Chapter 3

In approaching a patient with joint pain, the emergency physician should first remember that the source of the pain may be articular or periarticular (i.e., bursitis, tendonitis). When it has been determined that the origin of the pain is the joint itself, arthritis is the appropriate terminology if an inflammatory process is the cause. Noninflammatory joint pain is termed arthralgia.

### History

Evaluation begins with a thorough history. The physician should first determine when the pain started. An acute onset (hours to 1 week) suggests trauma, infection, or crystal-induced arthritis. A history of similar attacks may support a diagnosis of crystal-induced arthritis. Chronic joint pain usually suggests a chronic problem, but the clinician should be careful to note any new features that are unusual to the patient and might signify a concomitant condition (i.e., a septic joint in a patient with rheumatoid arthritis).

The distribution of affected joints and pattern is determined. Monoarthritis involves one joint, oligoarthritis involves two to three joints, and polyarthritis occurs in more than three joints.1 Symmetric involvement that is additive and initially involves the small joints is found in rheumatoid arthritis. Migratory arthritis is consistent with rheumatic fever and gonococcal arthritis.

Next, the patient should be questioned about constitutional symptoms. Fever and weight loss are important signs because they signify systemic illness. Stiffness is usually an indication of synovitis and worsening stiffness after sleep that gradually improves (i.e., gelling) suggests rheumatoid arthritis.2 If the patient complains of weakness, the clinician must differentiate generalized weakness from a focal deficit. Paresthesias may indicate a compressive neuropathy or radiculopathy. Significant muscle pain suggests the possibility of myositis.

### Examination

The clinician should determine whether the source of pain is the joint itself or periarticular structures. Some distinguishing features are listed in Table 3–1.

Table 3–1. Characteristic Features of Injury to Intra-Articular versus Periarticular Structures

Once it has been determined that the joint is the likely source of pain, ascertain whether the joint pain is inflammatory or noninflammatory. Inflammatory conditions, such as septic arthritis and gout, will cause swelling, erythema, and warmth. Tenderness to palpation is noted. Range of motion and the presence of an effusion are documented. The affected joints should be compared to the unaffected side. Although some exceptions exist, patients with inflammatory arthritis found on physical examination should have arthrocentesis performed to rule out septic arthritis.

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