MSK History

Joint Swelling



  • Swelling of one or more joints may be accompanied by joint pain or stiffness. It is important to consider septic arthritis, an imminently life-threatening cause, in any patient with joint swelling, however there are many other inflammatory and non-inflammatory causes.


    • Causes of Joint Swelling

    • Inflammatory

    • 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
    • Sarcoidosis
    • Degenerative

    • Osteoarthritis
    • Traumatic

    • Fracture
    • Dislocation
    • Soft tissue injury - menisceal tear, ligamentous tear
    • Haemarthrosis (traumatic or in the setting of coagulopathy)
    • Other

    • Malignancy - sarcoma, metastasis
    • Avascular necrosis
    • Tendonitis
    • Bursitis

Differential Diagnosis

    • Differential Diagnosis of Limb Swelling

    • Commonly Unilateral

    • Trauma - fracture, muscle sprain or rupture, compartment syndrome
    • Tenosynovitis
    • Skin / soft tissue infection - cellulitis, abscess, osteomyelitis
    • Venous - DVT, superficial thrombophlebitis, venous insufficiency
    • Lymphoedema
    • Commonly Bilateral / Generalised

    • Volume overload - heart failure, cirrhosis, nephrotic syndrome
    • Lymphoedema
    • Medications - NSAIDs, calcium channel blockers, beta blockers, alpha blockers, aciclovir, cyclophosphamide, cyclosporine, corticosteroids, oestrogen, progesterone
    • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure
    • Pretibial myxoedema (profound hypothyroidism)

History of Presenting Complaint

    • Distribution

      Number of joints affected, whether the swelling 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
    • Onset

      Whether the swelling began suddenly or gradually, and in what situation.
    • Sudden onset knee pain and swellingSuggestive of haemarthrosis
    • Onset post traumaSuggestive of fracture, dislocation or soft tissue injury
    • Onset post recent infectionSuggestive of reactive arthritis
    • Timing

    • How long the swelling has been going on for.
    • Associated Symptoms

      Whether the swelling is associated with any other symptoms.
    • PainNon-specific; swelling is often associated with 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
    • Severity

      How the swelling is 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
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