Approach to joint pain

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APPROACH TO JOINT PAIN Dr Anoop R Prasad

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INTRODUCTION 15% of patients in general practice presents with musculo-skeletal complaints Most common cause of long term pain and disability Joint diseases account for half of all chronic conditions in people aged 60 and over Osteoarthritis accounts for half of all chronic conditions in persons aged over 65. 25 % of people over the age of 60 have significant pain and disability from osteoarthritis

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Low back pain is the most frequent cause of limitation of activity in the young and middle aged, one of commonest reasons for medical consultation, and the most frequent occupational injury. Back pain is the second leading cause of sick leave.

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In children JRA : 58% Childhood SLE : 14% Rheumatic Fever : 12% Vasculitis : 7% Juvenile Dermatomyositis : 2% Best Practice & Research Clinical Rheumatology Vol. 22, No. 4, pp. 583–604, 2008

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NORMAL JOINT

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Is it Arthritis or Arthralgia? Presence of swelling of joint (synovial fluid , bony) Local warmth Tenderness along the joint line Redness (e.g. septic arthritis. acute gout .etc.) Range of motion (often reduced) Any deformity ( Rubor, Calor, Dolor, Tumor, Functio laesa )

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INFLAMMATORY Rubor, calor, dolor, tumor, Functio laesa Decreases with activity, increase with rest EMS > 1 hour Systemic symptoms like fever, weight loss, LOA ESR, CRP NONINFLAMMATORY No classical signs Increases with activity, decrease with rest EMS < 1 hour No systemic symptoms

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ARTHRALGIA Fibromyalgia Bursitis Tendinitis Hypothyroidism Neuropathic pain Metabolic bone disease Depression Drugs

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ARTHRITIS MONOARTHRITIS: Trauma Infection: DGI ± Skin lesion. Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection. Crystal induced arthritis Monosodium Urate crystals (MPJ) Ca pyrophosphate dihydrate crystals (knee) Lyme disease Systemic Rheumatoid diseases: Seronegative spondyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) Sarcoid periarthritis RA Osteoarthritis

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POLYARTHRITIS: Rheumatoid Arthritis Systemic lupus Erythrematosus Viral arthritis Reiter’s disease (Reactive arthritis) Psoriatic arthritis

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Articular Vs. Periarticular

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HISTORY Duration of complaints (acute<6wk versus chronic>6wk). Number of Joints involved (mono, oligo or polyarthritis). Distribution of joints involved (peripheral, axial, sparing some joints) Pattern of involvement (recurrent, additive, migratory etc.) History of joint swelling Duration of early morning stiffness (prolonged in Inflammatory arthritis)

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Extra-articular complaints (e.g. fever, rash, alopecia, oral ulcers, photosensitivity etc.) Associated medical illness (e.g. psoriasis. hypothyroidism, tuberculosis, IBD) Significant past history (similar episode of arthritis. drug allergy. peptic ulcer) Family history of rheumatic disease (e.g. gout. spondarthritis)

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Acute mono articular : Septic arthritis – orthopedic and medical emergency Crystal induced – gout , pseudogout Hemarthrosis - as in Hemophilia Chronic mono articular : Osteoarthritis Monoarticular presentation of RA or psoriatic arthritis

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Acute polyarticular: Reactive arthritis Viral arthritis Post viral arthritis Drug-induced arthritis Poncet's arthritis Sarcoidosis

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Chronic polyarticular: Rheumatoid arthritis Spondarthritis {AS, Reiter's, lBD-associated, uSpA Juvenile spondylitis. Ps A) Psoriatic arthritis Juvenile Idiopathic Arthritis

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Distribution: Symmetrical- upper and lower limb eg. RA, SLE Asymmetric - psoriatic, gout, spondyloarthritidis Fist metatarsal – gout Hand joints with sparing of DIP – RA Axial joints – OA, AS, Spondyloarthritis, RA ( only cervical spine) DIP : OA, Ps A

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Pattern: Fleeting / migratory : Rheumatic fever Gonococcemia Meningococcemia Viral Arthritis Acute Leukemia Additive: SLE RA

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Age <30= SLE, Ankylosing spondylitis, Reactive Arthritis. 30-50= RA, Systemic sclerosis, Gout. >50= OA, Pseudogout, PMR Any Age group= Psoriatic arthritis, Enteropathic arthritis

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Extra articular manifestations :

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EXAMINATION JOINT: Swelling, warmth, effusion – inflammatory Deformity Synovial thickening Active and passive movements – both restricted- arthritis, passive normal & active restricted- enthesitis Number of joints involved

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Extra articular manifestations

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INVESTIGATIONS CBC – thrombocytosis, leukocytosis in inflammatory Acute phase reactants – ESR, CRP Urine analysis – pus cells in reactive arthritis, active sediments( 2-5 rbc, rbc cast, wbc cast) in SLE, vasculitis Viral serologies – HBsAg, HCV, EBV, Chikungunya,Parvo Serologies – RF -

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Rheumatoid Arthritis Factor Antibody against the Fc portion of IgG. above 20 IU/mL, 1:40, or over the 95th percentile 75-80% sensitivity, 85-90% specificity, 60% PPV, 92% NPV 80% pts with RA, 70% with Sjogrens Epstein-Barr virus or Parvovirus infection 5-10% of healthy persons chronic hepatitis

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primary biliary cirrhosis, any chronic viral infection, Bacterial endocarditis, leukemia, dermatomyositis, infectious mononucleosis, systemic sclerosis, systemic lupus erythematosus (SLE)(20-30%)

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Anti ccp (cyclic citrullinated peptide): Sensitivity – 80% Specificity – 85- 98% ANA - Systemic lupus erythematosus (lupus or SLE) - over 95% Progressive systemic sclerosis (scleroderma) - 60-90% Rheumatoid Arthritis - 25-30% Sjogrens syndrome - 40-70% Felty's syndrome - 100% Juvenile arthritis - 15-30% Anti dsDNA -- SLE

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Serum uric acid - >7mg/dl to be significant 0.1% develop gout if <7, 0.5% if 7-8.9, 5% if >9 Synovial fluid analysis: Monoarthritis Suspicion of infection Suspicion of crystal-induced arthritis Suspicion of hemarthrosis Differentiating inflammatory from noninflammatory arthritis

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RADIOLOGY

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12 OCTOBER- WORLD ARTHRITIS DAY 16 OCTOBER - WORLD SPINE DAY 17 OCTOBER- WORLD TRAUMA DAY 20 OCTOBER - WORLD OSTEOPOROSIS DAY

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THANK YOU

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