Some Causes of Pain in ≤ 4 Joints
Cause | Suggestive Findings | Diagnosis* |
|---|---|---|
Usually axial pain and stiffness, worse in the morning and relieved with activity Sometimes effusions in large peripheral joints Sometimes extra-articular manifestations (eg, uveitis, enthesitis, aortic insufficiency) More common among young adult males | Lumbosacral spine x-ray Sometimes MRI or CT, blood tests (erythrocyte sedimentation rate, C-reactive protein, and complete blood count), and/or specific (modified New York) clinical criteria | |
Arthralgia or arthritis Extra-articular manifestations, such as recurrent oral and/or genital lesions, or uveitis Usually begins during a person's 20s | Specific (international) clinical criteria | |
Crystal-induced arthritis‡, typically caused by uric acid crystals (gout), calcium pyrophosphate crystals (calcium pyrophosphate arthritis), or calcium hydroxyapatite crystals | Acute onset of arthritis with joint warmth and swelling May be clinically indistinguishable from infectious bacterial (septic) arthritis Sometimes fever | Arthrocentesis |
Arthralgia or arthritis Systemic symptoms, such as fever, night sweats, rash, weight loss, heart murmur | Blood cultures Echocardiography | |
Chronic pain more commonly affecting the base of the thumbs, PIP and DIP joints, knees, and hips Sometimes Heberden and/or Bouchard nodes | X-rays | |
Reactive arthritis and enteropathic arthritis† | Arthritis that is asymmetric and more common in large lower extremity joints Reactive arthritis: Gastrointestinal or genitourinary infection present 1–3 weeks before onset of acute arthritis Enteropathic arthritis: Coexisting gastrointestinal condition (eg, inflammatory bowel disease, intestinal bypass surgery) with a chronic arthritis | Clinical evaluation Testing for STIs as clinically indicated |
* Patients with acute joint effusion with inflammation should have arthrocentesis (with cell counts, Gram stain, cultures, and crystal examination), and usually erythrocyte sedimentation rate (ESR) and C-reactive protein. X-rays are often not helpful early in the disease course. | ||
† These disorders can manifest with axial involvement. | ||
‡ Crystal-induced arthritis is most often monoarticular but sometimes oligo- or polyarticular. | ||
DIP = distal interphalangeal; PIP = proximal interphalangeal. | ||