Aching Joints - Assessment, Investigations and Management in Primary Care

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

• 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

• 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

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?

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

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

• 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.