Some Causes of Pain in and Around a Single Joint
Cause | Suggestive Findings | Diagnosis* |
|---|---|---|
Crystal-induced arthritis, usually caused by uric acid crystals (gout) or calcium pyrophosphate crystals (calcium pyrophosphate arthritis) and sometimes by calcium hydroxyapatite crystals | Acute, self-limited, recurrent episodes of monarthritis, most often in the first metatarsophalangeal joint, ankle, or knee (gout) or wrist or knee (calcium pyrophosphate arthritis) Sometimes visible gouty tophi (usually on periarticular structures) | Arthrocentesis with examination for crystals Sometimes ultrasound Sometimes dual energy CT scan Sometimes radiographs for transient hydroxyapatite deposition causing calcific periarthritis |
Hemarthrosis | Acute pain and effusion spontaneously or after trauma Typically, a known bleeding disorder | Arthrocentesis |
Infectious (septic) arthritis (eg, bacterial, fungal, viral, mycobacterial, spirochetal) | Acute or subacute onset of pain, swelling, and warmth, commonly with decreased range of motion More frequent in immunosuppressed patients; patients who inject drugs; patients with diabetes, prior antibiotic use, or risk factors for sexually transmitted infections; and older patients with multiple comorbidities | Arthrocentesis with cell counts, Gram stain, and cultures |
Monarticular or oligoarticular arthritis in later stage of Lyme disease Prior manifestations of Lyme disease, such as erythema migrans, fever, malaise, and/or myalgias following a tick bite in an endemic area | Serologic testing for antibodies against Borrelia burgdorferi | |
Chronic indolent pain with or without swelling, usually in older adults Bony hypertrophy Sometimes obesity, history of joint overuse (eg, in professional athletes), and/or bony enlargement | Radiograph | |
Osteomyelitis adjacent to a joint (uncommon) | Fever and poorly localized pain without joint swelling or erythema | Radiograph plus bone scan, CT, or MRI Bone biopsy with culture |
Osteonecrosis (avascular necrosis) | Often past or current corticosteroid use or sickle cell disease Often asymptomatic in patients with systemic lupus erythematosus | Radiograph plus MRI or CT |
Periarticular disorders (eg, bursitis, epicondylitis, tendinitis, tenosynovitis) | Pain with active or resisted joint movement; minimal pain with passive movement and joint compression Point tenderness and sometimes swelling and/or erythema over the bursa, tendon insertion site, or other periarticular structure (eg, fascia); minimal localized tenderness over joint, no effusion | History and physical examination Sometimes aspiration of bursal fluid for Gram stain, culture, cell count, and crystal analysis |
Psoriatic arthritis (causes oligoarticular or polyarticular pain more often than monoarticular pain) | Usually large joint effusion in the painful joint, often in a patient with psoriasis May occur with dactylitis or enthesitis | History and physical examination Radiograph |
Trauma (eg, sprain, meniscal tear, fracture) | Onset following significant and usually recent trauma | Radiograph Sometimes MRI (eg, if radiograph normal) and/or arthroscopy |
Insidious, slowly progressive, and eventually constant pain, usually with joint swelling | Radiograph plus MRI | |
* Patients with acute joint effusion or inflammation should have arthrocentesis (with cell counts, Gram stain, cultures, and crystal examination), and usually erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Radiographs are often unnecessary. | ||