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Managing Joint Pain in Primary Care

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Managing Joint Pain in Primary Care J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S32 on 1 December 2004. Downloaded from Managing Joint Pain in Primary Care Trish Palmer, MD, and James D. Toombs, MD Joint pain is a common problem seen by family physicians. Although many pain complaints arise from self-limited conditions, a substantial number require immediate and ongoing care. Prompt appropriate treatment can help limit symptoms, prevent disability, and improve outcomes. The differential diagnosis is varied, with both laboratory studies and diagnostic imaging available to help evaluate the joint. At the initial evaluation and at each subsequent re-evaluation, there should be efforts to identify dangerous conditions and distinguish conditions with a disease-specific pathogenesis. Treatment of joint pain con- sists of both pharmacologic and nonpharmacologic modalities. Pharmacologic therapies may include medications specific for pain, inflammation, and adjuncts specific to the diagnosis. Treatment of pain should proceed in a step-wise fashion providing medications appropriate for treating the level of pain. Inflammation is treated with physical modalities and nonsteroidal anti-inflammatory or cyclo-oxygen- ase-2 inhibitors. Nonpharmacologic therapies may include protection, rest, ice, compression, elevation, and simple office procedures. Physical therapy and education can assist in the recovery process, and prevent recurrence. (J Am Board Fam Pract 2004;17:S32–42.) Joint pain is a common complaint presented by ment consists of both pharmacologic and nonphar- patients to family physicians. Each year there are macologic modalities. more than 315 million office visits for musculoskel- etal complaints.1 By some estimates, these account for more than 10% of all outpatient visits in general Differential Diagnosis and Definitions copyright. medical practice.2 In 2001, a telephone survey com- Acute joint pain is any arthralgia that is expected to pleted by the Centers for Disease Control and resolve within 6 weeks (some authors report 6 Prevention revealed arthritis and chronic joint months); chronic joint pain persists beyond this symptoms in a third of all adults.3 Because joint defined window. In acute joint pain, there is often complaints encompass many diagnoses, an appro- an unmistakable cause such as trauma or infection. priate history and physical examination are neces- It is important to keep in mind that acute joint pain sary to determine the cause. It is important to may also represent a flare of a chronic condition or be the initial presentation of an undiagnosed differentiate acute from chronic joint pain, because http://www.jabfm.org/ many treatments have a different short-term risk/ chronic condition, such as osteoarthritis, rheuma- benefit ratio compared with the long term. Treat- toid disease, or crystal-induced arthropathy. Acute joint pain may develop into chronic joint pain. Of the 1 million ankle injuries treated in the United States annually, an estimated 40% will produce recurrent symptoms.4 From the Pisacano Leadership Foundation and the De- Whether acute or chronic, the goals in treating on 25 September 2021 by guest. Protected partment of Family and Preventive Medicine, University of Utah, Salt Lake City (TP), and the Department of Anesthe- a joint complaint remain the same: (1) reduce pain, sia, University of Iowa Hospitals & Clinics, Iowa City (2) reduce inflammation, (3) facilitate healing, (4) (JDT). Address correspondence to Trish Palmer, MD, De- preserve function, and (5) reverse or slow the dis- partment of Family and Preventive Medicine University of Utah, 1138 E Wilmington, Salt Lake City, UT 84106 ease process. At the initial evaluation of the patient (e-mail: [email protected]). and at each subsequent re-evaluation, there should The Family Practice Pain Education Project (FP-PEP) acknowledges an unrestricted educational grant from Pfizer be an effort to identify dangerous conditions and to to Cardinal Health to produce educational materials for distinguish conditions with a disease-specific ther- primary care doctors about pain management. The informa- tion provided here is the opinions and research of the family apy or that may benefit from early referral. physicians who served on FP-PEP. The differential diagnosis of joint pain may be This work was presented in part at the 2003 American Academy of Family Physicians (AAFP) Scientific Sympo- divided into the general categories of trauma, in- sium. fection, crystal-induced arthropathy, degenerative S32 JABFP November–December 2004 Vol. 17 Supplement http://www.jabfp.org J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S32 on 1 December 2004. Downloaded from Table 1. Differential Diagnosis of Joint Pain Table 2. Prevalence of Selected Musculoskeletal 6 Trauma Conditions Sprain Osteoarthritis 20,700,000 Strain Fracture Rheumatoid arthritis 2,100,000 Dislocation Gout 2,100,000 Tear of ligament, tendon, or meniscus Polymyalgia rheumatica & giant cell arteritis 560,000 Tendinitis Spondyloarthropathy 383,000 Infection Gonococcal Systemic lupus erythematosus 239,000 Nongonococcal-viral, mycobacterial, or fungal Juvenile rheumatoid arthritis 40,000 Lyme disease Secondary to bacterial endocarditis Adapted from ref. 6. Secondary to enteric and urogenital infections Crystal-induced arthropathy Gout Pseudogout in Table 2. Osteoarthritis is by far the most com- Degenerative joint disease mon chronic joint condition encountered by the Osteoarthritis family physician. Malignancy Tumor Metastases Evaluation of the Patient with Joint Pain Leukemia Evaluation of the patient with joint pain begins Rheumatic with an accurate history and physical examination Rheumatoid arthritis Reiter syndrome to determine the diagnosis, prognosis, and appro- Psoriatic arthritis priate treatment. Lupus erythematosus Ankylosing spondylitis Other History Complex regional pain syndrome Several key questions will help to elicit the cause of Sjögren syndrome copyright. Polymyositis acute joint pain. The first key discrimination point Scleroderma is whether this pain stems from trauma. The mech- Sarcoidosis Fibromyalgia anism of injury may help to delineate the specific Erythema nodosum structures involved. A history of high impact or an Sickle cell disease Aseptic necrosis inability to bear weight indicates the possibility of a Charcot more severe injury, such as a fracture, dislocation, Drug reaction or soft tissue tear. Determination of the exact lo- Hypothyroidism Irritable bowel syndrome cation of the pain, such as specific bony tenderness, Osteochondritis dissecans may indicate the possibility of a fracture or avulsion http://www.jabfm.org/ Information from refs. 7, 8, and 13. of a ligament. Exceptional physical demand (high- intensity exercise or an acute increase in the fre- quency, duration, or intensity of the activity) may joint disease, malignancy, rheumatic, and other indicate a stress fracture7 instead of a sprain. (Table 1). Trauma in a patient who is still growing should prompt consideration of epiphyseal fracture. Prevalence and Natural History In chronic joint pain, obtaining the history usu- on 25 September 2021 by guest. Protected Joint pain is a frequent complaint of the active and ally requires directed questioning. In particular, the aging United States population. In a 1998 study, physician should ask about onset, progression, and 2.5% of all visits to family physicians were for acute systemic symptoms. Although an abrupt onset is sprains and strains, and 1.8% of visits were for most often associated with self-limited conditions, degenerative joint disease.5 The natural history of at times rheumatic disease may appear suddenly. acute joint pain depends on the diagnosis, with Progression of the joint pain should be noted. many causes expected to resolve within 6 weeks to Chronic knee pain that increases abruptly may 6 months. For persons aged 65 years and older, need a more intensive work-up. If several joints are chronic joint pain (arthritis) and musculoskeletal involved, it may be helpful to know which were complaints are the leading cause of disability.6 The affected first. History taking should also include prevalence of a number of these complaints is listed questions about family history of joint disease and http://www.jabfp.org Managing Joint Pain S33 J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S32 on 1 December 2004. Downloaded from rheumatic conditions. Many diseases, such as rheu- possible neurological or vascular problems. If the matoid arthritis, osteoarthritis, and gout, occur joint volume is increased, the physician should de- more often in patients with affected relatives.8 The termine whether this is tissue hypertrophy or a absence of certain features can be reassuring. A joint effusion. Range of motion (ROM) should be patient may be concerned that the pain in her hands assessed as well. Increased ROM may indicate an is rheumatoid arthritis; however, without involve- unstable joint; decreased ROM may represent ef- ment of the proximal interphalangeal joints, rheu- fusion, capsule fibrosis, or bony abnormality. Con- matoid arthritis is unlikely. tractures indicate a longstanding condition. De- Any history of prior injury of the same joint formity seen in the chronic setting probably repre- indicates the possibility of a recurrent problem and sents joint erosion. In rheumatoid arthritis, the is thus more likely to be a chronic process instead of synovium lining the joint can hypertrophy, forming an acute one. Injuries that do not heal in
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