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Evaluation of the Patient With Joint Symptoms

By

Alexandra Villa-Forte

, MD, MPH, Cleveland Clinic

Last full review/revision Feb 2020| Content last modified Feb 2020
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Topic Resources

Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures Overview of Fractures A fracture is a break in a bone. Most fractures result from a single, significant force applied to normal bone. In addition to fractures, musculoskeletal injuries include Joint dislocations... read more Overview of Fractures , Paget disease of bone Paget Disease of Bone Paget disease of bone is a chronic disorder of the adult skeleton in which bone turnover is accelerated in localized areas. Normal matrix is replaced with softened and enlarged bone. The disease... read more Paget Disease of Bone , tumors Overview of Bone and Joint Tumors Bone tumors may be benign or malignant. Malignant tumors may be primary or metastatic. In children, most bone tumors are primary and benign; some are malignant primary tumors (eg, osteosarcoma... read more ), muscles or other extra-articular soft tissues (eg, polymyalgia rheumatica Polymyalgia Rheumatica Polymyalgia rheumatica is a syndrome closely associated with giant cell arteritis (temporal arteritis). It affects adults > 55. It typically causes severe pain and stiffness in proximal muscles... read more , myositis Autoimmune Myositis Autoimmune myositis is characterized by inflammatory and degenerative changes in the muscles (polymyositis) or in the skin and muscles (dermatomyositis). Manifestations include symmetric weakness... read more Autoimmune Myositis ), or periarticular soft tissues (eg, bursitis Bursitis Bursitis is acute or chronic inflammation of a bursa. The cause is usually unknown, but trauma, repetitive or acute, may contribute, as may infection and crystal-induced disease. Symptoms include... read more Bursitis , tendinitis Tendinitis and Tenosynovitis Tendinitis is inflammation of a tendon, often developing after degeneration (tendinopathy). Tenosynovitis is tendinitis with inflammation of the tendon sheath lining. Symptoms usually include... read more , sprain Overview of Sprains and Other Soft-Tissue Injuries Sprains are tears in ligaments; strains are tears in muscles. Tears (ruptures) may also occur in tendons. In addition to sprains, strains, and tendon injuries, musculoskeletal injuries include... read more ). Arthritis has myriad possible causes, including infection, autoimmune disorders Introduction to Autoimmune Rheumatic Disorders Autoimmune rheumatic disorders include diverse syndromes such as Autoimmune myositis Eosinophilic fasciitis Mixed connective tissue disease Relapsing polychondritis read more , crystal-induced inflammation Overview of Crystal-Induced Arthritides Arthritis can result from intra-articular deposition of crystals: Monosodium urate Calcium pyrophosphate dihydrate Basic calcium phosphate (apatite) Rarely, others such as calcium oxalate crystals read more , and minimally inflammatory cartilage and bone disorders (eg, osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more Osteoarthritis (OA) ). Arthritis may affect single joints (monarthritis Pain in and Around a Single Joint Patients may report "joint" pain regardless of whether the cause involves the joint itself or surrounding (periarticular) structures such as tendons and bursae; in both cases, pain in or around... read more ) or multiple joints (polyarthritis Pain in Multiple Joints Joints may simply be painful (arthralgia) or also inflamed (arthritis). Joint inflammation is usually accompanied by warmth, swelling (due to intra-articular fluid, or effusion), and uncommonly... read more ) 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 Raynaud Syndrome Raynaud syndrome is vasospasm of parts of the hand in response to cold or emotional stress, causing reversible discomfort and color changes (pallor, cyanosis, erythema, or a combination) in... read more Raynaud Syndrome , mucocutaneous symptoms (eg, rash, eye redness or pain, photosensitivity), and gastrointestinal or cardiopulmonary symptoms, can be associated with various joint disorders.

Pain is the most common symptom of joint disorders (see Pain in and Around a Single Joint Pain in and Around a Single Joint Patients may report "joint" pain regardless of whether the cause involves the joint itself or surrounding (periarticular) structures such as tendons and bursae; in both cases, pain in or around... read more and Pain in Multiple Joints Pain in Multiple Joints Joints may simply be painful (arthralgia) or also inflamed (arthritis). Joint inflammation is usually accompanied by warmth, swelling (due to intra-articular fluid, or effusion), and uncommonly... read more ). 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:

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 Fatigue Fatigue occurs most often as part of a symptom complex, but even when it is the sole or main presenting symptom, fatigue is one of the most common symptoms. Fatigue is difficulty initiating... read more may reflect activity of a systemic inflammatory disorder as well as other disorders. Clinicians should try to distinguish fatigue from sleepiness.

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

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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 Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more Gout ) may be very painful.

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

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

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 Introduction to Autoimmune Rheumatic Disorders Autoimmune rheumatic disorders include diverse syndromes such as Autoimmune myositis Eosinophilic fasciitis Mixed connective tissue disease Relapsing polychondritis read more , as for the following:

Tests such as white blood cell count, erythrocyte sedimentation rate (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 rheumatoid arthritis Diagnosis Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more Diagnosis , gout Diagnosis Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more Diagnosis , or osteoarthritis Diagnosis Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more Diagnosis is suspected, erosions, cysts, and joint space narrowing with osteophytes may be visible. In calcium pyrophosphate arthritis (pseudogout) Diagnosis Calcium pyrophosphate arthritis involves intra-articular and/or extra-articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals. Manifestations are protean and may be minimal or... read more Diagnosis , 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 Overview of Crystal-Induced Arthritides Arthritis can result from intra-articular deposition of crystals: Monosodium urate Calcium pyrophosphate dihydrate Basic calcium phosphate (apatite) Rarely, others such as calcium oxalate crystals read more , 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 (see figures arthrocentesis of the shoulder Arthrocentesis of the Shoulder An evaluation of the shoulder includes a physical examination and sometimes arthrocentesis. (See also Evaluation of the Patient With Joint Symptoms.) Physical examination of the shoulder involves... read more , elbow Arthrocentesis of the Elbow An evaluation of the elbow includes a physical examination and sometimes arthrocentesis. (See also Evaluation of the Patient With Joint Symptoms.) Synovial swelling and thickening caused by... read more , and knee Arthrocentesis of the Knee An evaluation of the knee includes a physical examination and sometimes arthrocentesis. (See also Evaluation of the Patient With Joint Symptoms.) At the knee, gross deformities such as swelling... read more ). Ultrasound guidance has been shown to increase the likelihood of a successful aspiration.

Synovial fluid examination

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

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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 Diagnosis Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more Diagnosis , calcium pyrophosphate arthritis Diagnosis Calcium pyrophosphate arthritis involves intra-articular and/or extra-articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals. Manifestations are protean and may be minimal or... read more Diagnosis , and other crystal-induced arthritides Overview of Crystal-Induced Arthritides Arthritis can result from intra-articular deposition of crystals: Monosodium urate Calcium pyrophosphate dihydrate Basic calcium phosphate (apatite) Rarely, others such as calcium oxalate crystals read more . 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 most common crystals seen are those diagnostic of gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more 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 polymorphonuclear leukocytes), which appear most often in reactive arthritis

  • Amyloid fragments (identifiable by Congo red stain)

  • Sickled red blood cells (caused by sickle cell hemoglobinopathies)

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