Approach to joint pain and swelling: Clinical sciences

Chapters:

Watch video only

Introduction 0:00–0:33

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.

H&P0:33–1:05

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!

Assess for trauma 1:05–1:44

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!

Acute joint pain/swelling 1:44–2:15

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.

Septic arthritis 2:15–3:05

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!
Next up is disseminated gonococcal infection. This is usually seen in sexually active individuals who report a fever and rash.

Disseminated gonococcal infection 3:05–3:51

The physical exam reveals asymmetric polyarthritis involving the wrists, knees, and ankles. Additionally, you might notice tenosynovitis of the plantar fascia or Achilles tendon, and a pustular rash.
With these findings, consider disseminated gonococcal infection and order labs, including nucleic acid amplification testing or NAAT, blood cultures, and synovial fluid analysis.
If any of these tests are positive for Neisseria gonorrhoeae, diagnose disseminated gonococcal infection! Okay, let’s move on to disseminated viral infection!

Disseminated viral infection 3:51–4:52

Suppose your patient reports fever, malaise, and possibly a history of known exposure to a viral infection with a physical exam revealing lymphadenopathy and a rash.
In this case, consider disseminated viral infection and order serology for hepatitis B and C, HIV, and Parvovirus B19. If any of these serologies are positive, diagnose disseminated viral infection.
Here’s a clinical pearl to keep in mind! Lyme arthritis is an example of a disseminated infection that occurs when the bacteria Borrelia burgdorferi invades the joint space, eventually causing inflammation and pain.
Suspect Lyme arthritis in individuals who have traveled to Lyme endemic areas such as the Northeastern, Mid-Atlantic, and upper Mid-Western regions of the United States!
Now let's take a look at rheumatic fever! These patients are usually teenagers or young adults whose joint symptoms were preceded by group A streptococcal infection.

Rheumatic fever 4:52–5:45

The physical exam reveals migratory, asymmetric polyarthritis involving the elbows, wrists, knees, and ankles. Additionally, the physical exam might reveal a new heart murmur or pericardial friction rub, subcutaneous nodules, erythema marginatum, and even choreiform movements known as Sydenham chorea.
These findings are suggestive of rheumatic fever, so be sure to assess the Jones criteria, a validated metric used to diagnose rheumatic fever.
If your patient meets the criteria, diagnose rheumatic fever. Finally, let’s discuss crystal arthropathy!

Crystal arthropathy 5:45–6:45

These individuals typically report episodic joint pain and swelling, with a possible history of diuretic use, alcohol use, or a high-protein diet.
Next, their physical exam reveals erythema, warmth, swelling, and tenderness of the affected joint. In this case, consider crystal arthropathy, so your next step is to order a synovial fluid analysis, including the cell count and differential, gram stain, culture, and crystals.
If synovial analysis reveals elevated white blood cells between 2,000 and 50,000, negative gram stain and culture, and the presence of either monosodium urate or calcium pyrophosphate crystals, diagnose crystal arthropathy.
Now, let’s take a look at subacute or chronic joint pain and swelling, which lasts for six or more weeks. In this case, your first step is to assess for osteoarthritis.

Assess for osteoarthritis 6:45–7:28

Patients with osteoarthritis are typically older in age and report joint pain in one or more joints, such as the knees, hips, and hands that worsens with activity.
Additionally, your patient will report morning stiffness lasting less than 30 minutes. Next, if the physical exam reveals crepitus, limited range of motion, and bony hypertrophy, you should consider osteoarthritis, so be sure to obtain an X-ray of the affected joint.
If the X-ray reveals joint space narrowing, osteophytes, and subchondral sclerosis, diagnose osteoarthritis! However, if you rule out osteoarthritis, test for autoantibodies, including the antinuclear antibody or ANA and rheumatoid factor or RF for short.

ANA/RF Positive 7:28–7:57

If either ANA or RF are positive, consider systemic rheumatic diseases, primarily rheumatoid arthritis, systemic lupus erythematosus or SLE, systemic sclerosis, and Sjogren syndrome.
Let’s start with rheumatoid arthritis! These patients typically report joint stiffness that lasts more than 30 minutes and occurs either in the morning or with prolonged inactivity.

Rheumatoid arthritis 7:57–9:19

They might also report nonspecific symptoms, such as fatigue and malaise. The physical exam findings typically include symmetrical swelling and joint tenderness to palpation of the smaller joints.
The most commonly affected joints are the proximal interphalangeal and metacarpophalangeal joints or PIP and MCP. You may also find swelling and tenderness of the wrists and metatarsophalangeal or MTP joints.
Moreover, chronic joint inflammation can cause the surrounding structures to shorten, stiffen, and become constricted, which eventually results in contractures.
Important contractures to keep in mind include Boutonniere deformities, where there is persistent flexion of proximal interphalangeal joints and hyperextension of the distal interphalangeal or DIP joints; and Swan-neck deformities, where there’s persistent hyperextension of proximal interphalangeal joints and flexion of distal interphalangeal joints.
These findings are highly suggestive of rheumatoid arthritis. Moving on to systemic lupus erythematosus, or SLE!

Systemic Lupus Erythematosus 9:19–10:22

Your patient will likely describe nonspecific systemic symptoms like fatigue, fever, malaise, and weight loss, but also photosensitivity.
Additionally, the physical exam may reveal a classic malar rash, also known as a butterfly rash, as well as discoid rash, which is a chronic erythematous rash in sun-exposed areas like the arms and legs.
Other important findings include painless oral and nasal ulcers, as well as symmetric tenderness and swelling of the small joints, most commonly in the hands and wrists.
These findings are highly suggestive of SLE! Now, here’s a clinical pearl!
In individuals with SLE, you should always order additional labs, including anti-double-stranded DNA, anti-Smith, and antiphospholipid antibodies.
Also, don’t forget to check complement C3 and C4 levels. Okay, now let’s move on to systemic sclerosis!

Systemic sclerosis 10:22–11:33

Most patients with systemic sclerosis are biological females who report hand swelling and pain. Patients often experience the Raynaud phenomenon, which is a condition that affects blood flow, usually in the fingers and toes.
When exposed to cold temperatures or emotional stress, the blood vessels narrow, leading to reduced blood supply to certain areas, causing them to turn white or blue and feel cold and numb.
Physical examination reveals skin thickening, also known as scleroderma. There might also be sclerodactyly, which refers to the hardening of the skin of the hands, causing the fingers to flex inward.
Some patients might also have digital ulcerations, and telangiectasia, which refers to dilated blood vessels visible under the skin.
At this point, consider systemic sclerosis and order labs, including anticentromere, anti-topoisomerase, and anti-RNA polymerase III antibodies.
If these antibodies are positive, you can diagnose systemic sclerosis. Finally, let’s discuss Sjogren syndrome.

Sjogren’s syndrome 11:33–12:01

Your patient will report dry eyes and mouth with intermittent joint pain. Physical exam reveals conjunctival injection and dry mucous membranes.
At this point, consider Sjogren syndrome and order labs including anti-SSA and anti-SSB antibodies. If these are positive, diagnose Sjogren’s syndrome!
Okay, let’s go back to our autoantibodies. If ANA and RF are negative, you should consider seronegative arthritis, which includes reactive arthritis, psoriatic arthritis, and ankylosing spondylitis.

ANA/RF Negative 12:01–12:18

First up is reactive arthritis! In this case, the patient’s symptom onset typically follows a genitourinary or gastrointestinal infection, while their physical exam reveals asymmetric lower extremity oligoarthritis and possibly urethritis and conjunctivitis.

Reactive Arthritis 12:18–12:45

With these findings, diagnose reactive arthritis! Next up is psoriatic arthritis!

Psoriatic Arthritis 12:45–13:14

These patients will have a personal or family history of psoriasis, with the exam revealing upper extremity joint involvement, including the distal interphalangeal joints.
You might also observe nail pitting and onycholysis, which refers to the separation of the nail from the nail bed. With these findings, diagnose psoriatic arthritis!
Finally, let’s look at ankylosing spondylitis! Your patients will usually be biological males younger than 45 years old with progressive low back pain and stiffness that has lasted three months or more.

Ankylosing Spondylitis 13:14–14:27

Additionally, they will report that the pain is worse in the morning and improves with activity but not rest. The exam will reveal tenderness to palpation and a limited range of motion over the sacroiliac joints, lumbar spine, and sometimes peripheral joints too.
With these findings, consider ankylosing spondylitis, so next assess the ASAS criteria, a validated metric used to diagnose ankylosing spondylitis.
If your patient meets the criteria, diagnose ankylosing spondylitis! One last clinical pearl!
Reactive arthritis, psoriatic arthritis, and ankylosing spondylitis all share an association with human leukocyte antigen or HLA B27.
While the presence of this marker is not diagnostic for any of these conditions, its presence can help support these diagnoses.
Alright, as a quick recap… When a patient presents with joint pain or swelling, first assess for a traumatic joint injury.

Review 14:27–15:15

If trauma is not present, next assess the duration of symptoms to classify the underlying condition into acute or chronic causes.
Acute causes include septic arthritis, disseminated gonococcal infection, disseminated viral infection, rheumatic fever, and crystal arthropathy.
On the flip side, chronic causes include osteoarthritis; systemic rheumatic diseases like rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and Sjogren syndrome; and seronegative arthritis including reactive arthritis, psoriatic arthritis,