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 clinician’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.  Goes away on own.  Ordering lots of tests can generate many false-positive results, which can be quite bad for the person (see link).  We often treat for pain, wait and see. Some exceptions (see #2 below for the tests):

• Hand / Foot joints very swollen, red, warm, tender; pain worst in morning.  Test for Rheumatoid Arthritis
• Fevers — Probably just a simple virus, but consider some uncommon causes of acute arthritis:
  • Endocarditis, Acute HIV, Rheumatic Fever, Disseminated Gonorrhea, Acute Hepatitis
  • Fever / cough + Joint pains going on under 10 days  → get Covid Test, self-isolate. Every office & clinic has its own way of addressing Covid before they let you in the door.
• Lyme Disease Exposure in last few months — possibly Early Lyme Disease
• People with conditions that seriously weaken their immune system  —  Blood test for B19 Parvovirus (see Full Text)

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

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)

**  Systemic Lupus Erythematosus (Lupus; SLE)  —  Blood test for Anti-Nuclear Antibody (ANA); positive means the numerical titer ≥1:160).  If ANA positive:

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

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

**  Hepatitis C:  Blood test for Hepatitis C Antibody

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

• Complete Blood Count (CBC)
• Sedimentation Rate (“ESR”, “Sed Rate”) &/or C-Reactive Protein (CRP)
• Urinalysis

3.  If No Diagnosis:

**  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 ≥1:160 but no other evidence of Lupus:

• Order blood tests to rule out Sjögren’s Syndrome, Scleroderma, Mixed Connective Tissue Disease (rare)
• Each disease has various special tests; usually worth a referral to Rheumatology

**  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.