What are the diagnostic and management approaches for arthralgia?

From the Guidelines

Arthralgia diagnosis and management approaches should primarily involve a patient-centered framework, with a focus on early referral to a rheumatologist, clinical examination, and the use of ultrasonography to confirm arthritis.

Key Diagnostic Approaches

• Clinical examination is the method of choice for detecting arthritis, which may be confirmed by ultrasonography 1
• Assessment of patient needs, preferences, and priorities, as well as pain characteristics, previous and ongoing pain treatments, inflammation, and joint damage, should guide treatment decisions 1

Key Management Approaches

• Non-pharmacological interventions, such as dynamic exercises, occupational therapy, patient education, and weight management, should be considered as adjuncts to drug treatment 1
• Pharmacological treatment options typically include NSAIDs, systemic glucocorticoids, and DMARDs, with methotrexate considered the anchor drug 1
• Pain management should be guided by a biopsychosocial perspective, with consideration of local and generalized pain, and the use of treatment modalities such as physical activity, exercise, orthotics, and psychological interventions 1

Important Considerations

• Early referral to a rheumatologist is crucial for patients presenting with arthritis, with the goal of confirming the presence of arthritis, determining the diagnosis and prognosis, and initiating appropriate treatment strategies 1
• Regular monitoring of disease activity, adverse events, and comorbidities should guide decisions on choice and changes in treatment strategies 1
• Patient education and shared decision-making are essential components of the management of early arthritis 1

From the Research

Diagnostic Approaches for Arthralgia

• The initial evaluation of arthralgia should include 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 2.
• 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 2.
• Laboratory tests, joint aspiration, and imaging studies should be used to confirm a suspected diagnosis 2.
• Rheumatoid factor and cyclic citrullinated peptide antibody tests are helpful when there is concern for rheumatoid arthritis 2.
• Point-of-care musculoskeletal ultrasonography can also be a useful tool to detect findings that support a diagnosis of inflammatory arthritis 2.

Management Approaches for Arthralgia

• The cornerstones of osteoarthritis (OA) management include exercises, weight loss if appropriate, and education-complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications 3.
• Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy in OA management 3.
• Opiates should be avoided in OA management 3.
• Clinical trials have shown promising results for compounds that arrest structural progression or reduce OA pain 3.
• Persons with advanced symptoms and structural damage are candidates for total joint replacement 3.
• For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery 4.
• Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears, while surgery is likely required for severe traumatic tears 4.

Use of Algorithms in Diagnostic Approach

• An algorithm can help improve the misdiagnosis problem of joint pain patients by primary care physicians 5.
• The use of an algorithm can increase the proportion of correct diagnoses and decrease the number of tests requested in the development of clinical cases 5.
• The diagnostic algorithm proved to be an effective tool when used by primary care physicians, with a greater difference in cases of spondyloarthritis, systemic lupus erythematosus with joint involvement, rheumatoid arthritis, and osteoarthritis 5.

Importance of Early Diagnosis

• Early diagnosis is crucial in polyarthralgia, and clinical assessment is the most important factor in making a diagnosis 6.
• Early intervention, regardless of aetiology, is the key to successful management of polyarthralgia 6.
• Treatment is likely to be a combination of lifestyle modification, physical therapy, and medication, and this combined approach is most likely to negate the disability and chronic ill-health traditionally seen in patients with polyarthralgia 6.