Arthralgia (Joint Pain)
Overview
Pain affecting the hands, wrists, spine, knees or other joints may herald inflammatory or non-inflammatory arthropathy. By assessing certain characteristics of the pain it is possible to distinguish between these two broad groups and focus in on the cause of a patient's symptoms.
Aetiology
Causes of Joint Pain
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
History of Presenting Complaint
Site
Number of joints affected; whether the pain is symmetrical or asymmetrical; whether large or small joints are affected.- Monoarthralgia: one joint affectedNon-specific; most causes can (initially) present with monoarthralgia
- Polyarthralgia: 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 pain 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
Character
- Burning or 'electric' painSuggestive of neuropathic pain or fibromyalgia
- Deep, constant aching painRed flag for malignancy
Radiation
Whether the pain moves anywhere else.- Back pain radiating down the arm or legSuggestive of neuropathic pain
Associated Symptoms
Whether the pain is associated with any other symptoms.- Joint 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 Sjögren's syndrome
- RashPotential SLE or psoriatic arthritis
- Back pain with bladder or bowel symptomsRed flag for cauda equina syndrome
Timing
How long the pain has been going on for, and whether it is worse at any specific time of day.- Constant pain that does not improveRed flag for malignancy
- Acute attacks of painSuggestive of acute gout
Exacerbating Factors
Whether there is anything that makes the pain worse, such as exercise or prolonged rest.- Present at restSuggestive of inflammatory cause
- Exacerbated with activitySuggestive of non-inflammatory cause e.g. osteoarthritis
- Back pain worse walking downhillSuggestive of neuropathic pain
Alleviating Factors
Whether there is anything that relieves the pain.- Improved with activitySuggestive of inflammatory cause
- Back pain improved walking uphillSuggestive of neuropathic pain
Severity
How bad the pain is on a scale of 1-10 with 10 being the worst pain, and how the pain 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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