Joint Pain: Multiple Joints

BE SURE that we’re dealing with Joints, and not tendons, carpal tunnel, muscle pain, etc.  We only think of inflammatory types of arthritis when joints hurt most in the early morning, and pain lasts at least 30-60 minutes.  Tendons, etc. tend to hurt more as the day goes on.

The following represents the clinicianโ€™s condensed thought-process when face-to-face with a patient. For more in-depth discussion & explanations, see Joint Pain: Multiple Joints — Full Text.

1.  If Joint Pains going on less than 4-6 weeks:

Probably a Virus.ย  Goes away on own.ย  Ordering lots of tests can generate many false-positive results.ย  Some exceptions (see #2 below for the tests):

2.  Joint Pains for over 4-6 weeks, multiple small joints, with stiffness lasting at least 30-60 min. in early morning:

Most Common

Large-Joint Diseases
Which Occasionally Cause
Small Joint Arthritis in Many Joints

Uncommon

Rare Rheumatologic Conditions

  • Mixed Connective Tissue Disease
  • Relapsing Polychondritis
  • Vasculitis
  • Paraneoplastic Syndrome (from a cancer that hasn’t yet shown itself)

Blood Tests for the most common causes:

**  Rheumatoid Arthritis:

  • Rheumatoid Factor (RF), Cyclic Citrullinated Peptide antibody (CCP).
  • Also get X-Rays of wrists, hands, ankles, & feet for joint erosions (destruction)

**ย  Systemic Lupus Erythematosus (Lupus; SLE)ย  —ย  Blood test for Anti-Nuclear Antibody (ANA); positive means the numerical titer โ‰ฅ1:160).ย  If ANA positive:

  • blood antibody tests for double-stranded DNA (dsDNA), anti-Smith (โ€œSmโ€), and anti-Phospholipid;
  • C3 & C4 (“complement”); RPR (for false-positive syphilis test)
  • Inquire about current and past symptoms that suggest Lupus

**ย  Hepatitis B:ย  Blood test for Hepatitis B surface Antigen (HBsAg)

**ย  Hepatitis C:ย  Blood test for Hepatitis C Antibody

Also order general tests (if very abnormal, may lead to more work-up):

3.  If No Diagnosis:

**ย  If ESR / CRP are Very Elevated; or if CBC shows Anemia (“normocytic“)

  • Refer to Rheumatology (may be “Sero-Negative” Rheumatoid Arthritis)
  • Do normal cancer screening depending on age to rule out rare Paraneoplastic Syndrome (Mammogram if age >40-50, Pap Test every 3 yrs., Colonoscopy if age >50)

**  ANA โ‰ฅ1:160 but no other evidence of Lupus:

**  ANA Normal:  Refer to Rheumatology if other symptoms of certain diseases:

  • Psoriatic Arthritis:  Psoriasis
  • Chronic Gout:  1-week episodes in past of severe pain in toe, ankle, knee, or wrist
  • Vasculitis:  Purple rashes, coughing or urinating blood, bloody nose often), constant tingling or weakness in just one arm or leg
  • Sarcoidosis:  Swollen ankles; Chest X-Ray shows “hilar adenopathy”
  • Relapsing Polychondritis (very rare):  Episodes of outside ear turns red & inflamed

4.  Still None of Above, but joints keep hurting:  Refer to Rheumatology

  • Again, be sure we’re not dealing with tendons, carpal tunnel, muscle pain, etc.  See our topic on distinguishing among Musculoskeletal Conditions

See Joint Pain: Multiple Joints — Full Text for more in-depth explanations and discussions.

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