Joint Pain

Differentials

Inflammatory

• Polyarthritis (>4 joints):

  • Rheumatoid arthritis (RA)

  • Connective tissue diseases (SLE, scleroderma, Sjögren’s, polymyositis)

  • Polymyalgia rheumatica (PMR)

  • Viral arthritis (e.g. parvovirus, hepatitis)

  • Haemochromatosis arthropathy

• Oligoarthritis (2–4 joints):

  • Spondyloarthropathies (psoriatic, reactive, ankylosing spondylitis, enteropathic arthritis)

• Monoarthritis (1 joint):

  • Gout

  • Pseudogout

  • Septic arthritis

Non-Inflammatory

• Osteoarthritis (OA)

• Fibromyalgia (widespread pain, tender points)

• Non-articular pain (e.g. cervical spine radicular pain, referred pain from diaphragm or pulmonary pathology)

• Bursitis/tendonitis

History

Pattern of Joint Involvement

• Symmetrical involvement often suggests RA or SLE

• Asymmetrical involvement might indicate OA or a spondyloarthropathy

• Morning stiffness ≥1 hour → Inflammatory arthritis (RA, SLE, spondyloarthropathies)

• Pain worse with activity (and evening stiffness) → Osteoarthritis

Other Key Features

• Recent Infection: Suggests viral arthritis or reactive arthritis (GI or GU infection)

• Urethral Discharge: Consider reactive arthritis / STI link

• Travel History: Tropical infections

• Family History: e.g. RA, SLE, ankylosing spondylitis

• Associated Symptoms:

  • Vision loss, shoulder stiffness → PMR/GCA

  • Rash, diarrhoea, red eye → Spondyloarthropathies (psoriatic, IBD-related, reactive)

  • Dry eyes, pleuritic pain → Connective tissue diseases

  • Widespread pain → Fibromyalgia

  • Grinding or crepitus → OA

Examination

Inflammatory vs Non-Inflammatory

• Inflammatory: Synovitis with reduced ROM, swelling, tenderness, warmth, potential effusion

• Non-Inflammatory: Bursitis, tendon issues, or muscle pain often with normal passive ROM, painful active ROM only

Other Findings

• Deformities, erythema, effusions

• Extra-articular signs: Rash, nail changes (psoriatic), enthesitis, uveitis (spondyloarthropathies)

Investigations

General

• ESR/CRP: Raised in active inflammation; normal in non-inflammatory conditions

• FBC: Look for anaemia of chronic disease (normocytic, high ferritin)

• LFTs: Evaluate baseline for medication suitability

• Renal function: Check eGFR if suspect advanced disease or prescribing certain drugs

Inflammatory Markers

• RA: Rheumatoid factor (RF), anti-CCP (higher specificity)

• CTDs: ANA, ANCA (if suspect vasculitis)

• Myositis: CK (creatine kinase)

Joint-Specific

• Gout: Uric acid (though can be normal in acute flares)

• Haemochromatosis: Iron studies (transferrin saturation, ferritin)

• Infections: Viral serologies (parvovirus, hepatitis B/C)

Management

Non-Pharmacological

• Rest during active inflammation, but encourage gentle exercise for joint mobility

• Physical Activity: ~150 min/week low-impact exercises (walking, swimming)

• Splinting: For acute flares (hand/wrist)

• Physiotherapy: Muscle strengthening, joint mobilisation

• Rheumatology referral for severe or undifferentiated cases

Pharmacological

• NSAIDs (e.g., ibuprofen 400 mg TDS PRN) if no contraindications

• Corticosteroids: Prednisolone 5–15 mg daily short term for acute flares or bridging therapy

• DMARDs (Disease-Modifying Anti-Rheumatic Drugs) for RA or CTD (e.g., methotrexate, sulfasalazine, leflunomide)

• Biologics: e.g., TNF-alpha inhibitors if DMARD-refractory RA, psoriatic arthritis, or ankylosing spondylitis

• Adjuncts: Fish oil for RA (mild benefit), local or intralesional steroids if few joints involved

Specific Conditions

• Septic Arthritis: Urgent aspiration + IV antibiotics (e.g. flucloxacillin). Orthopaedic/ID consult

• Gout: Acute → Colchicine/NSAIDs/steroids; prophylaxis with allopurinol or febuxostat if recurrent

• PMR/GCA: Low-dose steroid for PMR; high-dose steroid for GCA (risk of vision loss)

Key Takeaways for Bilateral Hand Joint Pain in a 30-year-old Female with Elevated ESR

Possible diagnoses include:

1. Rheumatoid Arthritis: Symmetrical small joint involvement, morning stiffness >1 hour, elevated CRP/ESR, positive RF/anti-CCP

2. Systemic Lupus Erythematosus (SLE): Potential rash, photosensitivity, multi-system involvement (check ANA, dsDNA)

3. Viral Arthritis: e.g. parvovirus B19

4. Psoriatic Arthritis: Often has nail pitting, dactylitis, psoriasis skin plaques

5. Reactive Arthritis: Typically asymmetrical, associated with enthesitis, preceding GI/GU infection

6. Scleroderma: Skin thickening, Raynaud’s, possible ILD