- Joint stiffness is often accompanied by pain, and may be caused by inflammatory or non-inflammatory arthropathies. The clinical history can be used to delineate between these two major causes of arthropathy.
Causes of Joint Stiffness
- Rheumatoid arthritis
- Seronegative spondyloarthropathies - reactive arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-related arthritis
- Crystal arthropathies - gout, pseudogout
- Vasculitis - Wegener’s, polyarteritis nodosa, giant cell arteritis
- Systemic inflammation - SLE, polymyositis, dermatomyositis
- Septic arthritis - gonococcal, Staph, Strep, gram negative
- Other infection - TB, Lyme disease
- Soft tissue injury - menisceal tear, ligamentous tear
- Haemarthrosis (traumatic or in the setting of coagulopathy)
- Malignancy - sarcoma, metastasis
- Avascular necrosis
- Loose intra-articular body
History of Presenting Complaint
DistributionNumber of joints affected, whether the stiffness is symmetrical or asymmetrical and whether large or small joints are affected.
- Monoarthropathy: one joint affectedNon-specific; most causes can (initially) present with monoarthropathy
- Polyarthropathy: multiple joints affectedMore likely to represent an inflammatory cause
- Symmetrical small-joint involvementSuggestive of rheumatoid arthritis
- Affecting large joints of the lower limbSuggestive of osteoarthritis or reactive arthritis
- Pain, swelling and warmth in the great toeClassical presentation of acute gout
OnsetWhether the stiffness began suddenly or gradually, and in what situation.
- Onset post traumaSuggestive of fracture, dislocation or soft tissue injury
- Onset post recent infectionSuggestive of reactive arthritis
Associated SymptomsWhether the pain is associated with any other symptoms.
- Joint pain and swellingNon-specific, may be suggestive of inflammation
- Numbness / paraesthesiaSuggestive of nerve pain
- FeversSuggestive of septic arthritis or inflammatory cause
- Eye pain / conjunctivitisSuggestive of reactive arthritis
- DysuriaSuggestive of reactive arthritis
- Dry eyes / mouthSuggestive of Sjogren’s syndrome
- RashPotential SLE or psoriatic arthritis
TimingHow long the stiffness has been going on for and whether it is worse at any specific time of day.
- Morning stiffnessSuggestive of inflammatory cause
- Intermittent ‘locking’ of the jointSuggestive of mechanical issue e.g. intraarticular foreign body
Exacerbating FactorsWhether there is anything that makes the stiffness worse, such as exercise or prolonged rest.
- Exacerbated with activitySuggestive of non-inflammatory cause e.g. osteoarthritis
Alleviating FactorsWhether there is anything that relieves the stiffness.
- Improved with activitySuggestive of inflammatory cause
SeverityHow the stiffness if functionally affecting the patient.
- Hand - buttons, keys, taps, shopping bags, dressing, showering, eating
- Wrist - dressing, toilet, eating
- Elbow - dressing, lifting objects
- Shoulder - dressing, top shelves, hanging washing, lifting objects
- Back - walking, shoes, stairs, hills, lifting
- Hip - walking, getting in/out of cars, stairs
- Knee - chairs, shoes, stairs, kneeling, getting in/out of cars
- Ankle - walking