Chronic Joint Pain (Case 45)

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Chapter 53
Chronic Joint Pain (Case 45)

Robin Dibner MD, Joel Mathew MD, and Jessica L. Israel MD

Case: A 32-year-old generally healthy woman complains to her primary-care physician of pain and swelling in her hands. She has noticed for 3 months that her fingers feel stiff in the morning, and she has to place them under warm water to loosen them up. She has difficulty with small buttons when dressing, but by the time she gets to work she feels better and can work on the computer. She has tried over-the-counter ibuprofen with some benefit but feels it is causing dyspepsia. She has not had fevers, rashes, travel, tick bites, or any other new symptoms. She is quite worried, because she has an aunt with arthritis who has “twisted fingers” and a lot of pain. “I think I am too young to have arthritis, right?” she asks.

Differential Diagnosis

Osteoarthritis

Systemic lupus erythematosus (SLE)

Fibromyalgia

RA

Systemic sclerosis

Seronegative spondyloarthropathies

 

Speaking Intelligently

In taking a history from a patient whose arthritis is subacute or chronic, it is important to determine whether the symptoms have been present for longer than 6 weeks. For briefer durations of disease, self-limited entities such as viral arthritides, viral illnesses (e.g., from hepatitis B), and other serum sickness-like reactions from immune complex deposition must also be considered. Infective endocarditis, with an indolent organism such as a viridans streptococcus, is an example of the latter.

PATIENT CARE

Clinical Thinking

• It is important to consider the pattern of joint involvement in a patient who appears to have developed a chronic process—symmetrical or asymmetric? Large or small joints? Upper or lower extremity? The spine?

• A very complete review of systems is critical, looking for the other findings that can be seen in diseases that manifest with chronic arthritis.

• A difficult part of understanding the different disease entities has to do with the amount of overlap between the diseases, particularly the inflammatory arthritides of an autoimmune etiology, which go by the misnomers collagen vascular diseases and connective tissue diseases.

• Because of the heterogeneous nature of the rheumatic diseases, the American College of Rheumatology has developed criteria for several of the major diagnoses that are highly sensitive and specific. However, there is a great deal of overlap, and early in the course of these diseases there may not be many manifestations.

• Rheumatologists often tell such patients who do not fulfill the criteria for any of the conditions that they have undifferentiated connective tissue disease if they have inflammatory arthritis and a positive antinuclear antibody (ANA) test but insufficient other criteria to fulfill the diagnosis of SLE.

• There are many other rheumatologic signs and symptoms such as alopecia and Raynaud phenomenon that are seen in a variety of conditions and are therefore too nonspecific to be included in any criteria.

History

• Patient characteristics are important: women of childbearing age have SLE 10 times more commonly than men.

• Women are also affected by RA more often than men.

• Osteoarthritis frequency increases with age.

• The chief complaint defines the specific joints and the pattern of involvement.

• The history of the present illness must clarify the onset of the symptoms, which is important in deciding when criteria for RA have been met.

• More than an hour’s duration of morning stiffness is pathognomonic of active inflammatory arthritis.

• Past medical history can give clues to other systemic diseases that can cause chronic arthritis such as psoriasis and sarcoidosis.

• Medication history may suggest drug-induced lupus, a specific entity caused by an immunologic reaction to numerous medications.

• Response to prior treatments is also revealing.

• Family history will frequently reveal others with autoimmune disease, though not necessarily the same as the patient’s.

• The review of systems is tailored to the likely diagnosis and may include further probing for autoimmune disease such as evidence of Raynaud symptoms, hypothyroidism, or hyperthyroidism.

• A functional history can help guide treatment goals.

Physical Examination

• Involved joints should be examined for swelling, tenderness, range of motion, and deformity.

• Symmetrical joint involvement is characteristic of RA, lupus, and some other inflammatory conditions.

• Inflamed joints often have palpable synovial thickening, which feels doughy.

• The most characteristic joint involvement in RA is involvement of the metacarpophalangeal joints.

• Osteoarthritis is never purely symmetrical; however, it may appear so if many joints are involved. The joints may appear swollen, but the enlargement is bony and represents proliferation of osteophytes.

• Effusions are more common in inflamed joints but can be present in noninflamed joints.

• The skin exam may show characteristic findings, such as the classic erythematous butterfly rash of lupus over the cheeks and bridge of the nose, psoriatic plaques and nail pits, or subcutaneous rheumatoid nodules on the proximal ulnar aspect of the forearm.

• There may be other extra-articular manifestations such as the bluish fingertip discoloration of Raynaud syndrome, crackles of interstitial lung disease, the rub of pericarditis, edema in patients with nephrotic syndrome, or red eyes in episcleritis or scleritis seen in some RA patients.

Tests for Consideration

• Complete blood count (CBC): Will usually show a normochromic, normocytic anemia secondary to chronic inflammation.

$11

• Chemistry panel: Important to determine whether there is renal involvement in lupus.

$12

• Liver function abnormalities are a potential contraindication to certain medications.

$12

• Urinalysis: To evaluate for renal lupus.

$4

• Rheumatoid factor (RF): Seventy-five percent of patients have RF positivity at some point in the disease; high titers of RF are associated with extra-articular manifestations and poor outcome.
It may be negative in early disease and is negative in the spondyloarthropathies such as reactive arthritis, psoriatic arthritis, and ankylosing spondylitis.

$8

• Anti-CCP (antibodies to cyclic citrullinated peptide): Positive in about 65% of patients with RA, is more specific than RF, and may be positive before the RF. In such cases it has been shown to be a predictor of rapid progression to erosions and poor prognosis.

$18

• ANA: Positive in more than 95% of patients with lupus.

$14

• ESR or CRP

$4, $7

• Creatine phosphokinase (CPK)

$9

• Thyroid-stimulating hormone (TSH)

$24

• Consider serologies for Borrelia burgdorferi, hepatitis B, hepatitis C, and HIV.

$24, $32, $22, $13

 

IMAGING CONSIDERATIONS

→ It generally takes at least 6 months for erosions to be visible on plain radiographs in patients with RA, so early radiographs are not helpful in establishing a diagnosis. Erosions can be seen much earlier on MRI, but this is rarely necessary except in drug studies where the timing of the development of erosions needs to be assessed. In a patient with established disease, plain radiographs may be helpful in distinguishing among RA, psoriatic arthritis, and lupus, among others. Osteoarthritis has characteristic radiographic findings distinct from those of inflammatory diseases.

 

Clinical Entities Medical Knowledge

Osteoarthritis

Pφ

Osteoarthritis occurs as the structural integrity and the chemical composition of joint cartilage wear down and change over time. As this process occurs, there is less protection from friction created as bones rub against other bony structures in the joint. Age, obesity, and chronic repetitive motion on particular joints are all considered risk factors.

TP

Osteoarthritis typically affects the large weight-bearing joints, distal and proximal interphalangeal joints, and the first carpometacarpal joint of the hand. Patients usually complain of pain with activity that is relieved with rest. Pain at rest, or pain specifically worsening at night, is related to more serious advanced disease. Some patients also present with morning stiffness, but this stiffness generally lasts <30 minutes. Joint swelling is not usually a major feature, but some patients can develop bony outgrowths on the distal (Heberden nodes) and proximal (Bouchard nodes) interphalangeal joints. These can be painful and limit motion. In osteoarthritis of the knee, the examiner may feel crepitus when passively flexing the joint.

Dx

Osteoarthritis is a clinical diagnosis. The physical findings are surprisingly minimal, especially in early disease. Osteoarthritis of the knees can be reliably diagnosed if the patient is over 50 years of age, has stiffness lasting <30 minutes, crepitus, bony tenderness or enlargement of the joint, and no palpable warmth (American College of Rheumatology clinical criteria). Radiographs of the affected joints may show joint space narrowing, but the findings do not correlate well with disease symptoms.

Tx

Nonpharmacologic treatments include weight loss and changes in activity if repetitive actions are an issue. Physical therapy benefits hip and knee osteoarthritis. Assistive devices (such as jar openers and special kitchen utensils) may also be helpful. Pharmacologically, acetaminophen and NSAIDs are frequently used as a first line, with tramadol and opioids as a second-line therapy. More intensive treatments include corticosteroids and hyaluronan joint injections. Joint replacement therapy is considered when medical therapy is no longer helpful or when the arthritis-related debility has a serious and limiting impact on the patient’s quality of life. See Cecil Essentials 88.

 

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