What is the initial workup and treatment for a patient presenting with joint pain?

Initial Workup and Treatment for Joint Pain

The initial workup for joint pain should include a thorough clinical examination to detect synovitis, followed by laboratory tests including complete blood count, urinary analysis, transaminases, and antinuclear antibodies, with patients presenting with arthritis of more than one joint being referred to a rheumatologist within six weeks of symptom onset. 1

Initial Assessment

Clinical Examination

• Look for joint swelling associated with pain or stiffness
• Assess number of swollen and tender joints
• Check for morning stiffness duration (>30 minutes suggests inflammatory arthritis)
• Evaluate metacarpophalangeal and metatarsophalangeal joint involvement
• Use "squeeze test" on hands and feet to detect joint involvement 1
• For doubtful cases, consider ultrasound, power Doppler, or MRI to detect synovitis 1

Laboratory Testing

• Complete blood cell count
• Urinary analysis
• Transaminases
• Antinuclear antibodies
• ESR or CRP
• Rheumatoid factor and anti-CCP antibodies 1

Imaging

• Plain radiographs to assess for structural damage and exclude other causes
• Consider more advanced imaging (ultrasound, MRI) if clinical examination is inconclusive 1

Treatment Approach

Non-Pharmacological Interventions

1. Patient education about the disease, treatment options, and self-management strategies 1
2. Exercise therapy - strongly recommended for all types of arthritis:
   • Aerobic exercise
   • Strength and resistance training
   • Neuromuscular training for knee problems
   • Aquatic exercise for low-impact options 2
3. Weight management for overweight patients, especially with knee or hip involvement 2
4. Physical therapy focusing on:
   • Restoring flexibility
   • Building strength
   • Core strengthening exercises 2

Pharmacological Treatment

First-Line Therapy

• Paracetamol (acetaminophen) up to 4000 mg/day as initial treatment 1, 2
• Topical NSAIDs for localized joint pain to minimize systemic exposure 2

Second-Line Therapy

• Oral NSAIDs after evaluation of gastrointestinal, renal, and cardiovascular status 1, 2
• Use lowest effective dose for shortest possible duration 2
• Consider adding proton pump inhibitor for GI protection 2

For Inflammatory Arthritis

• Systemic glucocorticoids for temporary relief of inflammation 1
• Intra-articular glucocorticoid injections for localized symptoms 1
• Disease-modifying antirheumatic drugs (DMARDs) for patients at risk of persistent or erosive arthritis 1
• Methotrexate is considered the anchor drug for persistent inflammatory arthritis 1, 3

Specific Treatment Algorithms

For Osteoarthritis

1. Start with paracetamol/acetaminophen (up to 3000-4000 mg/day)
2. If inadequate response, add or switch to topical NSAIDs
3. If still inadequate, consider oral NSAIDs at lowest effective dose
4. Consider intra-articular corticosteroid injections for single joint involvement 1, 2

For Inflammatory Arthritis

1. Refer to rheumatologist within 6 weeks of symptom onset
2. Start NSAIDs for symptomatic relief
3. Consider short-term systemic glucocorticoids
4. Initiate DMARDs early in patients at risk for persistent disease
5. Methotrexate is the preferred initial DMARD 1, 3

Monitoring and Follow-up

• Monitor disease activity every 1-3 months until remission is achieved
• Assessment should include:
  • Tender and swollen joint counts
  • Patient's and physician's global assessments
  • ESR and CRP
  • Functional assessment
• Structural damage should be assessed by radiographs every 6-12 months during first few years 1

Common Pitfalls to Avoid

1. Delayed referral - patients with arthritis of more than one joint should be referred to a rheumatologist within six weeks 1
2. Overreliance on medications without implementing exercise and weight management 2
3. Using oral NSAIDs as first-line therapy instead of topical treatments, increasing risk of adverse effects 2
4. Neglecting non-pharmacological approaches such as exercise therapy, which is essential for most joint conditions 2
5. Failing to start DMARDs early in patients at risk for persistent inflammatory arthritis 1

Early diagnosis and treatment are critical to prevent joint damage and disability. The main goal of treatment should be to achieve remission or low disease activity, improve function, and enhance quality of life.