What is the approach to diagnosing and managing joint pain (arthralgia) in internal medicine?

From the Guidelines

The approach to diagnosing and managing joint pain (arthralgia) in internal medicine involves a patient-centered framework, considering both the biological and psychological aspects of pain, and should be guided by a multidisciplinary approach.

Key Principles

• Early referral to a rheumatologist, ideally within 6 weeks after the onset of symptoms, is recommended for patients presenting with arthritis of more than one joint 1.
• Clinical examination is the primary method for detecting synovitis, with ultrasound, power Doppler, and MRI used in doubtful cases 1.
• Laboratory tests, including complete blood cell count, urinary analysis, transaminases, and antinuclear antibodies, are essential for excluding diseases other than rheumatoid arthritis 1.

Management

• DMARDs, such as methotrexate, should be started as early as possible in patients at risk of developing persistent or erosive arthritis, even if they do not fulfill established classification criteria for inflammatory rheumatological diseases 1.
• NSAIDs can be used for symptomatic relief, but should be used at the minimum effective dose for the shortest time possible, after evaluating gastrointestinal, renal, and cardiovascular risks 1.
• Systemic glucocorticoids can reduce pain and swelling, but should be used at the lowest dose necessary as temporary adjunctive treatment 1.
• Non-pharmacological interventions, such as dynamic exercises, occupational therapy, and hydrotherapy, can be applied as adjuncts to pharmaceutical interventions in patients with early arthritis 1.

Monitoring

• Disease activity should be monitored regularly, including tender and swollen joint counts, patient and physician global assessments, ESR, and CRP, with the goal of achieving clinical remission 1.
• Radiographic and patient-reported outcome measures, such as functional assessments, can be used to complement disease activity monitoring 1.

Pain Management

• Patient-centered pain management is essential, considering the biological, psychological, and social factors that contribute to pain, and should be guided by a biopsychosocial perspective 1.
• Physical activity and exercise interventions, as well as psychological interventions, have been shown to have positive effects on pain reduction in patients with inflammatory arthritis and osteoarthritis 1.

From the Research

Approach to Diagnosing Joint Pain

• The evaluation of patients with joint pain begins during the medical history and physical examination, when the differential diagnosis can often be narrowed to a few likely possibilities 2.
• A detailed history of the patient's symptoms, with a focus on inflammation, location of pain, duration of symptoms, the presence of systemic symptoms, and any exposures to pathogens that could cause arthritis, is essential 3.
• A systematic approach to the physical examination that assesses for a pattern of joint involvement and presence of synovitis can help narrow the differential diagnosis 3.

Laboratory Tests and Imaging

• Laboratory tests for rheumatologic problems lack the sensitivity and specificity to allow their use as screening tools, and should be used selectively in patients with a clinically significant likelihood of disease 2.
• Laboratory tests, such as rheumatoid factor and cyclic citrullinated peptide antibody tests, can be helpful when there is concern for rheumatoid arthritis 3.
• Imaging studies, such as conventional radiography and magnetic resonance imaging, can be used to confirm a suspected diagnosis and identify erosive bony changes and inflammation 3.
• Point-of-care musculoskeletal ultrasonography can also be a useful tool to detect findings that support a diagnosis of inflammatory arthritis 3.

Management of Joint Pain

• Many patients with joint pain have mild, self-limited symptoms that are best managed conservatively 2.
• Treatment of joint pain consists of both pharmacologic and nonpharmacologic modalities, including medications specific for pain, inflammation, and adjuncts specific to the diagnosis 4.
• Nonpharmacologic therapies, such as protection, rest, ice, compression, elevation, and simple office procedures, can also be effective in managing joint pain 4.
• Physical therapy and education can assist in the recovery process and prevent recurrence 4.