Joint+Pain+differential

 ** 1. **** Is it really arthritis? **  ·  Periarticular: bursa, fascia, tendon, ligament, epicondyle, myofacial pain/fibromyalgia  ◦ Bursitis – usually only painful with palpation  ◦ Tendonitis – usually pain with active or resisted motion  ◦ Arthritis – usually pain with passive motion, as opposed to soft tissue problem don't usually hurt with passive motion  · Non-articular: nerve entrapment, bone tumor, vasculopathy, etc.  ** 2. **** Acute or chronic? **  ·  Acute < 8 weeks – gout, viruses (parvovirus), serum sickness often self-limited  ** 3. **** Inflammatory or not? **    *Fibromyalgia – AM stiffness, pain with use and at night, polyarticular pain w/ myalgias, tender pts  ** 4. **** Pattern of Joint involvement ** Crystals – Gout (monosodium urate), pseudogout Hemarthrosis Pauciarticular juvenile RA     Osteomyelitis   ||   OA      Trauma/fracture/osteochondritis dissecans Neoplastic Congenital hip dysplasia  || Crystals – Gout, pseudogout  ||   OA   || Sarcoid Pseudogout (Calcium Pyrophospate Dihydrate Crystal Deposition Disease) Autoimmune – RA, SLE Spondyloarthropathy – Reactive arthritis (Formerly Reiter’s syndrome), Psoriatic, Ankylosing spondylitis, Inflammatory bowel disease associated arthritis  ||   OA   ||  · MCP/PIP = RA    ·  DIP/PIP = OA    ·  Symmetric = RA    ·  Asymmetric = Gout, Psoriatic, reactive arthritis  ** 5. **** Systemic features? **    Malar rash – SLE Erythema nodosum – Sarcoid, Crohn's     Pyoderma gangrenosum – IBD, SLE, RA, anklyosing spondylitis, sarcoid   || Boudard's nodes (PIP) - OA     Boutonniere and swan neck deform – RA      Dactylitis (sausage digits), bursitis, enthesitis - Spondyloarthropathies   ||  ** 6. **** Patient demographics? **    Women – RA, SLE, fibromyalgia Younger – RA, SLE, reactive arthritis, spondyloarthopathies Men – Gout, Spondyloarthropathy Older – OA, polymylagia rheumatica
 * Breaking down the Joint Pain differential **
 * || ** Inflammatory ** (Infectious, Gout/crystals, Psoriatic, RA, SLE, Viruses)   ||  ** Non-inflammatory ** (OA)   ||
 * AM stiffness   ||   >30 min   ||   <15 min   ||
 * With rest  ||   More stiff   ||   Relief of pain   ||
 * With use/exercise  ||   Relief of pain   ||   Worsening of pain   ||
 * Synovial fluid  ||   >2000 cells (mostly PMNs)   ||   <2000 cells   ||
 * ||  Inflammatory   ||   Non-inflammatory   ||
 * Monoarthritis   ||   ID – Gonnorhea, bacterial, TB, fungal, Lyme disease
 * Pauciarthritis (2-4 jts)  ||   ID – Dis. Gonnorhea, Endocarditis
 * Polyarthritis  ||   ID- Parvovirus, HCV, Lyme disease
 * Skin  ||   Plaque, pitted nails – Psoriasis
 * Musculoskeletal  ||   Heberden's nodes (DIP) - OA