Joint Pain: One / Few Joints

Pain in Just One JointFirst, rule out an Emergency:

New onset of acute, single red, hot, swollen joint could be Septic Arthritis

  • Bacteria in joint (usually Staph) — very destructive; can spread to blood (& be lethal)
  • Almost always with fever (except the very elderly)

Conditions that may look like septic arthritis, but aren’t: Bursitis, Cellulitis, Hemarthrosis (blood in joint).ย  To rule-out Septic Arthritis:

  • If examiner can wiggle a relaxed joint in one or another direction without pain, unlikely to be true arthritis (joint disease).ย  May be bursitis — see topic Musculoskeletal Pain.
  • If same as above, but especially if pain with lightly scratching red, hot skin, or stretching skin without moving joint, likely Cellulitis (bacterial skin infection)
  • Hemarthrosis occurs with trauma, also if bleeding disorder like Hemophilia

The vast majority of patients with Septic Arthritis have a risk factor:

* Age >80
* Rheumatoid Arthritis
* Known chronic joint disease
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* Skin Infection
* Diabetes
* Prosthetic (artificial) Joint
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* Recent joint surgery
* Recent steroid injection
* Injection Drug Use 
* Alcoholism

Diagnosis of Septic Arthritis:  aspirate fluid from joint, in ER

If no suggestion of Septic Arthritis, continue on below

Pain in just One, or a Few, Joints
(Monoarticular / Oligoarticular Arthritis

Causes of Monoarticular *** / Oligoarticular Arthritis

*** NOTE — This assumes if only one joint is inflamed, we ruled out the possibility of Septic Arthritis.

More Common  Less Common
* Osteoarthritis
* Gout
* Pseudogout
* Psoriatic Arthritis
* Lyme Arthritis
* Rheumatoid Arthritis
* Reactive Arthritis
* Sarcoidosis (esp. both ankles)
* Behรงetโ€™s Syndrome
* Stillโ€™s Disease (Adult)
* Inflammatory Bowel Disease
* Avascular Necrosis (hip)

Diseases Diagnosed and Treated by Generalist Clinicians

Most Common Cause  —  Osteoarthritis (aka Degenerative Joint Disease [DJD])

  • Elderly (usually begins >60 y.o.)
  • Develops very gradually
  • Almost never causes acute pain or flares
  • Mostly knees, hips, fingers, feet, and spine
  • Easily diagnosed by X-Ray

Gout and Pseudogout cause recurrent Attacks (or Flares)

KNEE  —  Aspirate joint to diagnose Gout or Pseudogout.  Examine fluid for:

  • Crystals  —  need special polarizing microscope to distinguish between the two
  • White Blood Cell counts — in case there’s really a Septic Arthritis.
  • Gram Stain & Culture — in case there’s really a Septic Arthritis.

X-Ray can sometimes identify Pseudogout

Note:ย  Lots of swollen knees are really bursitis, not a true arthritis (joint disease).ย  See Monoarticular Arthritis — Full Text, see also Musculoskeletal Pains.

BIG TOE  —  Probably Gout.  Hard to aspirate.  Order blood test for Uric Acid, but beware:

  • Many people whoโ€™ll never get gout have a high uric acid
  • Up to 40% of Gout sufferers may have a normal uric acid during attack
  • Best time to check uric acid:  >2 weeks after the attack completely gone

ANKLE  —  Same as Big Toe.

  • New arthritis in both ankles together suggests Sarcoidosis (diagnose by chest x-ray)

HIP  —  Usually Osteoarthritis

  • Rarely Avascular Necrosis (bone death loss of blood supply) from alcoholism, chronic steroids, Sickle Cell, Lupus, advanced HIV, others (including some just in children)
  • May be seen on X-ray; MRI is better
  • Refer to Orthopedist for surgery

Referral to Rheumatology

Most types of Arthritis are diagnosed by Clinical Clues, NOT by lab tests or x-rays

  • Rheumatologists have the experience
  • Still, same labs as for Polyarthritis (which may begin in one or few joints)
  • Joint x-rays to look for destruction

Clinical Clues for diagnosing Monoarticular or Oligoarticular Arthritis

**  History of Flares  —  Patterns & duration of recurrences are key:

**  Psoriasis  —  Diagnose  Psoriatic Arthritis if also has Psoriasis

  • silvery-white scaly plaques (usually backs of the elbows, fronts of the knees, scalp, Achilles tendon, or sacrum), PLUS:
  • Finger arthritis in the far joint
  • Nail pits
  • โ€œSausage Digitsโ€ (fingers / toes that taper at the ends)

**  Age >65 at Onset  —  Pseudogout

  • Usually involves the knee
  • May cause as intermittent flares
  • May look like chronic osteoarthritis in joints where that disease would be very unusual (knuckles, wrists, elbows, shoulders)

**  Oral / Genital Ulcers  —  Behรงetโ€™s Syndrome

  • Arthritis tends to occur during ulcer flares
  • Medium-sized joints:  knees, ankles, wrists
  • Turkish descent, or ancestors from the โ€œSilk Roadโ€ (Arabic Peninsula on through Iran & the Indian subcontinent, to China-Korea-Japan)

**  History of Diarrhea (chronic / bloody)  —  Inflammatory Bowel Disease

  • Arthritis / Arthralgias tends to occur early in disease

**  Recent Bacterial Diarrheal Infection or Genital Chlamydia  —  Reactive Arthritis

  • Infection occurred days to weeks before arthritis
  • Large / medium joints usually
  • Also swelling at heel
  • Keratoderma blennorrhagica — thick, scaly plaques on palms / soles

**  Lived in Lyme Disease area  —  we’d wonder about Late Lyme Disease

  • Visible swelling (knee, shoulder, ankle, elbow, wrist, TMJ)
  • <5 joints; NOT symmetrical
  • History of attacks lasting weeks – months
  • Positive blood test for Lyme Antibody IgG  [including confirmation with Western Blot].  A hard diagnosis, since many people who live in Lyme Disease areas have positive blood tests without any symptoms or complications (most people get cured on their own)

**  Eye Disease (Painful: iritis, uveitis, episcleritis, scleritis)  —  we’d consider various possibilities

**  Dactylitis (โ€œsausage digitsโ€)  —  we think:

**  Enthesitis  (inflammation where tendon/ligament meets bone)  [esp. heel]  —  we think:

**  Erythema Nodosum  (painful red nodules on shins)  —  we think:

**  Intermittent Fevers (lasting โ‰ฅ1 week)  —  we think Stillโ€™s Disease

  • salmon-colored maculopapular rash may come & go during fever

See Joint Pain: Just One / Few Joints — Full Text for more in-depth explanations and discussions

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