Approach to joint pain and swelling: Clinical sciences

Joint pain and swelling are common patient concerns that stem from a range of conditions affecting ligamentous, cartilaginous, or bony structures. Based on the underlying cause, joint pain and swelling can occur in combination or separately, and can be associated with traumatic and non-traumatic causes. Moreover, based on the duration of symptoms, non-traumatic conditions can be further subdivided into acute and chronic.

Now, if your patient presents with joint pain and swelling, perform a focused history and physical examination.

Your patient will report joint pain and their physical exam will usually reveal edema, erythema, and warmth over the affected joints, as well as joint line tenderness. Additionally, they might have an effusion, limited range of motion, or associated crepitus. These findings are suggestive of arthralgia or arthritis.

Your next step is to assess for trauma. If your patient presents shortly after an obvious mechanism of injury, such as a motor vehicle collision or sports accident, and has exam signs that suggest trauma, like ligamentous laxity or joint deformity, consider traumatic joint injury, order imaging, primarily an X-ray of the affected joint! Additionally, if you suspect internal derangement of soft tissue, order an MRI! If imaging confirms the presence of a fracture, dislocation, or soft-tissue derangement, diagnose a traumatic joint injury!

On the other hand, if there’s no evidence of joint trauma, assess the duration of symptoms.

If your patient is presenting with acute joint pain, meaning less than 6 weeks, assess the underlying cause!

Here’s a clinical pearl! When approaching a patient with painful joints, consider ordering inflammatory markers, such as ESR and CRP because elevated levels support the diagnosis of underlying infectious and inflammatory causes.

First up is septic arthritis! In this case, history typically reveals fever and malaise, with a possible history of immunosuppression or pre-existing joint disease. The physical exam reveals a monoarticular joint effusion, limited range of motion, erythema, and warmth of the overlying skin. With these findings, consider septic arthritis, so be sure to aspirate synovial fluid for analysis, including the cell count and differential, gram stain, culture, and crystals. If the synovial fluid contains more than 50,000 white blood cells, yields a positive gram stain and culture, appears purulent, and is negative for crystals, diagnose septic arthritis!