PAIN OR SWELLING OF JOINTS
Musculoskeletal complaints are extremely common in outpatient medical practice and are among the leading causes of disability and absenteeism from work. Pain in the joints must be evaluated in a uniform ,thorough ,and logical fashion to ensure the best chance of accurate diagnosis and to plan appropriate follow up testing and therapy. Joint pain and swelling may be manifestation of disorders affecting primarily the musculoskeletal system or may reflect systemic disease.
GOALS FOR THE INITIAL ASSESSMENT OF A MUSCULOSKELETAL COMPLAINT
1. Articular versus nonarticular .Is the pain located in a joint or in a periarticular structure such as soft tissue or muscle ?
2. Inflammatory versus noninflammatory .Inflammatory disease is suggested by local signs of inflammation ( erythema ,warmth ,swelling ) ,systemic features ( morning stiffness ,fatigue ,fever ,weight loss ) ,or laboratory evidence of inflammation ( thrombocytosis ,elevated ESR or C-reactive protien ).
3. Acute ( < or equal 6 weeks ) versus chronic .
4. Localized versus systemic .
HISTORIC FEATURES
- Age ,sex ,race and family history .
- Symptom onset ( abrupt or indolent ) ,evolution ( chronic constant ,intermittent ,migratory ,dditive ) ,and duration ( acute versus chronic ).
- Number and distribution of involved structures ,mono-articular ( one joint ) , oligoarticular ( 2-3 joints ) , polyarticular ( > joints ); symmetry .
- Other articular features : morning stiffness ,effect of movement ,features that improve / worsen Sx .
- Extra-articular Sx : e.g fever ,rash ,weight loss ,visual change ,dyspnea ,diarrhea ,dysuria ,numbness ,weakness.
- Recent events : e.g trauma ,drug administration ,travel ,other illnesses.
PHYSICAL EXAMINATION
Complete examination is essential : particular attention to skin ,mucous membranes ,nails ( may reveal characteristic pitting in psoriasis ) ,eyes .Careful and thorough examination of involved and uninvolved joints and periarticular structurs : this should proceed in an organized fashion from head to foot or from extremities inward toward axial skeleton :
Special attention should be paid to identifying the presence or absence of
_ Warmth and / or erythema.
_ Swelling.
_ Synovial thickening.
_ Subluxation ,dislocation ,joint deformity.
_ Joint instability.
_ Limitation to active and passive range of motion.
_ Creptus.
_ Periarticular changes.
_ Muscular changes including weakness ,atrophy.
LABORATORY INVESTIGATIONS
Additional evaluation usually for monarticular ,traumatic ,inflammatory ,or chronic conditions or for conditions accompanied by neurologic changes or systemic manifestations.
_ For all evaluation : include Complete blood count ,Erythrocyte Sedimentation rate , or C-reactive protien.
_ Should be performed where there are suggestive clinical features ,rheumatoid factor ,ANA ,antineutrophilic cytoplasmic antibodies ( ANCA ) ,antistreptolysin O titer ,Lyme antibodies.
_ Where systemic disease is present or suspected : renal / hepatic function tests.
_ Uric acid :useful only when gout diagnosed and therapy contemplated.
_ CPK ,aldolase : consider with muscle pain ,weakness .
_ Synovial fluid aspiration and analysis ,always indicated for acute monarthritis or when infectious or crystal - induced arthropathy is suspected .Should be examined for (1) appearance ,viscosity .(2) cell count and differential ( suspect septic joint if White Blood Cells count > 50.000 ): (3) crystal using polarizing microscope : (4) Gram's stain ,cultures .
DIAGNOSTIC IMAGING
Plain radiographs should be considered for
_ Trauma.
_ Suspected chronic infection .
_ Progressive disability.
_ Monarticular involvement .
_ Baseline assessment of a chronic process.
_ When therapeutic alterations are considered.
Additional imaging procedurs ,including ultrasound ,radionuclide scintigraphy ,CT and MRI may be helpful in selected clinical settings.
SPECIAL CONSIDERATION IN THE ELDERLY PATIENT
The evaluationof joints and musculoskeletal disorders in the elderly patients presents a special challenge given the frequency insidous onset and chronincity of disease in this age group ,the confounding effect of other medical conditions ,and the increased variability of many diagnostic tests in the geriatric population .Although vertually all musculoskeletal conditions may afflict the elderly ,certain disorders are especially frequent .Special attention should be paid to identifying the potential rheumatic consequences of intercurrent medical conditions and therapies when evaluating the geriatric patients with musculoskeletal complaints .
