Approach to the patient with monoarticular pain

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Approach to the patient with monoarticular pain

• Caroline Gordon
• Department of Rheumatology
• City Hospital and
• University of Birmingham

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Assessment of joint pain

• Site (distribution)
• Type
• Associated features
• Duration and onset
• Risk factors
• Physical signs
• Differential diagnosis

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Structures associated with a joint
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Site of pain

• Patient complains of pain in the knee
• Is pain coming from the joint arthritis
• Is pain from the surrounding tissues
• tendonitis, enthesitis, bursitis
• or bone pain
• Is there pain in other joints?

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Site and distribution of pain

• Is it joint, peri-articular or muscle pain?
• Which joint is involved?

Achilles tendonitis
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What type of joint pain?

• Is it inflammatory?
• Is it mechanical or degenerative?

• Pain worse at rest
• and improved by exercise
• Pain worse on exercise
• and improved by rest

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Other inflammatory features?

• Early morning stiffness?
• Redness?
• Warmth?
• Tenderness?
• Swelling?

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Duration and onset

• Is it acute or chronic?
• What were circumstances of onset?
• Is it getting rapidly or slowly worse?
• Have there been any previous episodes?

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Differential diagnosis

• Acute Inflammatory
• Septic arthritis
• Crystal arthritis
• Haemarthrosis
• Other
• Chronic
• TB arthritis

• Acute non-inflammatory
• usually trauma related
• cartilage or ligamentous
• aseptic necrosis
• Chronic
• Osteoarthritis

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Systemic features?

• Fever
• Malaise
• Weight loss
• Loss of appetite
• Infections- skin, respiratory, urinary etc

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Past medical history- risk factors

• Predisposition to infection?
• Associations with gout/other crystals

• Recent infection
• Joint replacement
• Diabetes mellitus
• Chronic systemic disease/malignancy
• Dehydration
• Renal failure
• Hypertension
• Hypercholesterolaemia

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Other risk factors

• Family history of
• gout
• haemophilia or other bleeding disorder
• Social history of
• alcoholism
• drug abuse

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Treatment history

• Risks for sepsis
• Corticosteroids
• Cytotoxic drugs
• IV drug use/abuse

• Risks for gout
• Diuretics
• Nephrotoxic drugs
• Risks for haemarthrosis
• anticoagulation

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Clinical features of inflammatory monoarthritis

• Fever
• Erythema
• Local pain and tenderness
• Inflammatory signs
• Impaired function
• Signs of infection
• Petechiae or purpura
• Gouty tophi

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Gouty tophi
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Differential diagnosis of monoarthritis

• Inflammatory
• septic arthritis
• crystal arthritis eg gout, pseudogout (CPPD)
• haemarthrosis (bleed)
• Non-inflammatory
• osteoarthritis

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Features suggesting infection

• Fever
• Lymph nodes
• Erythema and heat
• One joint flare in RA
• One or few joints-sequential/additive
• Other risk factors

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Tuberculous infection

• Indolent
• Mild fever
• Rarely warmth/redness
• Some tenderness/swelling
• Usually monoarthritis
• Chest often normal
• Mantoux positive

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Investigations in acute monoarthritis

• FBC (WC diff) , ESR or viscosity or CRP
• Renal function urate
• Blood cultures
• Synovial fluid
• Swabs, urine, stool
• X-rays

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Synovial fluid analysis

• Infection or crystals ? (or blood ?)
• Cell count and differential
• Gram stain /- Ziel-Nielsen stain
• Culture for bacteria including TB
• Polarised light microscopy for crystals

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Aspirate after correcting clotting if necessary
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Synovial fluid analysis

• Macroscopic
• Cells
• Chemistry

• turbid
• not viscous
• poor mucin clot
• increased gt50,000/mm3
• gt90 neutrophils
• low glucose in infection

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Aspirate to distinguish infection from crystals
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Septic arthritis due to Staph. aureus
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X-ray changes in infection

• Soft tissue swelling
• Joint space narrowing
• No reactive osteopenia or sclerosis early
• Destruction and flattening of weight-bearing
  surfaces (eg hip)
• Diffuse loss of cortex not discrete erosion
• Late sclerosis/fusion

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X-ray change in infection
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Crystal arthritis

• GOUT
• urate crystals
• Middle aged males
• Post-menopausal female
• Peripheral small joints
• Medium sized joints less

• PSEUDOGOUT (CPPD)
• calcium pyrophosphate dihydrate
• Elderly females gt males
• Medium large joints most
• May be associated with OA

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Gout
Usually monoarticular at onset
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Uric acid crystals
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X-rays in gout
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Severe tophaceous gout
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PseudogoutCalcium pyrophosphate arthropathy
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CPPD arthropathyoften associated with
osteoarthritis
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Aspirate to distinguish infection from crystals
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Calcium pyrophosphate crystals
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Chondrocalcinosisassociated with CPPD arthritis
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Chondrocalcinosis in the triangular ligament
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Treatment of acute inflammatory monoarthritis

• Reverse anticoagulation if appropriate
• Aspiration/drainage
• Antibiotics- parenteral then oral if septic
• NSAIDs, other analgesia
• Rest
• Physiotherapy
• Other therapy if crystals confirmed

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Treatment of septic arthritis

• Antibiotics
• Staph aureus
• Strep/H. infl
• Gram negative
• Penicillin allergic

• Flucloxacillin
• Sodium fucidate
• Vancomycin
• Amoxicillin
• Gentamycin
• Cefuroxime
• Erythromycin

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Type of pain associated features of inflammation

• Is it inflammatory?
• What makes the pain worse/better?
• Is there morning stiffness/gelling?
• Has there been any swelling?
• Is the joint tender to touch?
• Has the joint been red or warm?

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Acute inflammatory monoarthritis

• Infection-acute/chronic
• Crystals-gout/CPPD
• Trauma
• Bleed (haemarthrosis-coagulopathy)
• Other inflammatory arthritis
• Tumour (very rare)

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Clinical features of osteoarthritis

• SYMPTOMS
• Use-related pain
• Mild am stiffness
• Inactivity gelling
• Loss of joint motion
• Instability
• Disability

• SIGNS
• Periarticular tenderness
• Bony swelling joint margin
• Cool effusions
• Coarse crepitus
• Restricted painful movement
• Instability

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Osteoarthritis monoarticular or polyarticular
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Osteoarthritis (OA)

• Joint failure
• Dysregulation of normal tissue turnover repair
• Extremely common age-related disorder
• Major cause of disability inability to work
  gt50yrs

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Pathological features of OA

• Focal areas of destruction of articular cartilage
  (fibrillation and erosion)
• Hypertrophy of subchondral bone, joint margin
  capsule (synovial metaplasia)
• Pseudocysts

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Normal and OA joint
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Radiological changes of OA

• Joint space narrowing
• Subchondral bone sclerosis and cysts
• Marginal osteophyte formation

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Normal knee and osteoarthritis
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Management of osteoarthritis

• Establish diagnosis
• Analgesia
• Education
• Exercise
• Walking stick etc
• Surgery

• clinical assessment
• X-rays
• blood tests
• paracetamol, codeine
• future expectations
• physio
• OT
• plan appropriate time