Joint pains are a common presentation in general practice. This article focuses on red flag symptoms in widespread arthralgia as opposed to more specific joints.
Red flag symptoms
- Night sweats
- Appetite loss
- Unintentional weight loss
- Joint swelling/redness and heat
- Early morning stiffness
- Persistent fever of more than 3 weeks
- Night pain
- New onset headaches
- Jaw claudication
- Scalp tenderness
- Significant lethargy
- History of inflammatory bowel disease
- History of uveitis/iritis
It is important to establish why the patient has presented now and explore their thoughts and fears around the problem in order to achieve a satisfactory shared management plan. Questions to ask include the following:
- When did the symptoms start? Which joints are affected? Is it a specific joint or is the joint pain widespread?
- Has the pain got worse? if so, how has it progressed?
- Has the patient noticed any stiffness, swelling or redness associated with any of their joints? How does the stiffness develop over time?
- Have there been systemic symptoms - sore throat, headaches, cough, colds, diarrhoea?
- Does the patient take any medication, especially statins? Have they recently started any new medications? Do they take any anticoagulation therapy? Has there been any foreign travel?
- How has their quality of life been affected? Has it stopped them doing normal day-to-day activities? Have they experienced this problem before and if so, have they been investigated and diagnosed?
- Do they have any significant family history? Does the patient smoke, drink or engage in any recreational drugs?
A sexual history may be necessary if a reactive arthritis is suspected. Does the patient have a history of inflammatory bowel disease, or any history of iritis or uveitis?
Have there been any other systemic symptoms such as dry mouth, dry eyes or recurrent mouth or genital ulcers?
- Inspect the joint. Is there any swelling/redness or deformity? Are the joints affected symmetrically or asymmetrically?
- Palpate for any synovitis/bogginess of the joints or any bony tenderness
- Assess movement. Is there any restriction to active and or passive movement?
More widespread pain may be slightly more difficult to examine but a GALS screening examination may prove useful. This includes a very brief assessment of the gait, arms, legs and spine. If any abnormalities are detected, then you can do a more focused examination of the specific joint if relevant.
If any systemic symptoms are revealed in the history then a more specific examination of that system may be necessary.
Primary care investigations
These will mainly be guided by your history and examination but may include:
- Blood work including FBC, UEs, CRP, ESR, Ca, phosphate, LFTs, TSH, Hba1c
- Rheumatoid factor
- Serum vitamin D
- Coeliac screen
- Serum urate
- Serum creatinine kinase
- Autoimmune screen
- Chlamydia or gonococcal testing, with or without HIV testing
- Plain chest film
- Specific joint X-rays
- Throat swab
- Systemic sclerosis
- Other connective tissue disorders
- Rheumatoid arthritis
- Psoriatic arthritis
- Gout or pseudogout
- Non-specific self-limiting viral infections
- Viral gastroenteritis
- Acute respiratory infections
- Post-strep throat
- Reactive arthritis secondary to gonococcus/chlamydia/campylobacter
- Parvovirus B19
- HIV seroconversion illness
- Septic joint
- Vitamin D deficiency
- Diabetes mellitus
- Medications such as statins, PPIs
- Paraneoplastic syndromes
- Vasculitis such as polymyalgia rheumatica
- Normal ageing process
- Metastatic disease
Presentations involving arthralgia and swelling
Osteoarthritis, although degenerative, can have an inflammatory component to it and present as swelling of a joint alongside pain. Rheumatoid arthritis typically presents with swelling and pain of peripheral joints. Polymyalgia rheumatica does not typically cause swelling.
Gout and haemarthrosis can present with swelling and pain, and anticoagulant therapy can increase the likelihood of haemarthrosis. Haemarthrosis is more likely to be a single joint, but gout can present as a polyarthralgia.
- Dr Pipin Singh is a GP in Northumberland