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160

Definition

Arthralgia m e a n s p a i n i n a j o i n t . Polyarthralgia means pain

i n s e v e r a l j o i n t s ( t w o o r m o r e f o r t h e p u r p o s e s o f t h i s d i s -

c u s s i o n ) . A r t h r i t i s i s a d i a g n o s i s a n d i s n o t a s y m p t o m ; i t s

d i a g n o s i s r e q u i r e s t h e p h y s i c a l s i g n s o f a r t i c u l a r i n f l a m -

m a t i o n o r t h e p h y s i c a l o r r o e n t g e n o g r a p h i c s i g n s o f o s -

t e o a r t h r i t i s . T h e m a j o r d i s o r d e r s a s s o c i a t e d w i t h a r t h r i t i s

( a n d h e n c e w i t h a r t h r a l g i a ) a r e s u m m a r i z e d i n T a b l e 1 5 9 . 2

i n t h e p r e c e d i n g c h a p t e r .

TechniqueO n c e a r h e u m a t i c p a i n s y n d r o m e h a s b e e n l o c a l i z e d t o o n e

o r m o r e j o i n t s , a d d i t i o n a l h i s t o r i c a l d a t a a r e r e q u i r e d . F i r s t

d e t e r m i n e w h e t h e r o r n o t o t h e r s i g n s o f i n f l a m m a t i o n ( o f

t h e j o i n t ) h a v e b e e n o b s e r v e d b y t h e p a t i e n t . R e d n e s s , w a r m t h

( " f e v e r " ) , a n d e s p e c i a l l y s w e l l i n g s h o u l d b e s p e c i f i c a l l y a d -

d r e s s e d . T h e n a t u r e o f t h e o n s e t s h o u l d b e e s t a b l i s h e d e a r l y

i n t h e i n t e r v i e w . I f t h e a r t h r a l g i a b e g a n r e c e n t l y a n d w a s

r a p i d i n o n s e t , t h e s y n d r o m e c a n b e c o n s i d e r e d a c u t e a n d

a s p e c i f i c d i f f e r e n t i a l d i a g n o s i s ( T a b l e 1 6 0 . 1 ) i s s u g g e s t e d .

R e g a r d l e s s o f t h e n a t u r e o f t h e o n s e t , a r t h r a l g i a t h a t h a s

p e r s i s t e d f o r a m o n t h o r l o n g e r c a n b e c o n s i d e r e d c h r o n i c

o r p e r s i s t e n t , a n d o t h e r d i f f e r e n t i a l d i a g n o s e s a r e s u g -

g e s t e d , d e p e n d i n g o n w h e t h e r o n e j o i n t ( T a b l e 1 6 0 . 2 ) o r

m o r e t h an o n e j o i n t (T a b l e 16 0 . 3 ) h a s b e e n s y m p t o m a t i c .

O b v i o u s l y t h e a f f e c t e d j o i n t o r j o i n t s s h o u l d b e l i s t e d b y

t h e p a t i e n t , i n t h e o r d e r o f t h e i r i n v o l v e m e n t i n t h e c a s e o f

p o l y a r t h r a l g i a . I t i s h e l p f u l t o k n o w i n w h a t j o i n t t h e a r -

t h r a l g i a b e g a n a n d i t s s u b s e q u e n t p a t t e r n o f s p r e a d . " W h e r e

d i d i t m o v e n e xt ? " i s a u s e f u l q u e st i o n . M e a n w h i l e , t h e

i n t e r v i e w e r s h o u l d n o t l o s e s i g h t o f t h e b e h a v i o r o f e a c h

a f f e c t e d j o i nt ; b r i e f n o t e s a r e a l m o s t e s s e nt i a l f o r t h i s p u r -

pose when more than three or four have been involved .

F o r e a c h a f f e c te d j o i n t o r s e t o f j o i n t s , t h e i n t e r v i e w e r m i g h t

r e c o r d t h e d a t e o f i n i t i a l i n v o l v e m e n t , s e v e r i t y , p r o g r e s s i o n ,

a n d d a t e o f r e s o l u t i o n , i f t h a t h a s o c c u r r e d . C l a s s i c m i g r a -

t o r y p o l y a r t h r i t i s a n d d i s c r e t e e p i s o d e s o f a c u t e o r s e l f -

l i m i t e d a r t h r i t i s w i l l b e a p p a r e n t b y s u c h n o t a t i o n s . I n t h e

c a s e o f p e r s i s t e n t p o l y a r t h r a l g i a i t i s w o r t h a s k i n g w h i c h

j o i n t o r j o i n t s h a v e b e e n m o s t s y m p t o m a t i c d u r i n g t h e i l l -

n e s s , t h o u g h t h e r e s u l t i n g i n f o r m a t i o n m a y b e m o r e h e l p f u l

t h e r a p e u t i c a l l y t h a n d i a g n o s t i c a l l y .

A l l t h e d i s o r d e r s a s s o c i a t e d w i t h i n f l a m m a t o r y p o l y a r -

t h r i t i s h a v e e x t r a a r t i c u l a r o r s y s t e m i c m a n i f e s t a t i o n s , a n d

t h e s e s h o u l d b e a d d r e s s e d d u r i n g t h e i n t e r v i e w , p e r h a p s

b y a " r e v i e w o f s y s t e m s " a p p r o a c h . T h e m a j o r e xt r a a r t i c u la r

m a n i f e s t a t i o n s o f s o m e o f t h e m o s t c o m m o n a r t h r o p a t h i e s

are summarized in Tabl e 159 . 3 i n t h e p r e c e d i n g c h a p t e r .

T h e i n e x p e r i e n c e d i n t e r v i e w e r m i g h t b e n e f i t f r o m r e f e r -

r i n g t o s u c h a l i s t d u r i n g t h e i n t e r v i e w i n o r d e r t o a s s u r e

c o m p l e t e n e s s i n t h i s c r u c i a l a r e a . T h e i m p o r t a n c e o f t h e s e

q u e s t i o n s c a n n o t b e o v e r e m p h a s i z e d ; r e sp o n s e s t o th e m p l a y

Arthralgia

JOE G. HARDIN

7 5 7

a m a j o r r o l e i n s u g g e s t i n g s p e c i f i c c o n n e c t i v e t i s s u e d i s e a s e s

o r s p o n d y l o a r t h r o p a t h i e s .

O s t e o a r t h r i ti s o f t h e s m a l l h a n d j o i n t s a n d a l l o f t h e

c o n n e c t i v e t i s s u e d i s e a s e s a r e f a m i l i a l , e s p e c i a l l y i n w o m e n .

F i f t e e n t o 2 0 % o f p a t i e n t s w i t h a s p o n d y l o a r t h r o p a t h y g i v e

T a b l e 1 6 0 . 1

D i f f e r e n t i a l D i a g n o s i s o f A c u t e - O n s e t A r t h r i t i s

D i s e a s e A s s o c i a t e d f e a t u r e s Comment

A c u t e t r a u m a t i c None H i s t o r y o f j o i n t

F l a r e i n None

t r a u m a ( u s u a l l y

k n e e )

H i s t o r y o f p r i o r j o i n t

o s t e o a r t h r i t i s symptoms and his-

Pseudogout F e v e r o c c a s i o na l l y

t o r y o f o v e r u s e

Common in knee,

Gout Fever is common

a n k l e , s h o u l d e r ,

a n d w r i s t ; u s ua l ly

m o n a r t i c u l a r

Common in first

Re i t e r 's Fever is common

m e t a t a r s o -

p h a l a n g e a l , k n e e ,

m i d - f o o t , a n k l e ,

a n d w r i s t . F i r s t

f e w a t t a c k s u s u a l l y

m o n a r t i c u l a r

Common cause of

syndrome ( s e e T a b l e 1 6 0 . 3 ) a c u t e a r t h r i t i s i n

Gonococcemia F e v e r , s k i n l e s i o n s ,

young menCommon cause of

S e r u m s i c k n e s s -

a n d h a n d t e n o s y -

n o v i t i s a r e c o m -

mon

F e v e r a n d r a s h ( u s u -

a c u t e a r t h r i t i s i n

young women .

May be monarticu-

l a r o r p o ly a r t i c u l a r

H i s t o r y o f d r u g o r

l i k e r e a c t i o n s a l l y u r t i c a r i a ) h e p a t i t i s B e x p o -

Nongonococcal Fever

s u r e

U s u a l l y m o n a r t i c u l a r

ba c t e r i a l a n d l a r g e j o i n t ;

a r t h r i t i s h i s t o r y s u g g e s t i v e

S y s t e m i c l up u s S e e T ab l e I 6 0 . 3

of compromised

h o s t

Common mode of

erythematosus o n s e t o f S L E ;

(SLE) k n e e s a n d f i n g e r

Rheu matoid May be none ; f e v e r

p r o x i m a l i n t e r -

p h a l a n g e a l j o i n t s

commonly in-

v o l v e d

Unusual mode of

a r t h r i t i s uncomm on in o n s e t i n a d u l t s

a d u l t s ( s e e T a b l e

160. 3 )

Erythema F e v e r a n d t y p i c a l A n k l e s u s u a l l y i n -

nodosum s k i n l e s i o n s v o l v e d

Acute Fever ; o th er f ea tu re s C l as si c mi gr at or y po l -

rheumatic uncomm on in y a r t h r i t is ; h i s t o r y

f e v e r a d u l t s o f s o r e t h r o a t o r

p r i o r a t t a c k s

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T a b l e 1 6 0 . 2

D i f f e r e n t i a l D i a g n o s i s o f C h r o n i c M o n o a r t h r i t i s

T a b l e 1 6 0 . 3

The Seven Common Diseases Associated w ith Chronic

P o l y a r t h r i t i s

a f a m i l y h i s t o r y o f a s i m i l a r d i s e a s e . G o u t i s a l s o f a m i l i a l ,

a n d s o m e r a r e p a t t e r n s a r e g e n e t i c a l l y d e t e r m i n e d . C o n -

s e q u e n t l y , a f a m i l y h i s t o r y i s a n e c e s s a r y p a r t o f t h e m u s -

c u l o s k e l e t a l h i s t o r y w h e n a r t h r a l g i a i s p r e s e n t . " I s t h e r e

a r t h r i t i s i n y o u r f a m i l y ? " i s a n a p p r o p r i a t e i n i t i a l q u e s t i o n ,

b u t a p o s i t i v e r e s p o n s e s h o u l d b e f o l l o w e d b y q u e s t i o n s

c o n c e r n i n g j o i n t d i s t r i b u t i o n , s i g n s o f i n f l a m m a t i o n , a n d

d e g r e e o f r e s u l t i n g d i s a b i l i t y . W i t h s u c h a n i n q u i r y i t m a y

b e p o s s i b l e t o i d e n t i f y t h e d i s e a s e f a i r l y a c c u r a t e l y i n e a c h

a f f e c t e d r e l a t i v e . S u c h a n i d e n t i f i c a t i o n c a n s i g n i f i c a n t l y

c o n t r i b u t e t o t h e d i a g n o s i s o f t h e p a t i e n t b e i n g i n t e r v i e w e d .

F o r t h e r a p e u t i c r a t h e r t h a n d i a g n o s t i c r e a s o n s , i t i s i m -

p o r t a n t t o q u a n t i f y t h e s e r i o u s n e s s o f a c h r o n i c a r t h r a l g i a

s y n d r o m e i n t e r m s o f d i s a b i l i t y . " W h a t c a n ' t y o u d o b e c a u s e

o f y o u r j o i n t p r o b l e m ? " i s a u s e f u l i n i t i a l q u e s t i o n . When-

XII MUSCULOSKELETAL SYSTEM

e v e r p o s s i b l e , e a c h m a j o r d i s a b i l i t y s h o u l d b e l i n k e d t o t h e

i n v o l v e m e n t o f o n e o r m o r e s p e c i f i c j o i n t s . F o r s o m e p a -

t i e n t s , i t i s h e l p f u l t o a p p r o a c h t h i s i s s u e f r o m t h e v i e w p o i n t

o f t h e j o i n t r a t h e r t h a n t h e d i s a b i l i t y : " W h a t d o e s y o u r k n e e

( o r h i p o r o t h e r j o i n t ) p r o b l e m k e e p y o u f r o m d o i n g ? " P r o -

g r e s s i o n o f d i s e a s e c a n a l s o b e d o c u m e n t e d b y c o m p a r i n g

d i s a b i l i t y a t t w o m o m e n t s i n t i m e : " W h a t c a n ' t y o u d o n o w

t h a t y o u c o u l d d o o n e y e a r a g o ? " A t t h e c o m p l e t i o n o f t h i s

p o r t i o n o f t h e h i s t o r y , t h e i n t e r v i e w e r s h o u l d h a v e a d -

d r e s s e d g a i n f u l o c c u p a t i o n , p l e a s u r a b l e a c t i v i t i e s , a n d h o m e

a n d s e l f - c a r e , a s w e l l a s m o r e s p e c i f i c f u n c t i o n a l l i m i -

t a t i o n s .

Basic Science

O s t e o a r t h r i t i s i s b a s i c a l l y a n o n i n f l a m m a t o r y a r t h r o p a t h y ,

a n d i t c a n b e t r a u ma t i c i n o r i g in ; h o w e v e r , o v e r u s e o f a n

o s t e o a r t h r i t i c j o i n t c a n i n i t i a t e a s e c o n d a r y i n f l a m m a t o r y

p r o c e s s . P a t te r n s o f j o i n t u s a g e a n d a h i s t o r y o f j o i n t t r a u m a

s h o u l d b e e x p l o r e d i n p a t i e n t s s u s p e c t e d o f o s t e o a r t h r i t i s .

T h e o t h e r c o m m o n a r t h r o p a t h i e s r e s u l t f r o m a n i n i t i a l

and primary inflammatory process in the synovial mem-

b r a n e o f t h e j o i n t . S y m p t o m s r e f l e c t t h i s i n f l a m m a t o r y p r o c -

e s s , a t l e a s t i n i t i a l l y . M a n y o f t h e s e d i s e a s e s h a v e a p o t e n t i a l

f o r c a u s i n g a r t i c u l a r d e s t r u c t i o n , a n d s y m p t o m s t h a t o c c u r

l a t e i n t h e i r c o u r s e o f t e n r e f l e c t j o i n t d a m a g e . I n g e n e r a l ,

t h e s e m e c h a n i c a l s y m p t o m s i n c l u d e l e s s s t i f f n e s s a n d l e s s

j o i n t p a i n a t r e s t t h a n d o t h o s e p r e d o m i n a n t l y d u e t o i n -

flammation . T h e i n f l a m m a t o r y a r t h r o p a t h i e s a r e a h e t e r -

o g e n e o u s g r o u p o f d i s e a s e s ; t h e i r e t i o l o g i e s ( w h e n k n o w n )

a n d p a t h o g e n e t i c m e c h a n i s m s a r e d i v e r s e .

Clinical Significance

A r t h r a l g i a i s t h e m o s t s i g n i f i c a n t r h e u m a t i c s y m p t o m b e -

c a u s e o f t h e p o t e n t i a l l y s er i o u s d i s e a s e s i t m a y r e f l e c t . A r -

thralgia unaccompanied by signs of inflammation and

e x t r a a r t i c u l a r s y m p t o m s m a y b e t r a n s i e n t a n d o f l i t t l e c l i n -

i c a l i m p o r t a n c e , o r m a y r e p r e s e n t t h e i n i t i a l s t a g e s o f a

c o n n e c t i v e t i s s u e d i s e a s e o r o t h e r s e r i o u s d i s o r d e r . When

a c c o m p a n i e d b y s i g n s o f i n f l a m m a t i o n o r e x t r a a r t i c u l a r

s y m p t o m s , a r t h r a l g i a i s a l m o s t a l w a y s c l i n i c a l l y s i g n i f i c a n t

a n d u s u a l l y r e f l e c t s a d i a g n o s a b l e d i s e a s e .

References

American Rheumatism Association . Dictionary of the rheumaticdiseases, vol 1. New York : Contact Associates International,1982 .

Kelley WN, Harris ED Jr, Rudd y S, et al . , e d s . Textbook of rheu-

m at o lo gy , 3rd e d . Philadelphia : W.B . Saunders, 1989 ;Chaps .24-25 .McCarty DJ, ed . Arthritis and allied conditions . A textbook of rheu-

matology , 11th ed . Philadelphia : Lea & Febiger, 1989 ;55-68 .Morgan WL Jr, Engel GL. The clinical approach to the patient .Philadelphia: W .B . Saunders, 1969 .

Polley HF, Hunder GG . Rheumatologic interviewing and physicalexamination of the joints . 2d ed . Philadelphia : W .B. Saunders,

1978 .

Osteoarthritis : Most often knee

Interna l d eran gem ent (torn meniscus, osteochondritis, loose

body, etc . ) : Usually knee ; history of injury

S y n o vi t i s o f un k n o wn c a u s e : Usually knee and usually remits in

months or a few years

Rheumatoid arthritis : Inflammatory history ; always progresses

to involve other joints, only more slowly than typical RA

Traumatic synovitis : Usually knee ; history of definite traumaSpondyloarthropathy: See Tabl e 160 . 3 ; alway s progresses toinvolve other joints, only more slowly than typical spond ylo-

arthropathy

C ho n dro c alc i n o s i s : Often knee; history sugg estive ofpseudogoutChronic infection : Systemic symptoms may occurTumor (including pigmented villonodular synovitis) : May be

rapidly destructive, leading to progressive disability

Osteoarthritis : Inflammation is minimal . Symptoms usually

limited in distribution . Small hand joints (except

metacarpophalangeal) , neck, hips, and knees are common

s i t e s . Older age onset

Rheumatoid arthritis : Inflammation is prominent . Prominent

polyarthralgias and stiffness . Spine below neck is spared .

Middle-aged (female) onset

C hro n i c ( t o p hac e o u s ) go ut : History of earlier d iscrete attacks .

Spine, shoulders, and hips are uncommonly affected . Middle-

aged to older (male) onset

S y s t e m i c l u p u s e ry t he m at o s u s : History of multisystem

involvement (Table 159 .3 ) . Small hand joints and knees

commonly affected. Young (femal e) onset

Reiter's syndr ome : History of urethritis and conjunctivitis and

acute onset in about ha lf. Large lower extremity jointspredominate. Young (male) onset . See Table 159 .3Ankylosing spondylitis : History of back pain . Spinal (axial)

i n vo l ve m e n t p re do m i n at e s . Young (male) onset. See Table

15 9 . 3

Psoriatic arthritis : History of psoriasis (in most) . Variable joint

distribution with distal interphalangeal joint involvement

typical. Affects adults at any age . See Table 159 . 3