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  Joint Pain       Introduction      
 
 
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This section looks at sources of pain in and around the major joints in the body (shoulder, elbow, hip, and knee).

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Every adult in the UK over the age of 60 years will have signs of osteoarthritis on their X-rays, but most will have no symptoms. Many people think that joint pain automatically means that "arthritis" is the cause. In many cases this is not true, as the source of pain is coming from outside the joint. It is important to keep an open mind and consider all the possible causes.

Joint Pain Classification
  • Look at the table below for a classification of joint pain by structure, diagnosis and associated pain relief treatments. Please also look at Assessment and Diagnosis.
Pain
Structure
Diagnosis
Treatments
Local Joint Pain
Overlying Muscle
Sprain / Myofascial Pain

Trigger point Injection, Acupuncture, Exercises and Stretches

Overlying Tendon / Tendon Sheath
Tendonitis (Tendinitis)/ Tenosynovitis
Tendon Sheath Injection
Associated Joint Bursa
Bursitis
Bursa Injection, Surgical Drainage / Removal
Joint Ligaments (External and Internal)
Partial or Full Thickness Tear
Prolotherapy (Partial), Surgical Repair (Full)
Joint Capsule (Outer layer)
Capsulitis e.g. Frozen Shoulder / Capsular Tear
Steroid / LA Injection, Joint Mobilisation, Surgical Repair
Joint Synovium (Inner layer), Periosteum (Outer Bone layer)
Arthritis - Osteo, Rheumatoid, Acute, Reactive
Steroid / LA Injection, Ostenil Injection, Joint Mobilisation, Surgical Joint Replacement
Pain
Structure
Diagnosis
Example
Proximal Muscles
Sprain / Myofascial Pain
Quadriceps refers pain to the knee area . Infraspinatus refers pain to the shoulder area
Proximal Joints
All of the above Local Causes

Hip Joint refers pain to the knee area

Nerves
Neuralgia / Sciatica

C5 Nerve in the neck refers pain to the shoulder region. L3 Nerve in the lower back refers pain to the knee area

Spinal Structures
Lower Back Pain, Neck Pain
Vertebrae, Spinal Ligaments and Facet Joint Joints all can refer pain in the appropriate dermatome .

Assessment and Diagnosis

History

  • Diagnostic Triage is essential to exclude serious red flag conditions like HIV, infection, carcinoma, nerve root impairment, bony fracture / collapse.
  • Diagnosis in these red flag cases depends mainly on the history, and therefore questioning should enquire about  recent trauma, constant progressive non-mechanical pain (particularly at night), previous history of cancer, long term oral steroid use, history of drug abuse or HIV, being systemically unwell, recent unexplained weight loss, persisting severe restriction of joint movement, widespread neurological changes, and structural deformity.
  • If many joints are painfully swollen with early morning stiffness, particularly if the pattern is mainly peripheral joints affected symmetrically, then specific blood tests should be performed to exclude rheumatological conditions like Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosis (SLE).
  • If there is a family history of bleeding disorder and a history of an acutely painful swollen joint (especially knees) after minimal trauma, then haemophilia and other coagulation defects should be excluded.

Examination

  • When being examined in the clinic, patients often point to a spot and say "It's just there Doc". However the patient's brain and the examining finger can be deceived by referred pain and referred tenderness. If a segment of the spinal cord becomes sensitised by a painful process, then the whole dermatome will be painful and sensitive to touch, making it difficult to find the exact source of the pain.
  • It is important therefore not just to examine where the patient has indicated the pain is, but to consider all the potential causes of local and referred pain as shown in the tables above.
  • The tissues around a joint can be classified as contractile and non-contractile.
  • Contractile tissues are muscles, tendons, and points where they both attach to bone. Problems with these structures can be revealed by performing a resisted movement test. A resisted movement test is where the patient pulls gently against the examiner with the joint held in mid-range e.g. trying to bend the elbow starting with it bent at 90 degrees.
    • Results and Interpretation
      • Strong and Painless - suggests there is nothing wrong with the contractile structure
      • Strong and Painful - suggests there may be a minor problem with muscle, tendon or its attachment.
      • Weak and Painless - suggests either a complete rupture of muscle / tendon OR impaired nerve function to the muscle involved.
      • Weak and Painful - suggests either a serious problem like a fracture or secondary tumour (rare) OR pain inhibition causing non-compliance with the test i.e. patients do not like to induce severe pain unnecessarily (more common).
      • Painful on Repetition - suggests intermittent claudication (poor blood supply) especially if the resisted movements were very strong initially but fade with repeated testing.
      • All resisted movements hurt - more common with neurosis, but can occur with a severe capsulitis of a more proximal joint.
  • Non-contractile tissues are joint capsule, ligaments, bursae, and fascia. Problems with these structures can be revealed by performing a passive movement test. A passive movement test is where the patient relaxes the part being examined so that the examiner can assess the range and feel of the movements in the joint.
    • Results and Interpretation
      • Nearly All Movements Painful - suggests a capsular pattern (inflammation of the internal lining of the joint capsule). Painful movements may vary between different joints.
      • Only a Few Movements Painful - may suggest internal derangement of the joint e.g. severe arthritis.
      • Only One Movement Painful - may suggest a sprain of a single ligament, and is often associated with more pain at the extreme end of range.
  • Please Note: It is very important for the patient to completely relaxed during passive movement testing. If the patient resists the examiners efforts by contracting muscles due to excessive anxiety, then the examiner will think that the pain is coming from non-contractile structures, when in fact the pain may be coming from contractile structures instead, causing a mis-diagnosis.

Investigations

  • X-rays give information about calcium containing structures like bones. They are useful for diagnosing fractures, subluxations (displacements), and tumours. Cartilage height can be inferred from the empty gap between two bones e.g. hip and knee joint. They do not give any information about the function of, or pain coming from soft tissues like muscles, tendons, ligaments, and bursae. As most joint pain arises from soft tissues, X-rays therefore have limited use except to tell the patient they haven't got a fracture or a tumour. There is mostly poor correlation between pain severity and the degree of structural change on an X-ray (excluding carcinoma and fractures).
  • MRI scans can provide more information about the soft tissues in and around a joint. They can pick up rotator cuff, ligament, and tendon tears, as well as inflammation in relation to tendons.
  • Bone scans can provide information about disease processes which cause an increased blood flow to bones e.g. arthritis, inflammation, bone cancer deposits, osteoporotic vertebral fractures.
  • Bone Densitometry (DEXA) scans provide information about osteoporosis by looking at bone thickness in the hip (neck of femur) and spine (L4 vertebra).
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