Monarticular Joint Pain
Margaret A. Tryforos
Approach
Evaluation of monarticular joint pain should differentiate inflammatory from degenerative conditions and clarify whether immediate treatment is needed to prevent permanent joint damage. Distinction must be made between peri- and intraarticular disease. Consideration of an underlying systemic disease is also important. The differential diagnosis of monarticular joint pain is shown in Table 12.7.
History
A. Timing of the pain. What is the onset and duration of the pain? Was there a specific inciting incident or trauma? When does the pain occur? Pain wakening the patient from sleep may suggest a malignancy. Is pain present at rest? Does movement or weightbearing exacerbate the symptom? Any associated joint stiffness?
B. Location of the pain. Localization to the joint is typical in osteoarthritis (OA). Exceptions are hip OA, where pain can localize to the groin or thigh, and OA of the spine, where pain can localize to the buttocks. Radiation of the pain may suggest periarticular or neuropathic problems.
C. Associated symptoms. Fever, night sweats, or weight loss may suggest an infectious cause or an underlying systemic illness. Rash can occur with infectious or inflammatory arthritides.
D. Medical history. Many medical problems can be associated with an inflammatory or a degenerative arthritis (Table 12.7). Knowledge of prior joint surgery or prosthesis placement is important. A history of childhood joint disease (e.g., slipped capital epiphysis) or bone disease (e.g., osteochondritis dissecans) can predispose to early onset degenerative joint disease.
E. Social history. The patient’s support system is especially important if severe functional impairment is present. The employment or recreational history may indicate a risk of repetitive joint trauma. Sexual risk factors and a history of alcohol or intravenous (IV) drug abuse are important.
F. Medications. What medication or treatment has been used and what was the response? A history of systemic steroid use can lead to osteonecrosis of the femoral head.
Physical examination
Is discomfort apparent? Is fever present? Assess the patient’s gait and note if a mobility aide is used. Inspect the joint for surgical or traumatic scars, muscle atrophy, deformity, joint swelling, and erythema. Palpate for warmth, tenderness, and effusion. Evaluate joint range of motion (ROM). If active ROM is full and normal, evaluation of passive ROM is unnecessary. Pain with active, but not passive ROM suggests a periarticular process. Depending on the joint involved, palpate the relevant periarticular structures and perform the appropriate provocative maneuvers. Examine for rash.
Testing
No studies are routinely indicated for all cases of monarticular joint pain.
A. Imaging studies. Radiographs may be warranted if evaluation suggests degenerative joint disease, but they are not necessarily indicated at initial presentation. Radiographic findings of OA, which are more prevalent than symptomatic disease, can be found in 85% of patients aged 65 years (1). Radiographic study is clearly indicated if the pain is chronic, or if there is a history of recent trauma, night pain, or childhood joint disease. In cases of acute inflammatory arthritis, radiographs will likely reveal soft tissue swelling and not provide diagnostic certainty, but could exclude other diseases. Bone scans are not helpful, as they will be positive in all forms of arthropathy. Computed tomography or magnetic resonance imaging scans are not indicated in the routine initial evaluation of monarticular joint pain.
B. Laboratory testing. In the presence of an inflamed joint, a complete blood count and erythrocyte sedimentation rate (ESR) may help distinguish a septic or inflammatory condition from crystal-induced arthritis. Rheumatoid factor or antinuclear antibody may be positive in inflammatory arthritis (Chapters 16.3 and 17.3). Serologic testing for syphilis should be done when gonococcal infection is suspected. Serum uric acid, Lyme titers, and human immunodeficiency virus testing may be warranted. The uric acid level may be normal during an acute gouty attack.
C. Joint aspiration. Fluid analysis is necessary in all cases of suspected septic arthritis, and for the definitive diagnosis of presumed crystal-induced arthropathy at initial presentation. Fluid should be analyzed for cell count and crystals and sent for Gram’s stain, culture, and sensitivity. Patients with immune compromise or tuberculosis require culture for mycobacteria and opportunistic organisms. In suspected septic arthritis, Gram’s stain and culture of the blood, skin lesions, cervix, urethra, pharynx, and rectum may be indicated.
Diagnostic assessment
The history and physical examination usually determine whether the cause of joint pain is inflammatory or degenerative. Occasionally, an acute, inflammatory appearing monarthritis, with a mildly elevated ESR, can be the initial presentation of degenerative disease. OA typically presents with a slow, insidious progression of symptoms over months to years. The pain is achy, brought on by joint use, and relieved by rest. Short-lived (<30 minutes) stiffness may be apparent in the morning and after inactivity.
Gouty arthritis is seen most frequently in men aged more than 30 years. Of patients, 50% present classically with inflammation in the first metatarsal joint of the foot. In women, upper extremity joint involvement predominates. Synovial fluid analysis will reveal monosodium urate crystals or calcium pyrophosphate crystals in the case of pseudogout. Synovial white blood cell (WBC) count suggests inflammation (3,000–50,000 cells/µL). Synovial fluid should be cultured, even if crystals are identified, as bacterial infection can coexist. When in doubt, a diagnostic or therapeutic trial of colchicine can be considered.
Infectious arthritis should be considered with any inflamed joint. Risk factors include an immunocompromised state, a damaged or prosthetic joint, sexual promiscuity, and alcohol or intravenous drug abuse. Onset is usually rapid, over hours to days. Gonococcal arthritis can present with a few days of migratory polyarthralgias. In septic arthritis, the joints commonly affected are the knees, hips, and shoulders. Severe joint pain, swelling, and limited ROM suggest the diagnosis, especially if high fever is present. An elevated WBC count, with a left shift, is present in more than 50% of cases. Definitive diagnosis is dependent on arthrocentesis. Synovial fluid WBC count of greater than 50,000 is supportive of infection. A negative Gram’s stain finding does not rule out infection. Gonococcal arthritis can present with a lower synovial fluid WBC count and the synovial fluid culture is positive in only 25% of cases (2).
Lyme arthritis has an acute, oligoarticular onset and especially affects large joints, most commonly the knee. Symptoms tend to be episodic and are associated with marked swelling, often disproportionate to the amount of pain. Presentation can be weeks to months after the initial infection, and the patient may be unable to give a history of tick bite or the erythema chronicum migrans rash (3). Serology and Western blot testing for Lyme disease should be positive.
References
1. Baker DG, Schumacher HR. Acute monoarthritis. N Engl J Med 1993;329:1013–1020.
2. Zimmerman B, Lally EV, Liu NYN. Infectious agents and the musculoskeletal system. In: Noble J, ed. Textbook of primary care, 2nd ed. St. Louis: Mosby, 1996.
3. Sigal LH. Musculoskeletal manifestations of Lyme arthritis. Rheum Dis Clin North Am 1998;24:323–351.
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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 Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Ankle pain
» Next page: Ankle/Foot Pain (Field Guide to Bedside Diagnosis)
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