Joint Pain

Victor Febriant 07120120116

Pembimbing:
dr. Euphemia, SpPD
 Definition
Arthralgia (from Greek arthro- +
algos) is a symptom of injury,
infection, illnesses or an allergic
reaction to medication
Arthritis -> term should be used
when the condition is inflammatory
 Pathophysiology
Arise from structures within or adjacent to
the joint or referred from more distant
sites
Basic pathophysiologic types of joint
disease include:
Synovitis
Enthesopathy
Crystal Deposition
Infection
Structural or Mechanical Derangements
 Synovitis
Synovial membrane -> principal site of
inflammation
Characterized by:
Neovascularization
Infiltration of the synovium with lymphocytes,
plasma cells, and macrophages
Synovial lining cell hyperplasia
Causes synovial proliferation -> manifested by
warmth, tenderness, and boggy (lembek)
consistency of the soft tissue overlying the
joint
 Enthesitis
Transitional zone where tendons and
ligaments are attached to the bone
Inflammation -> collagen fibers
undergo metaplasia, forming fibrous
bone
Results in new bone formation
(periostitis) ossification of
syndesmoses, and syndesmophyte
formation
 Crystal Deposition
Deposition of crystals lead to symptomatic joint disease
Responsible crystals
Monosodium urate, calcium pyrophosphate dihydrate,
calcium phosphate, calcium oxalate
Monosodium urate crystal deposits on the surface of
hyaline cartilage, within synovium, tendon sheaths and
bursae
Inflammation realted to urate crystal deposits may be
localized to a bursa or tendon sheath on a joint or
widespread in multiple joints
Acute phase: inflamed, with erythema, warmth or both
Prominent periarticular inflammation may resemble
cellulitis
 Crystal Deposition
Calcium pyrophosphate crystal
deposition is confined to hyaline
cartilage, fibrocartilate and areas of
chondroid metaplasia (degenerated
areas of tendons, ligaments and the
joint capsule)
This may trigger an acute
inflammatory arthritis -> Pseudogout
 Infectious Arthritis
Synovium -> site of acute of chronic
infections related to bacterial, fungal or
viral organisms
Cardinal pathologic findings
Infiltration by neutrophils with necrosis of the
synovium
Formation of granulation and scar tissue
Dense mass of fibrin infiltrated by neutrophils
Bacterial products released may cause rapid
cartilage destruction
 Structural or Mechanical Joint
Derangement
Degeneration of articular cartilage ->
OA
Previous joint trauma (e.g. Meniscal
Tears)
Congenital or developmental joint
alteration (Congenital hip dysplasia)
Alterations of subchondral bone
(osteopetrosis, avascular necrosis, Paget
disease_
Alteration of supporting structures
(hypermobility)
 History Taking
Symptoms
Pain (referred pain, autonomic pain)
Stiffness
Swelling
Deformity
Weakness
Instability
Change in Sensibility
Loss of Function
 History Taking
Previous Disorders
Family History
Social Background (Work, travel,
home, etc)
 History Taking
Pain
Location (Referred/Autonomic)
Referred
Deep structures are more diffuse and
distribution is s/times unexpected eg. Hip
disease may manifest as pain in the knee
Due to inability of cerebral cortex to distinguish
between sensory messages from
embryologically related sites
Autonomic
Does not fit the usual pattern
 History Taking
Stiffness
Generalized / Localized
Timing (Morning -> RA) (Transient ->
OA)
Locking (Present/Not)
Sudden inability to complete movement
e.g. due to a torn meniscus trapped between
articular surfaces
 History Taking
Swelling
Rapid (Hematoma/Hemarthrosis) or
Slowly (tissue/joint inflammation or joint
effusion)?
Painful (acute inflammation/infection) or
comes and goes?
Size (Increasing/not)
 History Taking
Deformity
Shape
Progressive
One side or both?
Weakness
Duration
Muscle group
 History Taking
Instability
The joint gives way or Jumps out
Suggests ligamentous deficiency, recurrent
subluxation or internal derangement
Change in Sensibility
Tingling or numbness
Loss of Function
I cant sit for long -> backache
I cant put my socks on -> stiff hip
 History Taking
Previous Disorders
Accidents, Illnesses, Operations, etc.
Family History
Musculoskeletal problems in the family
Social Background
Work, home circumstances, etc.
 Physical Examination
Look
Feel
Move
Special Test
 Look
Shape, Posture, Gait
Scars, Discoloration
Swelling, Wasting, Lump, Local
Deformity
Local posture
 Feel
Skin: Warm or cold? Moist or dry? Is
the sensation normal?
Soft tissues: Lump? Pulse
(Normal/Irregular)
Bones and Joints: Outlines (Normal or
not), Excessive fluids?
Tenderness: Location, Present/Not
 Move
Active Movement
Assess Power
Passive Movement
Assess for pain or crepitus
Abnormal Movement
Assess Stability
 Joint Deformities
Varus and valgus -> knee
Kyphosis and lordosis -> spine
Scoliosis -> spine
 Diagnostic Imaging
Plain Film Radiography
Computed Tomography (CT)
Magnetic Resonance Imaging
Diagnostic Ultrasound
 Plain Film Radiography
Normally requested at least two views ->
to distinguish positions
How to read:
Patient Identity
Soft Tissues -> wasting or swelling, changes
in tissue density
Bones -> textures, shape, deformity,
density, vacant areas (radiolucent)
Joints -> narrowing of space, osteophytes,
erosion
 Differential Diagnoses

Joint Pain

Monoarthriti
Polyarthritis
s

Inflammatory Non-Inflammatory Acute Chronic

Rheumatic
Acute Chronic Acute Chronic Non-
Fever Inflammatory
Inflammatory
Gonococcal
Osteoarthrit Arthritis
is Polyarticular
Ischemic Gout
Necrosis Polyarticular
Pseudogout Rheumatoid
Septic Hemarthros Viral Arthritis Arthritis
Arthritis Juxta- is Bacterial SLE Osteoarthritis
Septic Lyme articular Paget Endocarditis Viral Arthritis Hemochromat
Arthritis Disease Disease Rheumatoid Psoriatic osis
Gout fracture Arthritis Arthritis
Crystalline Stress Ochronosis
Pseudogout Synovitis Trauma Fracture Still Disease Reactive Hypertrophic
Hemarthr SLE Arthritis pulmonary
Systemic Rheumatoid Osteomyelit Reactive Enteropathis osteoarthropa
Rheumatic Arthritis osis is Arthritis Arthropathies thy
Disease Systemic Osteonecr Osteosarco Acute Sarcoid Behcets Amyloidosis
Rheumatic Arthritis Disease
osis ma Acromegaly
Disease Mediterranean Ankylosis
Metastatic Fever Spondylitis
tumor Enteropathis
Synovial Arthropathies
Osteochond
romatosis
 Treatment
Pain Relief (NSAID, COX-2 Inhibitor,
Opioid)
Restoration or maintenance of joint
function
Prevention of joint damage