DIFFERENTIAL DIAGNOSIS OF
JOINT PAIN
assoc. prof. Petr Němec, M.D.,Ph.D.
Rheumatology clinic, 2nd Dept. of Internal Medicine
St. Anne´s University Hospital in Brno
Pain in the joint area
 Paint in the joint area is a common finding with a wide
differential diagnosis
 It can be an initial symptom of a number of joint
diseases or soft tissue rheumatic pain syndromes
Articular or extra-articular
 Articular disease
 deep and diffuse pain that worsens during active and also
passive movement
 we often observe a change of the joint shape (deformation), a
change of the joint axis (deformity), swelling, eventually the
presence of exudate in the joint, crepitation, reducing of joint
mobility, increase of skin temperature or skin color changes
Articular or extra-articular
 Extra-articular (soft tissue) diseases
 localized pain/soreness (tender points) and pain worsening
during active movement, not worsening during passive
movement
 passive movement of the joint is not limited
 tendons (tendinopathy/tendonitis/tendinitis), tendon sheaths
(tenosynovitis/tenovaginitis), insertions of tendons and
ligaments (enthesopathy/enthesitis), synovial bursae (bursitis),
fascias (fascitis), muscles (myosis and myogellosis),
subcutaneous and adipose tissue (fibrositis and panniculitis)
Articular or extra-articular
 Extra-articular (soft tissue) diseases
 the source of pain may also be transmitted pain within the
head zones (deep somatic or visceral pain)
 transmitted pain is not affected by local movement
 pain is usually accompanied by vegetative manifestations
Sources of pain
articular structures Extra-articular
structures
other sources
synovial membrane tendons and tendon
sheaths
transmitted deep
somatic and visceral
pain from other organs
attachment of tendons
and ligaments
(enthesis)
radicular pain
intraarticular ligaments bursae pseudoradicular pain
articular capsule muslces
bones
juxtaarticular bone skin, subcutaneous and
adipose tissue
nerves
inflammatory or non-inflammatory
inflammatory or non-inflammatory
symptom Inflammatory disease
(e.g. rheumatoid arthritis)
non-inflammatory disease
(e.g. osteoarthritis)
Morning
stiffness
significant, long-term
> 60 min
localized, short-term
<30 min
General
symptoms
present absent
Local signs of
inflammation
present absent
worst trouble after rest (morning) after exercise (evening)
symmetry common occasional
inflammatory or non-inflammatory
 Inflammatory disease (arthritis) is characterized by:
 presence of systemic symptoms (fever, stiffness, weight loss, fatigue, etc.)
 presence of local signs of inflammation (pain, swelling, erythema, increase
of skin temperature and reduction of joint mobility)
 articular stiffness typically after rest (morning stiffness) and improves after
exercise
 morning stiffness > 60 min is characteristic for inflammatory diseases (e.g.
rheumatoid arthritis)
 lab signs of inflammation (increase ESR, CRP, hypoalbuminemia,
normocytic, normochromic anemia, thrombocytosis)
 inflammatory diseases may be autoimmune (RA, SLE), reactive
(ReA), infectious (septic arthritis) or crystal induced (gout)
 Synovitis (inflammation of the synovial membrane) is
characterized by:
 soft, painful swelling in the joint area
 change of the joint shape (rounded joint edges)
 local increase of skin temperature
 possible local skin erythema
 lost of joint mobility
 Joint synovitis is best seen in:
 RC, MCP and IP joints of hands, knees and joints of legs and feets.
 It is recommended to use the USG or MRI imaging technique to
distinguish between synovial membrane hyperplasia and joint
effusion
inflammatory or non-inflammatory
 Non-inflammatory disease (arthralgias) is characterized by:
 absence of systemic symptoms
 Joint pain without local signs of inflammation
 mostly normal lab tests
inflammatory or non-inflammatory
Duration of symptoms
 Acute joint syndrome < 6 weeks
 Chronic joint syndrome > 6 weeks
 the time factor helps to distinguish between:
 acute joint syndrome (sudden onset of symptoms) (e.g. injury,
acute gout, septic arthritis)
 chronic joint syndrome (gradual development of symptoms)
(e.g. RA, SLE, peripheral SpA)
Number of affected joints
 Monoarticular syndrome - involvement of one joint
 Oligoarticular syndrome - involvement of 2-4 joints
 Polyarticular syndrome - involvement ≥ 5 joints
 It is always necessary to investigate the contralateral joint and
compare the finding in the case of monoarticular syndrome
Number of affected joints
 most common causes of monoarticular sy / monoarthritis:
 injury with intra-articular or extra-articular fracture
 hemartros (haemophilia)
 osteoarthritis with or without synovitis
 osteonecrosis (hip joint)
 crystal-induced arthritis (gout, pseudo-gout)
 infection and septic arthritis (often present with fever, general alteration)
 reactive arthritis (aseptic arthritis), develops weeks after the infection,
mainly in the urogenital or gastrointestinal tract (Chlamydia trachomatis,
Ureoplasma ureolyticum, Campylobacter jejuni, Shigella, Salmonella,
Yersinia)
 monoarthritis as an initial symptom of systemic autoimmune diseases (RA,
SLE, JIA, peripheral SpA)
 neuropathic arthropathy (Charcot joint) in DM
Gout
Number of affected joints
 most common causes of oligoarthritis:
 ankylosing spondylitis - chronic inflammatory disease affecting the spine
(sacroiliitis, spondylitis), peripheral joints and enthesis, frequent
extraskeletal manifestations (include acute anterior uveitis), genetic testing
often reveals the presence of HLA-B27
 psoriatic arthritis
 reactive arthritis
 juvenile idiopathic arthritis
 early stages of rheumatoid arthritis
 systemic lupus erythematosus
 other acute oligoarthritis (viral arthritis, septic arthritis, crystals induced
arthritis, rheumatic fever, sarcoidosis or Lyme disease)
Ankylosing spondylitis
Number of affected joints
 most common causes of polyarthritis:
 rheumatoid arthritis
 psoriatic arthritis
 systemic lupus erythematosus
 Sjögren's syndrome
 juvenile idiopathic arthritis
 gouty arthritis
 osteoarthritis
Early rheumatoid arthritis
Established rheumatoid arthritis
Psoriatic arthritis
Osteoarthritis
Location of affected joints
osteoarthritis rheumatoid arthritis
Location of affected joints
psoriatic arthritis ankylosing spondylitis
Location of affected joints
gout
Age distribution
< 16years 20 – 30 years 30 – 50 years > 50 years
JIA
rheumatic fever
rheumatoid arthritis
SLE
reactive arthritis
Infectious arthritis
gout
osteoarthritis
polymyalgia rheumatica
ankylosig spondylitis