Clinical Examination of Patients with Joint Inflammation in Primary Health Care

Essentials

• Septic arthritis should be diagnosed and treated as a medical emergency in the nearest hospital. Other causes requiring specific treatment should be excluded within a time span of 2 weeks.
• All cases of suspected rheumatoid arthritis Rheumatoid Arthritis must be referred for specialist health care without delay.
• Gout Gout and Pseudogout can be diagnosed and the treatment started in primary health care.
• Osteoarthritis Osteoarthritis of the Hip and Knee is principally treated in primary health care, and it should be differentiated from other inflammatory joint conditions Disease-Specific Signs and Symptoms in Patients with Inflammatory Joint Diseases.
• Polyarthritis of recent onset should initially be considered as rheumatoid in origin.
• Laboratory tests, other than inflammatory parameters and rheumatoid factor (RF), should be requested with restraint.
• Imaging studies often confirm diagnosis.
• Local care pathways should be observed.

In general

• There are numerous potential causes of polyarthritic symptoms and establishing the correct diagnosis may require a monitoring period lasting for several weeks or even months.
• Treatment is directed more against the inflammatory process in the organ system rather than against a specific classified disease. Therefore, a specific diagnosis is not always necessary for starting treatment.
• In joint inflammations that may become chronic, starting treatment sufficiently early has a considerably strong impact on the patient's prognosis.

Epidemiology

• See table T1.

Clinical history

• The patient's clinical history is elicited in accordance with the list below. First-line laboratory investigations based on data obtained from clinical history: see table T2.
  • Morning stiffness and its duration in the affected joint
  • Joint pain on movement, ache
  • Lower back pain at rest
  • Lower back pain improves with movement
  • Recent history of trauma
  • History of previous joint symptoms
  • Family history for joint inflammation, psoriasis
  • Psoriasis (skin, nails)
  • Recent history of diarrhoea
  • Symptoms of ocular inflammation
  • Urinary problems, purulent discharge from the urethra
  • Sexual contacts
  • Other signs of infection (pharyngitis?)
  • Raynaud's phenomenon
  • Solar dermatitis
  • Use of beer or diuretics
  • Metabolic syndrome

Clinical examination

• Clinical examination should always be based on a detailed history.
• Ask the patient to undress down to underclothes.
• Clinical observation of the patient is important: handshaking, walking, undressing.
• Is the patient accompanied by another person due to the severity of symptoms?
• The general examination should be fairly comprehensive: heart and lung auscultation, blood pressure, palpation of lymph nodes and abdomen, inspection of the mouth and skin.
• After the general examination, all joint regions should be checked on the first visit.
• Thereafter it should be determined whether the symptoms originate from the joint itself or from another problem associated with the joint or its adjacent tissues, e.g. scleroderma that causes joint stiffness and limitation of joint movement through hardening of the skin.
• When the symptom has been localised to the joint, the next step is to evaluate, based on the history and clinical examination, whether there is joint inflammation Clinical Diagnosis of Joint Inflammation in the Adult. The aim is to differentiate between joint pain (arthralgia), which may be associated with, for example, many infectious diseases, and inflammatory symptoms, the presentation of which may vary according to the joint inflammation in question:
  • pain on movement
  • ache
  • swelling
  • heat
  • stiffness
  • limited movement of the affected joint.
• If the clinical examination arouses a suspicion of a systemic disease, e.g. hypothyroidism (see Hypothyroidism), further investigations may be warranted and treatment initiated if indicated.

Further investigations in confirmed joint inflammation History, Physical Examination, and Laboratory Tests in the Diagnosis of Septic Arthritis

• In acute monoarthritis, perform arthrocentesis and obtain an analysis of the synovial fluid (see Investigation of Synovial Fluid). If the patient is febrile or has an increased plasma CRP, ESR or leucocyte count, consider the possibility of purulent arthritis, reactive arthritis Reactive Arthritis or gout Gout and Pseudogout.
  • If the synovial fluid is turbid, the patient should be admitted to hospital for the exclusion of purulent arthritis (bacterial culture and Gram staining of the synovial fluid, blood culture). The risk of purulent arthritis is highest in patients with pre-existing articular damage (osteoarthritis, endoprosthesis), a systemic disease such as diabetes or a recent history of a surgical procedure, including the extraction of a tooth with purulent discharge. The most common causative agent is staphylococci.
  • If the synovial fluid is purulent (leucocyte count exceeding 40 000 × 10⁶ /l), the patient should be admitted to hospital without delay. Even a lower synovial fluid leucocyte count does not exclude septic arthritis; in such cases the decision whether to start antimicrobial drug therapy (always parenterally in a hospital) is based on the clinical picture and the plasma CRP level. It is recommended that some of the synovial fluid sample obtained is sent with the patient to the hospital for further analysis (e.g. Gram staining).
  • A synovial fluid sample for crystals is also necessary to confirm the diagnosis of gout, and a sample should be obtained as soon as possible because the fluid may quickly disappear making later sample collection impossible. Patients who present with a typical clinical picture of gout (rapid onset, markedly tender and reddish first metatarsophalangeal joint in a man or in a woman using diuretics), can be given an intra-articular injection of methylprednisolone as first aid treatment.
• The clinical picture and the synovial fluid findings are usually helpful in distinguishing osteoarthritis from an inflammatory joint disease already at an early stage Disease-Specific Signs and Symptoms in Patients with Inflammatory Joint Diseases. If the leucocyte count of the synovial fluid exceeds 2 000 × 10⁶ /l the condition is considered inflammatory and is suggestive of rheumatoid arthritis or other inflammatory arthritis. Normal ESR and CRP levels support the diagnosis of osteoarthritis.
• For the symptoms of borreliosis in the musculoskeletal system, see the article on Lyme borreliosis Lyme Borreliosis (LB).
• More specific investigations are performed according to table T2, depending on the clinical picture. For diagnostic clues based on clinical signs: see Disease-Specific Signs and Symptoms in Patients with Inflammatory Joint Diseases.

Imaging studies

• If arthritis is detected in a single joint of a finger or a toe, the whole hand or foot should be imaged. X-rays of both hands and feet are always warranted in polyarthritis affecting the small joints.
• Oligoarthritis: imaging studies as per local protocols. Unnecessary x-rays should be avoided, particularly in the young and children.
  • If an adult presents with symptoms affecting a single large joint, the first-line examination is an ultrasound examination, which can be followed by x-rays, magnetic resonance imaging (MRI), CT and other imaging studies as indicated.
  • An ultrasound examination is also the first-line investigation in children, and it can be followed by x-rays or MRI depending on the child's history, clinical presentation, the age of the child and the facilities available at the place of treatment (MRI in a small child requires general anaesthesia).
• Spondylarthritides
  • The recommended initial imaging investigation in patients less than 35 years is MRI.
  • In older patients the initial imaging investigations may consist of routine x-rays.

Arrangement of treatment