Joint Swelling
February 15th, 2021
Overview
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.
Aetiology
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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