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 x-rays 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, IV drug users, patients with diabetes or prior antibiotic use, and patients with risk factors for sexually transmitted infections | 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 | X-ray | |
Osteomyelitis adjacent to a joint (uncommon) | Fever and poorly localized pain without joint swelling or erythema | X-ray plus bone scan, CT, or MRI Bone biopsy with culture |
Osteonecrosis (avascular necrosis) | Often past or current corticosteroid use or sickle cell disease | X-ray Usually MRI |
Periarticular disorders (eg, bursitis, epicondylitis, fasciitis, tendinitis, tenosynovitis) | Pain with active 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 | Clinical evaluation Sometimes aspiration of bursal fluid for Gram stain, cell count, crystal analysis, and culture |
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 | Clinical evaluation X-ray |
Trauma (eg, sprain, meniscal tear, fracture) | Onset following significant and usually recent trauma | X-ray Sometimes MRI (eg, if x-ray normal) and/or arthroscopy |
Insidious, slowly progressive, and eventually constant pain, usually with joint swelling | X-ray MRI | |
* Patients with 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. X-rays are often unnecessary. | ||