The complex challenge to the physician is to safely diagnose simple arthralgia from degenerative joint disease, inflammatory arthropathies or pain secondary to other diseases.

Epidemiology

• Arthralgia was estimated by the Arthritis Research Council¹ to be as frequent as 4-30% of presenting childhood problems in primary care.
• Further research shows 5% between 16-24 years, and 54% at 85 years plus. Knee and back problems account for 10% of these.²

At risk groups

• Family history of rheumatoid arthritis
• Genetic component also suggested for OA - twins studies show 50% concordance in women with OA in hands³
• Occupational history of prolonged, repetitive use of hands
• Manual labour
• Overweight
• Previous history of trauma in the joint

Presentation

Symptoms and signs

There should be a full clinical examination to detect possible lymphadenopathy and hepatosplenomegaly (possible in haematological malignancy). Breast examination should be mandatory.
Full drug history including over-the-counter (OTC) and complementary preparations.

Simple arthralgia:

• Pain is main symptom
• No stiffness
• No swelling seen around the joint
• May be history of viral illness

NB: Arthralgia is a known side-effect of the following; ACE inhibitors, proton pump inhibitors, quinolones, gonadorelin analogues and tibolones.

Osteoarthritis:

• Tends to be mainly large joints affected, carpo-metacarpal joint of the thumb, distal inter-phalangeal joints of the fingers.
• Heberden's nodes seen, (distal inter-phalangeal nodes).
• Crepitus audible/palpable.
• May be associated with weight gain, sedentary lifestyle, repetitive use and past history of trauma to the joint.

• History of psoriasis
• Bowel disorders (Crohn's or ulcerative colitis)
• Bladder symptoms
• Anterior uveitis
• Streptococcal sore throat
• Bowel infection - yersinia, salmonella or shigella
• Chlamydial urethritis
• Presents with asymmetrical large joint pain
• Oligoarticular involvement and possibly sacroiliitis

• Diagnosis should be made clinically with 4 of the following signs present for 6 weeks or more:
  • Pain and swelling in at least 3 joint areas
  • Symmetrical disease
  • Early morning stiffness for > 1hour daily⁴
  • Metacarpo-phalangeal, wrist or proximal inter-phalangeal joint swelling
  • Subcutaneous nodules
  • Positive rheumatoid factor
  • Radiological evidence of erosions
• Examination should be on at least 2 occasions and should note:⁵
  • Which joints are affected, their symmetry/ asymmetry
  • If the MCP joint has swollen, this can be noted by the loss of the groove between the knuckles in a formed fist
  • The active and passive range of movement and the function of the joint
  • Can the patient write, grip and hold objects? Are there nodules present on elbows and shins? Is there nail pitting?

Differential diagnosis

Investigations

Where inflammatory pathology is suspected (rheumatoid arthritis is the commonest):

• FBC - low Hb is common
• Inflammatory markers - plasma viscosity, ESR and CRP:
  • These can be normal in 60-70% of patients
  • If there are good clinical signs a normal result should not inhibit referral
• Rheumatoid factor:
  • Only 33% of patients have a positive result
  • However, where it is positive it can be a useful prognostic tool
  • In juvenile RA, a positive result is associated with increased risk of disease continuing into adult life
• Plain X-rays:
  • Hands and feet - 90% are involved in RA
  • CXR if considering methotrexate (as a baseline for risk of pulmonary side-effects)
  • 50% of people aged over 65 years have radiological evidence of osteoarthritis including joint space narrowing, osteophytes, cysts, sclerosis and deformity
• Examination of joint fluid is often essential in making a definitive diagnosis.⁹

Management

General principles

• For most reassurance and explanation will be sufficient.
• Lifestyle advice around exercise and weight loss may help.^10,11
• For inflammatory pathology advice to rest the joint affected is helpful. Physiotherapy and occupational therapy, (for splinting and assessment for home aids) should be considered.
• Review after 1 month to monitor improvement or reconsider diagnosis.
• Patients may need referral for education and long-term support in rheumatoid arthritis.
• They should receive positive messages about treatment reducing disease progression and that they are unlikely to be confined to a wheelchair.¹²

Pharmacological

• Most can be managed with simple analgesia e.g. paracetamol.
• Inflammatory pathology may need non-steroidal anti-inflammatories, if there are no contra-indications.¹³ Short courses have been found to be better than placebo in the short term, but long-term use is not recommended.¹⁴
• If considering disease modifying treatment with methotrexate, remember haematological and biochemical monitoring will be required.
• Short courses of oral prednisolone (7.5 mg/day for 6-12 weeks) can be helpful in relieving symptoms and reducing disease progression, but are controversial, as peak bone loss occurs in the first 3 months.

Surgical

NICE Guidelines (2001) are available to advise when to refer for surgical opinion with view to replacement of joint in osteoarthritis.¹⁵

Complications

• Depending on the severity of the disease, work and social life may be affected. Work may be lost if manual.
• There can be a sense of social isolation.
• Inability to control pain may be associated with low mood.
• Drug adverse effects may be problematic.

Document references

1. Arthritis Research UK
2. Badley EM, Tennant A; Changing profile of joint disorders with age: findings from a postal survey of the population of Calderdale, West Yorkshire, United Kingdom. Ann Rheum Dis. 1992 Mar;51(3):366-71. [abstract]
3. Spector TD, Cicuttini F, Baker J, et al; Genetic influences on osteoarthritis in women: a twin study. BMJ. 1996 Apr 13;312(7036):940-3. [abstract]
4. How Do you recognise RA early? Clinical Rheumatology; Balliere. January, 2001.
5. No authors listed; Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum. 1996 Jan;39(1):1-8.
6. Walker UA, Tyndall A, Daikeler T; Rheumatic conditions in human immunodeficiency virus infection. Rheumatology (Oxford). 2008 Apr 15;. [abstract]
7. Randone SB, Guiducci S, Cerinic MM; Musculoskeletal involvement in systemic sclerosis. Best Pract Res Clin Rheumatol. 2008 Apr;22(2):339-50. [abstract]
8. Matsen FA 3rd; Clinical practice. Rotator-cuff failure. N Engl J Med. 2008 May 15;358(20):2138-47.
9. Siva C, Velazquez C, Mody A, et al; Diagnosing acute monoarthritis in adults: a practical approach for the family physician. Am Fam Physician. 2003 Jul 1;68(1):83; Excellent overview with useful clinical algorithms and full differential diagnoses. [abstract]
10. Brosseau L, MacLeay L, Robinson V. et al.; Intensity of exercise for the treatment of osteoarthritis (Cochrane Review). The Cochrane Library. Issue 2. Chichester, UK: John Wiley & Sons, Ltd. 2005
11. Perrot S, Menkes CJ; Nonpharmacological approaches to pain in osteoarthritis. Available options. Drugs. 1996;52 Suppl 3:21-6. [abstract]
12. Jones G, Halbert J, Crotty M, et al; The effect of treatment on radiological progression in rheumatoid arthritis: a systematic review of randomized placebo-controlled trials. Rheumatology (Oxford). 2003 Jan;42(1):6-13. [abstract]
13. Osteoarthritis and rheumatoid arthritis - cox II inhibitors, NICE Technology Appraisal (2001)
14. Bjordal JM, Ljunggren AE, Klovning A, et al; Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ. 2004 Dec 4;329(7478):1317. Epub 2004 Nov 23. [abstract]
15. Referral Advice, NICE Clinical Guideline (2001); A guide to appropriate referral from general to specialist services.

Internet and further reading

• Burbank KM, Stevenson JH, Czarnecki GR, et al; Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-60. [abstract]
• Osteoarthritis, Clinical Knowledge Summaries (2008)
• Rheumatoid arthritis, Clinical Knowledge Summaries (June 2009)
• van Middelkoop M, van Linschoten R, Berger MY, et al; Knee complaints seen in general practice: active sport participants versus non-sport participants. BMC Musculoskelet Disord. 2008 Mar 19;9:36. [abstract]

Acknowledgements