Arthralgia
Arthralgia: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Meredith A. Goodwin
Arthralgia is a general term that describes pain in one or more joints, with or without joint inflammation. The source can be local or systemic. Pain location, onset, duration, and associated symptoms are important data in determining the cause of arthralgia (1).
Approach
Joint pain can be categorized by pattern of involvement (Table 12.1).
History
A. Demographics. The patient’s age is sometimes helpful in determining the cause of arthralgia. Systemic lupus erythematosus (SLE) commonly presents between the second and fourth decades of life. Rheumatoid arthritis (RA) is more common between the fourth and sixth decades; osteoarthritis (OA) peaks in the seventh and eighth decades. Infectious causes, as well as trauma, have no particular age association. Younger, female patients are more likely to have RA or SLE, whereas postmenopausal women are affected by gout and OA of the knee and hand. Male patients more likely have gout, ankylosing spondylitis, and OA of the hip. Race is helpful in some disorders: SLE is more common in African-Americans.
B. Affected joints. The new onset of monarticular symptoms can be seen in trauma, infection, crystal-induced disease, periarticular problems, and degenerative and inflammatory arthritic processes. Early OA can present in one joint, most commonly the knee, or in any joint damaged by antecedent trauma. Recurrent pain in one joint can indicate OA flare, gout or pseudogout attack, SLE, sarcoidosis, or a periarticular problem. Gout presents in the first metatarsal phalangeal joint in 50% of cases (Chapter 12.6).
Multiple joint involvement, especially with other associated symptoms, is characteristic of a systemic process. Symmetric involvement of the metacarpal-phalangeal, proximal interphalangeal joints (PIPs), wrist, and feet is more common in RA; involvement of the knees or hips is unusual (1). OA favors the PIPs, distal interphalangeal, carpal-metacarpal joint of the thumb, hips, knees, ankles, feet, and spinal column (1), but involvement is not necessarily symmetric. Erosive OA can affect multiple joints of the hands. SLE often affects the hand and wrists.
C. Pain characteristics. Additional history includes the exact location of the pain (around vs. inside the joint), the time course (episodic or intermittent vs. constant pain), and the presence and onset of joint swelling or warmth. Joints that are stiff in the morning and hurt at rest are seen in RA. RA pain waxes and wanes throughout the day and night, and is unrelated to activity. OA pain is associated with use and improves with rest.
D. Family history. RA, SLE, gout, ankylosing spondylitis, and OA of the fingers all have a familial component. SLE is also found in families with other autoimmune diseases.
E. Lifestyle factors. Dietary history is important in gout, as a diet high in purine foods (liver, sweetbreads, kidneys, red meat, sardines, and anchovies) can precipitate an attack in susceptible individuals. Certain underlying diseases, sexual practices, alcoholism, and intravenous drug use are risk factors for septic arthritis.
F. Associated symptoms. Other complaints are often helpful in narrowing the differential diagnosis. Fatigue that does not improve with rest can be seen in RA, SLE, and infectious arthralgia. Rash can be seen in arthralgia resulting from a variety of infectious and inflammatory causes. Urticaria is common in the acute serum sickness syndrome. A history of a tick bite or targetlike rash may indicate arthritis from Lyme disease. Vaginal discharge, pelvic pain, or urethritis symptoms or discharge should raise the possibility of an infectious cause or Reiter’s disease. Fever is likely with infectious, and some inflammatory, causes of arthralgia.
G. Past medical history. Other known medical illnesses are also important as they may be associated with inflammatory or degenerative causes of arthralgia (Table 12.1). Childhood joint disease predisposes to early onset degenerative disease.
New medications, including diuretics, chemotherapeutic agents, antituberculosis drugs, and low-dose aspirin, can precipitate gout. Other medications and vaccination reactions can cause polyarticular arthralgias.
Physical examination
A. Joint examination. Inspect the joint for evidence of trauma, breaks in the skin, swelling, erythema, deformity (e.g., bony changes, tophi), and asymmetry with contralateral joints. Palpate the joint and surrounding tissues for warmth, tenderness, effusion, edema, and crepitus. Perform joint range of motion (ROM). Pain with active, but not passive ROM is more consistent with a periarticular problem.
B. Examination of other systems. Conjunctivitis, oral lesions, urethritis, genital or extremity ulcers, rash, tophi, and nail pitting can indicate a more systemic problem. Rheumatic disease can affect other organs (e.g., pleural effusion, splenomegaly, Raynaud’s phenomenon).
Testing
A. Laboratory tests. Perform arthrocentesis of an isolated, acutely inflamed joint and examine synovial fluid for cell count and differential, crystals, Gram’s stain, and culture (2). Suspected cases of gonococcal disease warrant culture of the pharynx, urethra, cervix, and rectum to increase the likelihood of a positive culture. Potentially useful blood tests include an erythrocyte sedimentation rate (ESR), antinuclear antibody, rheumatoid factor, syphilis, Lyme disease and other serologies, blood culture, uric acid, thyroid-stimulating hormone, calcium, liver function tests, blood urea nitrogen, and creatinine (2). The ESR is often elevated with inflammatory or infectious conditions, and can be mildly increased in primary generalized OA (Chapter 16.3).
B. Diagnostic imaging. Perform an x-ray study with a history of significant trauma or focal bone pain (2). In adults, x-ray findings of degenerative changes are more prevalent than symptomatic disease at all ages. Soft tissue swelling and erosive changes can be seen with rheumatic disease. Disruption of joint integrity is most clearly seen on magnetic resonance imaging (MRI). Radiographs and MRI are more helpful in the evaluation of trauma than in other situations, but can be used to follow the progression of a chronic process. Plain radiographs of the chest looking for lung nodules, infiltrates, interstitial processes, and cardiac enlargement may be helpful if rheumatic disease is suspected.
Diagnostic assessment
Arthralgia has many causes. Trauma and infection are the most serious problems in the acute setting where the history and physical examination will be the key to the diagnosis. Chronic or recurrent mon- or polyarticular arthralgia more likely indicates an arthritic process; further testing may be needed to narrow the differential diagnosis. Arthralgia without physical findings may suggest an overuse syndrome, viral infection, vaccine or other medication side effect, or metabolic bone disease (2). Keep in mind that arthralgia can be caused by disease in the surrounding soft tissue structures.
References
1. Johnson BE. Adult rheumatic disease. AAFP home study self assessment. Kansas City: American Academy of Family Physicians July, 1997.
2. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. In: Kelley WN, Ruddy S, Harris ED, Jr, Sledge CB, eds. Textbook of rheumatology, 5th ed. Philadelphia: WB Saunders, 1997.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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