiologies apply. The TMJ is often affected by malocclusion. The cervical spine is affected by cervical spondylosis, a condition where hypertrophic lipping of the vertebrae occurs in response to degeneration of the discs. Inflammation of the sacroiliac joint occurs most commonly in Marie–Strümpell disease, psoriatic arthritis, Reiter disease, and regional ileitis.
Approach to the Diagnosis
The approach to the diagnosis of joint pain includes a careful history and examination for other signs such as swelling, redness, and hyperthermia of the joints. Joint pain that is sudden in onset should be considered septic arthritis until proven otherwise. If the joint pain is worse in the morning, consider RA. If multiple joints are involved, look for RA, lupus, and osteoarthritis. Multiple joint involvement with oral and/or genital ulcers suggests Behçet disease. Single joint involvement suggests gonorrhea, septic arthritis, tuberculosis, or gout, among other things. Small joints are involved more frequently in RA, Reiter syndrome, and lupus, although the large joints are more frequently involved in osteoarthritis, gonorrhea, tuberculosis, and other infections. Remember, however, that both osteoarthritis and gonorrhea may involve the small joints of the hands and feet. Rheumatic fever presents a migratory arthritis; this is a helpful differential point. When the knee joint is involved, the astute clinician will always examine for a torn or subluxated meniscus and loose cruciate or collateral ligaments. MRI or arthroscopy will pin down this diagnosis.
Listed below are the most valuable diagnostic tests. Synovial fluid analysis for uric acid and calcium pyrophosphate, the character of the mucin clot, a white cell count, and culture can be done in the office and may make the diagnosis almost immediately. This may eliminate the need for hospitalization. CT scans or MRIs may be diagnostic.
A therapeutic trial of aspirin or colchicine is useful in diagnosing rheumatic fever or gout, respectively. If the joint fluid examination is nonspecific and no systemic signs of infection are evident, the injection of steroids into the joint is reasonable while the physician waits for the results of more sophisticated diagnostic tests.
Other Useful Tests
1. CBC (sickle cell anemia, infectious arthritis)
2. Sedimentation rate (inflammatory joint disease)
3. RA test
4. ANA (collagen disease)
5. Chemistry panel (gout, diabetes, e.g.)
6. Coagulation profile (hemophilia)
7. Antistreptolysin O (ASO) titer (rheumatic fever)
8. Brucellin antibody titer (brucellosis)
9. Serologic test for Lyme disease
10. Sickle cell prep
11. X-ray of the joint
12. Bone scan (rheumatoid spondylitis)
13. Urine for homogentisic acid (ochronosis)
14. Rheumatology consult
15. Orthopedic consult
16. Cultures of the joint fluid for atypical mycobacteria of fungi
17. Human leukocyte antigen (HLA)-B27 (rheumatoid spondylitis)
18. Anticyclic citrullinated peptide (CCP) antibody titer (RA)
19. 1, 25 hydroxy vitamin D3
20. Serum parvovirus B19 IgM
21. ANCA titer (Wegener granulomatosis)
22. Uric acid (Gout)
Because most joints may be affected by the same etiologic processes, a general discussion of the differential diagnosis of joint pain will be undertaken, followed by a discussion of exceptions that apply to certain joints.
Anatomic and histologic breakdown of the joint is not of much value in the differential diagnosis. It is sufficient to say that extrinsic lesions around the joint, such as cellulitis, bursitis, and tendonitis, must be considered in the differential diagnosis. Nonarticular rheumatism or fibromyositis comes to mind here also. To develop a differential list of intrinsic conditions of the joints, the mnemonic VINDICATE is useful.
V—Vascular suggests hemophilia and scurvy as well as aseptic bone necrosis (Osgood–Schlatter disease and so forth).
I—Inflammatory suggests several infectious lesions, but gonorrhea, Lyme disease, Staphylococcus, Streptococcus organisms, tuberculosis, and syphilis are most likely. Although uncommon, viral infections such as rubella, herpes simplex, human immunodeficiency virus (HIV), and cytomegalovirus may cause arthritis.
N—Neoplastic disorders to be ruled out are osteogenic sarcoma and giant
cell tumors.
D—Degenerative disorders bring to mind degenerative joint disease or osteoarthritis, which is so common that it is often the first condition to be considered in joint pain.
I—Intoxication suggests gout (uric acid) and pseudogout (calcium pyrophosphate). Drugs infrequently initiate joint disease, but the lupus syndrome of hydralazine (Apresoline) and procainamide and the “gout syndrome” of diuretics should be kept in mind.
C—Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.
A—Autoimmune indicates another commonly encountered group of diseases. RA is the most prevalent of these, but serum sickness, lupus erythematosus, rheumatic fever, Reiter syndrome, ulcerative colitis, regional ileitis, and psoriatic arthritis must be also considered. Do not forget polymyalgia rheumatica in elderly persons.
T—Trauma suggests numerous disorders. In addition to traumatic synovitis, one must consider tear or rupture of the collateral or cruciate ligaments, subluxation or laceration of the meniscus (semilunar cartilage), dislocation of the joint or patella, a sprain of the joint, and fracture of the bones of the joint.
E—Endocrine disorders that affect the joints include acromegaly, menopause, and diabetes mellitus (pseudogout).
Now it is useful to consider individual joints where special etiologies apply. The TMJ is often affected by malocclusion. The cervical spine is affected by cervical spondylosis, a condition where hypertrophic lipping of the vertebrae occurs in response to degeneration of the discs. Inflammation of the sacroiliac joint occurs most commonly in Marie–Strümpell disease, psoriatic arthritis, Reiter disease, and regional ileitis.
Approach to the Diagnosis
The approach to the diagnosis of joint pain includes a careful history and examination for other signs such as swelling, redness, and hyperthermia of the joints. Joint pain that is sudden in onset should be considered septic arthritis until proven otherwise. If the joint pain is worse in the morning, consider RA. If multiple joints are involved, look for RA, lupus, and osteoarthritis. Multiple joint involvement with oral and/or genital ulcers suggests Behçet disease. Single joint involvement suggests gonorrhea, septic arthritis, tuberculosis, or gout, among other things. Small joints are involved more frequently in RA, Reiter syndrome, and lupus, although the large joints are more frequently involved in osteoarthritis, gonorrhea, tuberculosis, and other infections. Remember, however, that both osteoarthritis and gonorrhea may involve the small joints of the hands and feet. Rheumatic fever presents a migratory arthritis; this is a helpful differential point. When the knee joint is involved, the astute clinician will always examine for a torn or subluxated meniscus and loose cruciate or collateral ligaments. MRI or arthroscopy will pin down this diagnosis.
Listed below are the most valuable diagnostic tests. Synovial fluid analysis for uric acid and calcium pyrophosphate, the character of the mucin clot, a white cell count, and culture can be done in the office and may make the diagnosis almost immediately. This may eliminate the need for hospitalization. CT scans or MRIs may be diagnostic.
A therapeutic trial of aspirin or colchicine is useful in diagnosing rheumatic fever or gout, respectively. If the joint fluid examination is nonspecific and no systemic signs of infection are evident, the injection of steroids into the joint is reasonable while the physician waits for the results of more sophisticated diagnostic tests.
Other Useful Tests
1. CBC (sickle cell anemia, infectious arthritis)
2. Sedimentation rate (inflammatory joint disease)
3. RA test
4. ANA (collagen disease)
5. Chemistry panel (gout, diabetes, e.g.)
6. Coagulation profile (hemophilia)
7. Antistreptolysin O (ASO) titer (rheumatic fever)
8. Brucellin antibody titer (brucellosis)
9. Serologic test for Lyme disease
10. Sickle cell prep
11. X-ray of the joint
12. Bone scan (rheumatoid spondylitis)
13. Urine for homogentisic acid (ochronosis)
14. Rheumatology consult
15. Orthopedic consult
16. Cultures of the joint fluid for atypical mycobacteria of fungi
17. Human leukocyte antigen (HLA)-B27 (rheumatoid spondylitis)
18. Anticyclic citrullinated peptide (CCP) antibody titer (RA)
19. 1, 25 hydroxy vitamin D3
20. Serum parvovirus B19 IgM
21. ANCA titer (Wegener granulomatosis)
22. Uric acid (Gout)
