CME INDIA Presentation by Dr. Mahadev Desai, Sr. Consultant Physician K. D. City Centre, Ahmedabad.

A patient having pain around joint may consult

  • Family Physician
  • Consultant Physician
  • Orthopedic Surgeon
  • Rheumatologist


  • Accurate Diagnosis
  • Symptomatic Rx
  • Minimum Investigations
  • Early initiation of Specific Rx based on diagnosis

Important causes of pain around a Joint

Viral lnfection
Rheumatoid Arthritis
Reactive Arthritis
Septic Arthritis
Rheumatic fever  
Psoriatic Arthritis
Ankylosing Spondylitis
Polymyositis / DM
Sjogren’s syndrome
Hemolytic dis.
Bone Disease  

Pattern Recognition

Approach to A Case of Joint Pain

First ask 5 Questions

Is it Articular or Non-articular Pain?
Is it Acute or Chronic (>6 weeks)
Is it Inflammatory or Non-inflammatory?
How many Joints are involved and what is the distribution of Joints involved?
Which Joints are involved?
Approach to A Case of Joint Pain

 2) Is it Acute or Chronic?


  • Infection
  • Gout, Pseudo gout
  • Reactive Arthritis (RA)
  • Initial presentation of
  • Chronic arthritis       

Chronic (>6 weeks)

  • RA, SLE
  • Psoriatic arthritis
  • Reactive Arthritis (RA) 
  • Scleroderma
  • Polymyositis
Approach to A Case of Joint Pain

4) How many joints are involved?

1 joint  Gout, Septic arthritis, RA, Trauma  
> 1-3 joints  Gout, Psoriatic, RA, Pauci articular RA  
≥ 4 joints  RA, SLE, Scleroderma, Polymyositis, Psoriatic

5) What is the distribution of joints involved?

Joint involvement

Symmetric -RA/ SLE

Asymmetric – Psoriatic, RA, SpA

Peripheral and / or Axial?

6) Which Joints are involved?

Approach to A Case of Joint Pain

Additional Points

7) Age

Young  →  RA, SLE, RA  

Middle-aged →  Fibromyalgia

Elderly  →  OA, PMR, Osteoporosis

8) Gender

Female → RA, SLE, Fibromyalgia, Osteoporosis  

Male  → Gout, Spondyloarthropathy

9) Important points in history & examination

  • Fever, Weight Loss
  • Myalgia
  • Skin Rash
  • Tightness of Skin
  • Oral Ulcers
  • Dryness of Mouth, Dry Eye
  • Nail Changes
  • Raynaud’s Phenomenon
  • Hair Loss
  • Dysuria
  • Tendon Involvement
  • Backache

10) Additional points in examination

  • Anemia
  • Hind-Bound Skin
  • Chest Expansion
  • Muscle Tenderness, Tender Points

11) Examination of Joint (s)

  • S/O inflammation
  • ROM
  • Deformity
  • Muscle Wasting
Approach to A Case of Joint Pain

12) Investigations 

  1. CBC, ESR, CRP, Urine analysis
  2. Rheumatoid factor, anti-CCP antibody, ANA, dsDNA, ANA profile…
  3. X-ray of joint(s)
  4. S. Uric acid
  5. Synovial fluid aspiration
  6. S. CPK, ANCA, S. Complement levels, HbsAg, HCV & HIV antibodies
  7. Biopsy – muscle, temporal artery, liver, renal

Rheumatoid Factor (RF)

  • Also used to be called Rose-Waller test
  • Autoantibody, against Fc fragment of IgG
  • Insist to get test (with titer) by IF, Nephelometry or ELISA
  • Two types: IgM (monoclonal), IgG (polyclonal)
  • Titer of >1:40 IgM is diagnostic for RA (sensitivity:28%; specificity 87%, if >1:640 specificity 99%) Higher the titre more destructive the joint damage
  • No need for repeated testing unless initial results
  • Inconclusive in strongly suspected case
  • False positive RF in Malaria, Viral infections, Hepatitis, SLE, Sjogren syndrome, Scleroderma, MCTD, Leukemia
  • Keep in mind: RA can be Seronegative

Anti-Cyclic Citrullinated Peptide (anti CCP) antibodies

(Conversion of amino acid arginine in a protein into amino acid citrulline)

  • Citrullination* of local synovial proteins like fibrin in a joint → CCP
  • Anti-CCP antibodies are potentially important surrogate
  • Markers for diagnosis and prognosis in RA
  • As sensitive as, & more specific than, RF in early & established RA
  • A marker of erosive disease in RA (especially titer>100 U/mL)
  • May be detected in healthy individuals, years before onset of clinical RA
  • Second-generation anti-CCP antibody assays (anti-CCP2), have improved sensitivity and specificity compared with the original anti-CCP1 assays

Anti-Neutrophil Cytoplasmic Antibodies (ANCA)

  • IgG antibodies against antigens in the cytoplasm of neutrophil granulocytes and monocytes → marker of Vasculitis
  • Two types → pANCA & cANCA based on the pattern of staining:  p for perinuclear & c for cytoplasmic
CharacteristicpANCAcANC A
Staining pattern       Perinuclear  Cytoplasmic
Diffusely granular  
Antigen target          Myeloperoxidase proteinase-3 (MPO) Perinuclear (PR3)  
Commonly Present Microscopic polyangiitis glomerulonephritis     Wagner’s granulomatosis

Last Stroke: always remember deceptive conditions

“Great masquerades’ past

  • Syphilis
  • Tuberculosis

“Great masquerades” in modern times

  • Fibromyalgia
  • Lupus
  • Tuberculosis
  • HIV
  • Vasculitis
  • Sarcoidosis
  • Lymphoma

Quick Take-Aways

  • Detailed h/o joint pain, onset & evolution of illness & illness & another s/s.
  • Systematic examination and Pattern recognition.
  • Involved joints are smaller or bigger, Peripheral or Axial etc.
  • Specific investigations (at times by specific methods).
  • Frequent follow up in undiagnosed cases, as many times.
  • s/s of typical disease appear late in the course of the illness.

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