Approach to Joint Pain - Arthritis Differential Diagnosis Framework Inflammatory Versus Noninflammatory Pain • Is it inflammatory vs noninflammatory? • Inflammation is suggested by warmth, effusion, erythema and WBC >2000 in synovial fluid • What is the time course (acute/subacute/chronic)? • How many joints are involved (monoarthritis, oligoarthritis, polyarthritis)? • Distribution - peripheral vs axial (spine, shoulders, hips)? • Is it symmetric? • Is there a pattern (additive vs migratory vs intermittent)? Autoimmune → Inflammation Mechanical/degenerative disorders → noninflammatory Signs of inflammation are: • Pain • Erythema • Soft tissue swelling • Warmth • Noninflammatory • Pain, stiffness < 30 mins • Pain worse with activity • Painful, stiff, stiffness after non-activity, may have effusion with few WBCs (200-2000/µL) • No constitutional symptoms Inflammation → • Morning stiffness lasting > 30 mins - 1 hour • Very hard to get out of bed, better after taking a shower and moving around in the morning • Effusion leukocyte count > 2000/µL • Better with activity • Better with NSAIDs • Waking up with pain at night Pain with passive range of motion → articular condition Pain with active range of motion → periarticular condition MONOARTHRITIS • Acute Monoarthritis: - Noninflammatory • Trauma • Hemarthrosis • Internal derangement/Avascular necrosis - Inflammatory • Crystal induced (Gout/Pseudogout) • Infectious (Gonococcal/Lyme etc) • Chronic Inflammatory Monoarthritis (>6 weeks) Can Be Caused By: - Chronic Infection • Mycobacterial • Fungal • Borrelia burgdorferi • Virus/Bacteria • Syphilis - Autoimmune Rheumatologic Disease OLIGOARTHRITIS • 2-4 joints • Typically in an asymmetric pattern Acute Inflammatory Oligoarthritis: • Gonorrhea • Rheumatic fever • Lyme • Gout/Pseudogout Chronic Inflammatory Oligoarthritis: • Autoimmune conditions such as spondyloarthritis POLYARTHRITIS • 5 or more joints Viral Infections: • Parvovirus B19 • HIV • Hepatitis B virus • Rubella Bacterial Infection: • Neisseria gonorrhoeae (gonorrhea) • Bacterial endocarditis • Campylobacter species • Chlamydia species • Salmonella species • Shigella species • Yersinia species • Tropheryma whippleii (Whipple's disease) • Group A streptococci (rheumatic fever) • Staphylococcus aureus • Gram-negative bacilli • Borrelia burgdorferi (Lyme disease) • Mycobacterium tuberculosis (tuberculosis) • Fungi, secondary syphilis Chronic Inflammatory Polyarthritis (>6 weeks in duration): • Rheumatoid arthritis • SLE • Psoriatic arthritis • Adult onset Still's • Ankylosing Spondylitis, IBD Symmetrical: • RA • SLE Asymmetrical: • Psoriatic arthritis • Reactive arthritis • Lyme arthritis #Arthritis #Joint #pain #Differential #Diagnosis #MSK #rheumatology #Monoarticular #Monoarthritis #Oligoarthritis #Polyarthritis #Polyarticular #Oligoarticular
