JOINT PAIN
Because most joints may be affected by the same etiologic processes, a
general discussion of the differential diagnosis of joint pain will be
undertaken, followed by a discussion of exceptions that apply to certain
joints.
Anatomic and histologic breakdown of the joint is not of much value in the
differential diagnosis. It is sufficient to say that extrinsic lesions
around the joint, such as cellulitis, bursitis, and tendonitis, must be
considered in the differential diagnosis. Nonarticular rheumatism or
fibromyositis comes to mind here also. To develop a differential list of
intrinsic conditions of the joints the mnemonic VINDICATE is useful.
V—Vascular suggests hemophilia and scurvy as well as aseptic bone
necrosis (Osgood–Schlatter disease, and so forth).
I—Inflammatory suggests several infectious lesions, but gonorrhea,
lyme disease, staphylococcus, Streptococcus organisms, tuberculosis, and syphilis are
most likely. Although uncommon, viral infections such as rubella, herpes
simplex, human immunodeficiency virus (HIV), and cytomegalovirus may cause
arthritis.
N—Neoplastic disorders to be ruled out are osteogenic sarcoma and
giant cell tumors.
D—Degenerative disorders bring to mind degenerative joint disease or
osteoarthritis, which is so common that it is often the first condition to
be considered in joint pain.
I—Intoxication suggests gout (uric acid) and pseudogout (calcium
pyrophosphate). Drugs infrequently initiate joint disease, but the lupus
syndrome of hydralazine (Apresoline) and procainamide and the “gout
syndrome” of diuretics should be kept in mind.
C—Congenital and acquired malformations bring to mind the joint
deformities of tabes dorsalis and syringomyelia and congenital dislocation
of the hip. Alkaptonuria is also considered here.
A—Autoimmune indicates another commonly encountered group of
diseases. RA is the most prevalent of these, but serum sickness, lupus
erythematosus, rheumatic fever, Reiter syndrome, ulcerative colitis,
regional ileitis, and psoriatic arthritis must be also considered. Do not
forget polymyalgia rheumatica in elderly persons.
T—Trauma suggests numerous disorders. In addition to traumatic
synovitis, one must consider tear or rupture of the collateral or cruciate
ligaments, subluxation or laceration of the meniscus (semilunar cartilage),
dislocation of the joint or patella, a sprain of the joint, and fracture of
the bones of the joint.
E—Endocrine disorders that affect the joints include acromegaly,
menopause, and diabetes mellitus (pseudogout).
Now it is useful to consider individual joints where special etiologies
apply. The TMJ is often affected by malocclusion. The cervical
spine is affected by cervical spondylosis, a condition where hypertrophic
lipping of the vertebrae occurs in response to degeneration of the discs.
Inflammation of the sacroiliac joint occurs most commonly in
Marie–Strumpell disease, psoriatic arthritis, Reiter disease, and regional
ileitis.
Approach to the Diagnosis
The approach to the diagnosis of joint pain includes a careful history
and examination for other signs such as swelling, redness, and hyperthermia
of the joints. If the joint pain is worse in the morning, consider RA. If
multiple joints are involved, look for RA, lupus, and osteoarthritis. Single
joint involvement suggests gonorrhea, septic arthritis, tuberculosis, or
gout, among other things. Small joints are involved more frequently in RA,
Reiter syndrome, and lupus, although the large joints are more frequently
involved in osteoarthritis, gonorrhea, tuberculosis, and other infections.
Remember, however, that both osteoarthritis and gonorrhea may involve the
small joints of the hands and feet. Rheumatic fever presents a migratory
arthritis; this is a helpful differential point. When the knee joint is
involved, the astute clinician will always examine for a torn or subluxated
meniscus and loose cruciate or collateral ligaments. MRI or arthroscopy will
pin down this diagnosis. Listed below are the most valuable diagnostic
tests. Synovial fluid analysis for uric acid and calcium pyrophosphate, the
character of the mucin clot, a white cell count, and culture can be done in
the office and may make the diagnosis almost immediately. This may eliminate
the need for hospitalization.
A therapeutic trial of aspirin or colchicine is useful in diagnosing
rheumatic fever and gout, respectively. If the joint fluid examination is
nonspecific and no systemic signs of infection are evident, the injection of
steroids into the joint is reasonable while the physician waits for the
results of more sophisticated diagnostic tests.
Other Useful Tests
-
CBC (sickle cell anemia, infectious arthritis)
-
Sedimentation rate (inflammatory joint disease)
-
RA test
-
ANA (collagen disease)
-
Chemistry panel (gout, diabetes, e.g.)
-
Coagulation profile (hemophilia)
-
Anti-streptolysin O (ASO) titer (rheumatic fever)
-
Brucellin antibody titer (brucellosis)
-
Serologic test for Lyme disease
-
Sickle cell prep
-
X-ray of the joint
-
Bone scan (rheumatoid spondylitis)
-
Urine for homogentisic acid (ochronosis)
-
Rheumatology consult
-
Orthopedic consult
-
Cultures of the joint fluid for atypical mycobacteria of fungi
-
Human leukocyte antigen (HLA)-B27 (rheumatoid spondylitis)
-
Anti–cyclic citrullinated peptide (CCP) antibody titer (RA)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Read excerpts from these other book chapters related to Behind knee pain:
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Behind knee pain
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