What is the management approach for a patient with polyarthralgia (multiple joint pains) for 1 month?

Management of Polyarthralgia for 1 Month

Begin with a systematic clinical assessment to differentiate inflammatory from non-inflammatory causes, as this distinction fundamentally determines treatment strategy and urgency of intervention. 1

Initial Clinical Assessment

Key Historical Features to Elicit

• Pattern of joint involvement: Determine if pain affects large joints (knees, ankles, wrists) versus small joints (fingers, toes), and whether distribution is symmetrical or asymmetrical 1
• Presence of true inflammation: Ask specifically about joint swelling, redness, warmth, and morning stiffness lasting >30-60 minutes (suggests inflammatory arthritis) 1, 2
• Systemic symptoms: Fever, weight loss, fatigue, rash, dry eyes/mouth, or urethritis point toward specific rheumatologic conditions 1
• Medication history: Recent initiation of immune checkpoint inhibitors, statins, or other drugs that can cause arthralgia 1
• Functional impact: Assess disability in activities of daily living, mobility limitations, and sleep disturbance 1

Physical Examination Priorities

• Palpate all peripheral joints for tenderness, swelling, warmth, and range of motion to identify true synovitis versus bony hypertrophy 1, 2
• Distinguish inflammatory synovitis (palpable joint swelling, warmth) from osteoarthritis (bony crepitus, hypertrophy without warmth) 2
• Assess muscle strength in proximal extremities to exclude myositis or polymyalgia-like syndromes 1

Diagnostic Workup

Essential Laboratory Tests

• Inflammatory markers: ESR and CRP are elevated in inflammatory arthritis and help differentiate from mechanical causes 1, 2
• Complete blood count, urinalysis, metabolic panel: Often more diagnostically useful than classic rheumatologic tests 2
• Rheumatoid factor and anti-CCP antibodies: Order when symmetrical polyarthritis resembling rheumatoid arthritis is suspected 1, 3
• Creatine kinase: To exclude myositis if proximal muscle pain or weakness is present 1

Imaging Considerations

• Plain radiographs remain the standard initial imaging for suspected inflammatory arthritis, though early disease may show only nonspecific changes 3, 2
• Musculoskeletal ultrasound can detect synovitis and effusions at point-of-care when available 3
• MRI is highly sensitive for erosive changes and inflammation but reserved for specific indications 1, 3

Treatment Algorithm

Step 1: Address Underlying Inflammation

If inflammatory markers are elevated and synovitis is present, optimize disease control or refer urgently to rheumatology 1. Early intervention within the first few months is crucial to prevent disability and chronic ill-health 4.

Step 2: First-Line Symptomatic Management

• NSAIDs as adjunct therapy: Naproxen 500 mg twice daily or equivalent, though NSAIDs alone are usually insufficient for inflammatory arthritis 1, 5
• Intra-articular corticosteroid injections: Use triamcinolone hexacetonide (preferred over triamcinolone acetonide) if only 1-2 joints are affected 1
• Avoid chronic oral corticosteroids: Short-term bridging therapy (<3 months) may be considered for high disease activity with significant mobility limitation, but chronic low-dose steroids are strongly contraindicated 1

Step 3: Physical and Occupational Therapy

For patients with or at risk for functional limitations, initiate physical therapy and/or occupational therapy 1. This includes:

• Strengthening exercises to preserve joint mobility 1
• Education on joint protection techniques and ergonomic adaptations 1
• Assistive devices (canes, orthotics) fitted by occupational therapist when indicated 1

Step 4: Address Pain-Related Factors

• Psychological support: If psychological distress, catastrophizing, or fear-avoidance behaviors are present, refer for cognitive behavioral therapy or self-management programs 1
• Sleep interventions: Provide education on sleep hygiene if sleep disturbance is reported; refer to specialized sleep clinic if severely disturbed 1
• Weight management: If obesity is present, discuss weight loss as it contributes to pain and disability; refer to dietitian or weight management services 1

Step 5: Escalation for Refractory Cases

If symptoms persist despite initial management, consider:

• Systemic DMARDs: Methotrexate is preferred over leflunomide or sulfasalazine for inflammatory polyarthritis 1
• Multidisciplinary treatment: When multiple interventions are needed or monotherapy fails 1
• Pharmacological pain management: Follow disease-specific guidelines for analgesics, considering topical agents (lidocaine patches, topical NSAIDs) for localized pain 1, 6

Critical Pitfalls to Avoid

• Do not delay rheumatology referral if inflammatory arthritis is suspected—early treatment prevents irreversible joint damage 4, 3
• Do not miss septic arthritis: Any single hot, swollen joint requires urgent arthrocentesis to exclude infection 1
• Do not overlook endocrine causes: Isolated ACTH deficiency can present with polyarthralgia, fever, and elevated inflammatory markers 7
• Do not use NSAIDs as monotherapy for inflammatory arthritis—they provide symptomatic relief only and do not modify disease 1
• Do not prescribe chronic corticosteroids regardless of disease activity due to long-term harm 1

Special Considerations

For patients on immune checkpoint inhibitors: Musculoskeletal symptoms occur in up to 40% of patients; inflammatory markers are typically very elevated, and corticosteroids or DMARDs may be required 1

For viral or self-limited causes: Acute polyarthritis from viral infections, crystal disease, or serum sickness typically resolves spontaneously, but chronic arthritides may present acutely and must be considered 2