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Symptoms
 
 

Arthralgia (Joint Pain)

 
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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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