Differential diagnosis of joint pain MUDr. Radoslav ROMAN Rheumatology unit, 2nd Dept. of Internal Medicine St. Anne´s University Hospital in Brno Dear students, welcome to this lesson. Today’s topic is differential diagnosis of joint pain. Today’s agenda •Theoretical basics •Clinical cases Pain 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 • Approach to the patient Picture: https://www.freepik.com if we want to investigate the cause of joint pain, we need to find answers to the following questions is pain a symptom of articular or extraarticular disease? what is the duration of symptoms? which joints are affected? how old our patient is? Or what was the age at which the symptoms of the disease began? 1. Articular or Extra-articular pain –Articular pain: •deep, diffuse pian •worsens with active and passive movement •joint swelling and palpable pain along joint space •Increased skin temperature •Skin colour changes are not usually present •(if present: septic arthritis, crystaline arthritis - gout) • 1. Articular or Extra-articular pain –Extra-articular pain: •sharp, localized pain •worsens with active movement (not with passive) •the patient ussually tells/ shows what kind of movement is causing him pain •examples: ØShoulder impigmement syndrome – tendinitis of supraspinatus tendon in subacromial space ØSubacromial bursitis • • Impigement syndrome/ subacromial bursitis Pictures: https://backintelligence.com/how-to-fix-shoulder-impingement/ https://pivotalphysio.com/wp-content/uploads/2015/03/sh5.png And here, closer look on subacromial space 2. Inflammatory or non-inflammatory dissease Symptom Inflammatory (e.g. rheumatoid artrhritis) Non-inflammatory (e.g. osteoarthritis) Morning stiffness significant, long-term > 60 min localized, short-term <30 min Maximum of symptoms after rest (morning) after exercise (evening) General symptoms present absent Local signs of inflammation present absent Symmetry of symptoms common occasional General symptoms: fatigue, fever, anorexia, weight loss Local signs of inflamation: swelling, increase of skin temperature (skin color changes) The following table shows what are the basic differences between the infl. and non infl. disease One of the significant differences between I and non-I is the duration of the morning stiffness that lasts more then, or less than Local signs of inflamation: swelling, increase of skin temperature or skin color changes 3. Duration of symptoms •Acute joint syndrome < 6 weeks –sudden onset of symptoms –e.g.: injury, acute gout attack, septic arthritis – •Chronic joint syndrome > 6 weeks –gradual development of symptoms –e.g.: rheumatoid arthritis, peripheral spondyloarthritis, SLE • • 4. Number of affected joints •Monoarticular syndrome - involvement of one joint •Oligoarticular syndrome - involvement of 2-4 joints •Polyarticular syndrome - involvement ≥ 5 joints • • •Note: •small joints: MCP, PIP, DIP, IP joint of thumb, wrist, MTP. •Large joints: shoulder,elbow, hip, knee, ankle • Approach to the patient Picture: https://www.freepik.com if we want to investigate the cause of joint pain, we need to find answers to the following questions is pain a symptom of articular or extraarticular disease? what is the duration of symptoms? which joints are affected? how old our patient is? Or what was the age at which the symptoms of the disease began? 5. Location of affected joints Long standing, poorly controlled gouty arthritis could also affect wrists and small joints of the hand 5. Location of affected joints Výsledek obrázku pro joint homunculus Výsledek obrázku pro joint homunculus osteoarthritis rheumatoid arthritis 5. Location of affected joints Výsledek obrázku pro joint homunculus Výsledek obrázku pro joint homunculus psoriatic arthritis ankylosing spondylitis 5. Location of affected joints Výsledek obrázku pro joint homunculus gout 6. 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 Clinical case #1 •50 yo male •Comorbidities: arterial hypertension , DM 2.type •Complain: severe right knee pain of 12-hour duration •No previous pain/surgery/injury • •1yr ago: pain + swelling of the base of his great toe → resolved after 5 days with ibuprofen •Clinical examination: –swelling with moderate effusion –erythematous warm skin, very tender on palpation – • Clinical case #1 •Approach: – articular –inflammatory –symptom duration < 6 weeks = ACUTE ARTHRITIS –# of affected joints: 1 = MONOARTHRITS –localization: large joint on distal extremity –Age: 50yo – Crystal induced -gout -CPDD = calcium-pyrophosphate deposition dissease (pseudogout) Septic arthritis staph. aureus, stepto. species, neisseria gonorhoeae, gramnegative,mycotis, etc. Clinical case #1 • •Next step? – – • - • Clinical case #1 • •Aspiration of the knee joint to send fluid for: Øsynovial fluid analysis – inflammatory type of fluid Øcrystal analysis in polarized light microscopy -needle shaped strongly negatively birefringent crystals ØCultures - negative • – – • - • According to these 4 characteristics synovial fluid can be devided into noninflammatory, inflammatory, septic or hemorrhagic Clinical case #1 • •Diagnosis: acute crystaline arthritis – acute gout • •Note: serum uric acid in acute gout attack- may be elevated or normal – – • - • Clinical case #2 •25 yo male •Comorbidities: none •Complains: –lower back pain that worsens at night –morning stiffnes of lower back >45min –left ankle swelling for 3 months –history of uveitis – •Orthopeadist –NSA treatment → reduced back pain and ankle pain, swelling did not resolve –1 intraarticular glukokortikoid injection in the ankle • – • Clinical case #2 •Approach: – articular –inflammatory –symptom duration > 6 weeks = CHRONIC ARTHRITIS –# of affected joints: 1 = MONOARTHRITS –localization: large joint on distal extremity –Age: 25yo –Other important symptoms: low back pain, history of uveitis – Clinical case #2 •Lab: CRP 7.0mg/l, ESR 35/60 mm/hour •Immunology: RF, anti-CCP, anti-MCV negative •HLAB27+ • • – • Clinical case #2 X-ray Diagnosis: axial spondyloarthritis Clinical case #3 • •32-yo woman with 3-month history of: –swelling of all MCP and PIP joint of the hand + both wirsts –morning stiffnes 1 hour –fatigue – • – • Clinical case #3 •Approach: – articular –inflammatory –symptom duration > 6 weeks = CHRONIC ARTHRITIS –# of affected joints: 18 = POLYARTHRITS –localization: symmetrical polyarthritis –Age: 32yo – – Clinical case #3 •Lab: –Elevated CRP and ESR –Pozitive auto-antibodies: •RF: rheumatoid factor •anti-CCP: cyclic citrulinated peptides •anti-MCV: mutated citrulinated vimentin • •X-ray hands+ feet –- normal (no erosive changes) • • – – • Clinical case #3 early RA Diagnosis: early rheumatoid arthritis -no deformities -no erosion on X-ray Established rheumatoid arthritis Ulnar deviation in MCP joints Swan-neck deformity Rheumatoid nodule Rheumaoid nodules – subcutaneous nodules typically found over extensor surfaces of the proximal ulna or other pressure points Established rheumatoid artrhitis •X-ray findings: -marginal erosions -MCPs joint space narrowing -severe erosions and destructions of the wrists - - Differential diagnosis Thank you for your attention