From the Guidelines
The approach to diagnosing and managing joint pain as an Internal Medicine (IM) resident should be guided by a patient-centered framework, considering multiple biological, psychological, and social factors.
Key Principles
- The health professional should have basic knowledge of the pathology, treatment, and sequelae of inflammatory arthritis and osteoarthritis 1.
- Assessment and treatment should be guided by a patient-centered framework, considering factors such as pain severity, physical disability, resilience, and social factors 1.
- It is essential to differentiate between localized and generalized pain, as these types of pain may coexist 1.
Assessment
- Assessment should include the patient's needs, preferences, and priorities regarding pain management, as well as pain characteristics, previous treatments, and perceived efficacy 1.
- Current inflammation and joint damage should be assessed as sources of pain, and whether these are adequately treated 1.
- Pain-related factors that may need attention include pain-related disability, beliefs and emotions about pain, social influences, sleep problems, and obesity 1.
Management
- In case of poorly controlled inflammation, disease control should be optimized or referral to a rheumatologist considered 1.
- For localized (nociceptive) pain related to osteoarthritis, joint-specific treatments should be considered in line with recommendations 1.
- Non-pharmacological interventions, such as dynamic exercises, occupational therapy, and hydrotherapy, can be applied as adjuncts to pharmaceutical interventions 1.
- Monitoring of disease activity should include tender and swollen joint count, patient's and physician's global assessments, ESR, and CRP, with regular assessment of arthritis activity and structural damage 1.
Referral to Rheumatologist
- Patients presenting with arthritis of more than one joint should be referred to, and seen by, a rheumatologist, ideally within six weeks after the onset of symptoms 1.
- Referral to a rheumatologist should be considered in cases of poorly controlled inflammation or when the diagnosis is uncertain 1.
From the Research
Diagnostic Approach
The approach to diagnosing joint pain involves a combination of history, physical examination, and simple laboratory tests 2, 3. A diagnostic algorithm can be used to support primary care physicians in the clinical approach to patients with joint pain, improving the correct diagnosis and reducing the number of paraclinical tests requested 4, 5.
Key Components of Diagnosis
- History: careful history taking to identify symptoms and signs related to joint pain 2, 3
- Physical examination: thorough physical examination to identify signs of joint inflammation or damage 2, 3
- Laboratory tests: simple laboratory tests such as blood counts and inflammatory markers to support diagnosis 2, 6
- Diagnostic imaging: use of diagnostic imaging such as X-rays or MRI to evaluate joint damage or inflammation 6
Management of Joint Pain
The management of joint pain involves a step-wise approach, including:
- Pharmacologic therapies: medications specific for pain, inflammation, and adjuncts specific to the diagnosis 6
- Nonpharmacologic therapies: protection, rest, ice, compression, elevation, and simple office procedures 6
- Physical therapy and education: to assist in the recovery process and prevent recurrence 6
Effectiveness of Diagnostic Algorithm
The use of a diagnostic algorithm has been shown to improve the proportion of correct diagnoses and reduce the number of tests requested in the development of clinical cases 5. The algorithm proved to be an effective tool when used by primary care physicians, with a significant increase in correct diagnoses and a decrease in the number of tests requested.