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Evaluation of the Patient With Joint Symptoms

By Alexandra Villa-Forte, MD, MPH, Staff Physician, Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic

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Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles or other extra-articular soft tissues (eg, fibromyalgia, myositis), or periarticular soft tissues (eg, bursitis, tendinitis, sprain). Arthritis has myriad possible causes, including infection, autoimmune disorders, crystal-induced inflammation, and minimally inflammatory cartilage and bone disorders (eg, osteoarthritis). Arthritis may affect single joints (monarthritis) or multiple joints (polyarthritis) in a symmetric or asymmetric manner, with or without involving the spine.

History

The clinician should focus on systemic and extra-articular symptoms as well as joint symptoms. Many symptoms, including fever, chills, malaise, weight loss, Raynaud phenomenon, mucocutaneous symptoms (eg, rash, eye redness or pain, photosensitivity), and GI or cardiopulmonary symptoms, can be associated with various joint disorders.

Pain is the most common symptom of joint disorders (see Pain in and Around Joints). The history should address the character, location, severity, factors that aggravate or relieve pain, and time frame (new-onset or recurrent). The clinician must determine whether pain is worse when first moving a joint or after prolonged use and whether it is present upon waking or develops during the day. Usually, pain originating from superficial structures is better localized than pain originating from deeper structures. Pain originating in small distal joints tends to be better localized than pain originating in large proximal joints. Joint pain can be referred from extra-articular structures or from other joints. Arthritis often causes aching pain, whereas neuropathies often cause a deep, boring pain or a superficial burning pain.

Stiffness refers to difficulty in moving a joint, but to patients, stiffness also may mean weakness, fatigue, or fixed limitation of motion. The clinician must separate the inability to move a joint from reluctance to move a joint because of pain. Characteristics of stiffness may suggest a cause, as in the following:

  • Discomfort that occurs with motion when attempting to move a joint after a period of rest occurs in rheumatic disease.

  • Stiffness is more severe and prolonged with increasing severity of joint inflammation.

  • The theater sign (short-lived knee or hip stiffness upon standing that necessitates walking slowly after sitting for several hours) is common in osteoarthritis.

  • Morning stiffness in peripheral joints that lasts > 1 h can be an important early symptom of joint inflammation, such as in RA, psoriatic arthritis, or chronic viral arthritis (see Table: Distinguishing Inflammatory vs Noninflammatory Joint Disease by Features).

  • In the low back, morning stiffness that lasts > 1 h may reflect spondylitis.

Fatigue is a desire to rest that reflects exhaustion. It differs from weakness, inability to move, and reluctance to move because of pain with movement. Fatigue may reflect activity of a systemic inflammatory disorder. Clinicians should try to distinguish fatigue from sleepiness.

Instability (buckling of a joint) suggests weakness of the ligaments or other structures that stabilize the joint, which are assessed by stress testing on physical examination. Buckling occurs most often in the knee and most often results from an internal joint derangement.

Distinguishing Inflammatory vs Noninflammatory Joint Disease by Features

Feature

Inflammatory

Noninflammatory

Systemic symptoms

Prominent, including fatigue

Unusual

Onset

Insidious in RA

Sudden in gout or infection

Gradual

1 joint or a few joints

Morning stiffness

> 1 h

< 30 min

Worst time of day

Morning

As day progresses

Effect of activity on symptoms (joint pain and stiffness)

Lessen with activity

Worse after periods of rest

May also have pain with use

Worsen with activity

Lessen with rest

Physical Examination

Each involved joint should be inspected and palpated, and the range of motion should be estimated. With polyarticular disease, certain nonarticular signs (eg, fever, wasting, rash) may reflect systemic disorders.

The rest position of joints is noted, along with any erythema, swelling, deformity, and skin abrasions or punctures. Involved joints are compared with their uninvolved opposites or with those of the examiner.

Joints are gently palpated, noting the presence and location of tenderness, warmth, and swelling. Determining whether tenderness is present along the joint line or over tendon insertions or bursae is particularly important. Soft masses, bulges, or tissues that fill normal concavities or spaces (representing joint effusion or synovial proliferation) are noted. Palpation of swollen joints can sometimes differentiate among joint effusion, synovial thickening, and capsular or bony enlargement. Small joints (eg, acromioclavicular, tibiofibular, radioulnar, sternoclavicular) can be the source of pain that was initially believed to arise from a nearby major joint. Bony enlargement (often due to osteophytes) is noted.

Active range of motion (the maximum range through which the patient can move the joint) is assessed first; limitation may reflect weakness, pain, or stiffness as well as mechanical abnormalities. Then passive range of motion (the maximum range through which the examiner can move the joint) is assessed; passive limitation typically reflects mechanical abnormalities (eg, scarring, swelling, deformities) rather than weakness or pain. Active and passive movement of an inflamed joint (eg, due to infection or gout) may be very painful.

Inability to reproduce pain with motion or palpation of the joint suggests the possibility of referred pain.

Patterns of joint involvement should be noted. Symmetric involvement of multiple joints is common in systemic diseases (eg, RA); monarticular (involving one joint) or asymmetric oligoarticular (involving 4 joints) joint involvement is more common in osteoarthritis and psoriatic arthritis. Small peripheral joints are commonly affected in RA, and the larger joints and spine are affected more in spondyloarthropathies. However, the full pattern of involvement may not be apparent in early disease.

Crepitus, a palpable or audible grinding produced by motion of damaged joint structures, is noted. It may be caused by roughened articular cartilage or by tendons; crepitus-causing motions should be determined and may suggest which structures are involved.

Specific features should be sought at each joint. Details of the physical examination and arthrocentesis procedures are discussed separately for the following joints:

Testing

Laboratory testing and imaging studies often provide less information than do the history and physical examination. Although some testing may be warranted in some patients, extensive testing is often not. Testing includes

  • Blood tests

  • Imaging studies

  • Arthrocentesis and synovial fluid analysis

Blood tests

Blood tests should be selected based on history and examination findings. Some tests, although not specific, can be helpful in supporting the possibility of certain systemic rheumatic diseases, as for the following:

  • Antinuclear antibodies (ANA) and anti–double-stranded DNA antibodies in SLE

  • Rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies in RA

  • HLA-B27 in spondyloarthropathy (eg, with symptoms of inflammatory back pain and normal x-rays, or with unexplained uveitis and a peripheral arthritis)

  • Antineutrophil cytoplasmic antibodies (ANCA) in certain vasculitides (sometimes useful when systemic involvement is suspected)

Tests such as WBC count, ESR, and C-reactive protein may help determine the likelihood that arthritis is inflammatory due to infectious or other systemic disorders, but these tests are not highly specific or sensitive. For example, an elevated ESR or C-reactive protein level suggests articular inflammation or may be due to a large number of nonarticular inflammatory conditions (eg, infection, cancer). Also, such markers may not be elevated in all inflammatory disorders.

Imaging studies

Imaging studies are often unnecessary. Plain x-rays in particular reveal mainly bony abnormalities, and most joint disorders do not affect bone primarily. However, imaging may help in the initial evaluation of relatively localized, unexplained, persistent or severe joint and particularly spine abnormalities; it may reveal primary or metastatic tumors, osteomyelitis, bone infarctions, periarticular calcifications (as in calcific tendinitis), or other changes in deep structures that may escape physical examination. If chronic RA, gout, or osteoarthritis is suspected, erosions, cysts, and joint space narrowing with osteophytes may be visible. In calcium pyrophosphate arthritis (pseudogout), calcium pyrophosphate deposition may be visible in intra-articular cartilage.

For musculoskeletal imaging, plain x-rays may be obtained first, but they are often less sensitive, particularly during early disease, than MRI, CT, or ultrasonography. MRI is the most accurate study for fractures not visible on plain x-rays, particularly in the hip and pelvis, and for soft tissues and internal derangements of the knee. CT is useful if MRI is contraindicated or unavailable. Ultrasonography, arthrography, and bone scanning may help in certain conditions, as can biopsy of bone, synovium, or other tissues.

Arthrocentesis

Arthrocentesis is the process of puncturing the joint with a needle to withdraw fluid. If there is an effusion and arthrocentesis is done correctly, fluid can typically be withdrawn. Examination of synovial fluid is the most accurate way to exclude infection, diagnose crystal-induced arthritis, and otherwise determine the cause of joint effusions. This procedure is indicated for all patients with acute or unexplained monarticular joint effusions and for patients with unexplained polyarticular effusions.

Arthrocentesis is done using strictly sterile technique. Infection or other rash over the site used to enter the joint is a contraindication. Preparations for collecting samples should be made before doing the procedure. Local anesthesia, with lidocaine and/or difluoroethane spray, is often used. Many joints are punctured on the extensor surface to avoid nerves, arteries, and veins, which are usually on the joint’s flexor surface. A 20-gauge needle can be used for most larger joints. Smaller joints of the upper and lower extremities are probably easier to access using a 22- or 23-gauge needle. As much fluid as is possible should be removed. Specific anatomic landmarks are used (eg, see Figure: Arthrocentesis of the shoulder., see Figure: Arthrocentesis of the elbow., and see Figure: Arthrocentesis of the knee.). Ultrasound guidance has been shown to increase the yield of joint fluid.

Synovial fluid examination

At the bedside, gross characteristics of the fluid are assessed, such as its color and clarity.

Gross characteristics allow many effusions to be tentatively classified as noninflammatory, inflammatory, or infectious (see Table: Classification of Synovial Effusions). Effusions can also be hemorrhagic. Each type of effusion suggests certain joint diseases (see Table: Differential Diagnosis Based on Synovial Fluid Classification*). So-called noninflammatory effusions are actually mildly inflammatory but tend to suggest diseases such as osteoarthritis, in which inflammation is not severe.

Classification of Synovial Effusions

Examination

Normal

Hemorrhagic

Infectious

Inflammatory

Noninflammatory

Gross examination

Appearance

Clear

Bloody

Turbid or purulent

Yellow, cloudy

Straw-colored, clear

Routine laboratory examination

Culture

Negative

Negative

Often positive

Negative

Negative

PMN %*

< 25

Usually >85

> 50

< 25

WBC count*

<200/μL

Affected by amount of blood

5,000–>100,000/μL

1,000–50,000/μL

200–1000/μL

*WBC count and PMN % in infectious arthritis are lower if the organism is less virulent (eg, in gonococcal, Lyme, tuberculous, or fungal arthritis) or partially treated. Some effusions in SLE and other connective tissue diseases are only equivocally inflammatory, with a WBC count of 500–2000/μL. Noninfectious effusions rarely have up to 100,000 WBC/μL.

Laboratory tests commonly done on joint fluid include cell count, leukocyte differential, Gram stain and culture (if infection is a concern), and wet drop examination for cells and crystals. However, the exact tests often depend on which diagnoses are suspected.

Differential Diagnosis Based on Synovial Fluid Classification*

Type of Effusion

Possible Causes

Hemorrhagic

Anticoagulants

Hemangioma

Trauma with or without fracture

Tumor

Infectious

Various organisms depending on patient characteristics (see Table: Organisms That Commonly Cause Acute Infectious Arthritis)

Inflammatory

Acute crystal synovitis (gout and calcium pyrophosphate arthritis [pseudogout])

Partially treated or less virulent bacterial infections

Reactive arthritis (including what was previously called Reiter syndrome)

RA

SLE(mild inflammation)

Synovial infarction (eg, caused by sickle cell disease)

Noninflammatory

Hypertrophic pulmonary osteoarthropathy

Metabolic diseases causing osteoarthritis

Osteochondritis dissecans

Osteochondromatosis

Osteonecrosis(including osteonecrosis caused by sickle cell disease)

SLE

Subsiding or early inflammation

Trauma

*See table: Classification of Synovial Effusions for classification. This differential diagnosis is only a partial listing.

Some disorders span classifications (eg, neuropathic arthropathy can be hemorrhagic or noninflammatory; systemic sclerosis can be inflammatory or noninflammatory).

Microscopic examination of a wet drop preparation of synovial fluid for crystals (only a single drop of fluid from a joint is needed) using polarized light is essential for definitive diagnosis of gout, calcium pyrophosphate arthritis, and other crystal-induced arthritides. A polarizer over the light source and another polarizer between the specimen and the examiner’s eye allow visualization of crystals with a shiny white birefringence. Compensated polarized light is provided by inserting a first-order red plate, as is found in commercially available microscopes. The effects of a compensator can be reproduced by placing 2 strips of clear adhesive tape on a glass slide and placing this slide over the lower polarizer. Such a homemade system should be tested against a commercial polarizing microscope.

The most common crystals seen are those diagnostic of gout (monosodium urate, negatively birefringent needle-shaped crystals) and calcium pyrophosphate arthritis (calcium pyrophosphate, rhomboid- or rod-shaped crystals that are positively birefringent or not birefringent). If crystals appear atypical in a wet drop, several less common crystals (cholesterol, liquid lipid crystals, oxalate, cryoglobulins) or artifacts (eg, depot corticosteroid crystals) should be considered.

Other synovial fluid findings that occasionally make or suggest a specific diagnosis include the following:

  • Specific organisms (identifiable by Gram or acid-fast stain)

  • Marrow spicules or fat globules (caused by fracture)

  • Reiter cells (monocytes on Wright-stained smears that have phagocytized PMNs), which appear most often in reactive arthritis

  • Amyloid fragments (identifiable by Congo red stain)

  • Sickled RBCs (caused by sickle cell hemoglobinopathies)

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