What is the workup for worsening body stiffness and pain with movement?

Workup for Worsening Body Stiffness and Pain with Movement

Begin by systematically assessing for musculoskeletal versus inflammatory versus vascular etiologies through targeted history, focused physical examination findings, and specific laboratory and imaging studies based on the clinical presentation.

Initial Clinical Assessment

Key Historical Features to Elicit

• Pattern of stiffness: Morning stiffness lasting >30-60 minutes suggests inflammatory arthritis; brief stiffness (<30 minutes) suggests mechanical/degenerative causes 1
• Pain characteristics: Velocity-dependent pain with movement suggests spasticity; rest pain suggests vascular insufficiency 1, 2
• Distribution: Axial (spine) involvement suggests ankylosing spondylitis; peripheral joint involvement suggests rheumatoid or psoriatic arthritis 1
• Associated symptoms: Skin changes (psoriasis), gastrointestinal symptoms (inflammatory bowel disease), or neurological deficits 1
• Medication history: Aromatase inhibitors in breast cancer survivors cause arthralgias/myalgias in up to 50% of patients 1

Critical Physical Examination Findings

• Vascular assessment: Pulse palpation in all extremities, auscultation for femoral bruits, bilateral arm blood pressure measurements (>15-20 mmHg difference suggests subclavian stenosis) 2
• Joint examination: Assess for warmth, effusion, range of motion limitations, and contractures 1
• Spinal mobility: Measure chest expansion, Schober's test, and cervical rotation for axial involvement 1
• Neurological examination: Assess for upper motor neuron signs if spasticity suspected 1

Diagnostic Testing Algorithm

First-Line Laboratory Studies

• Inflammatory markers: ESR and CRP to assess for active inflammation 1
• Creatine kinase (CK): Elevated levels suggest inflammatory myositis 2
• Complete metabolic panel: Assess renal and hepatic function before initiating NSAIDs 1

Vascular Studies (if claudication or limb weakness present)

• Ankle-brachial index (ABI): Initial diagnostic test for peripheral arterial disease; ABI <0.90 confirms diagnosis 2
• Urgent vascular surgery consultation: Required if acute limb ischemia suspected (medical emergency) 2

Imaging Studies

• Plain radiographs: Assess for joint space narrowing, erosions, or sacroiliitis in inflammatory arthritis 1, 3
• MRI: Consider for suspected spinal involvement, soft tissue pathology, or early inflammatory changes not visible on x-ray 1
• DEXA scan: If on aromatase inhibitors or other medications causing bone loss 1

Management Based on Etiology

For Inflammatory Arthritis (Ankylosing Spondylitis, Rheumatoid Arthritis)

NSAIDs are first-line pharmacologic treatment for pain and stiffness, with continuous rather than on-demand dosing showing superior outcomes 1:

• Start with continuous NSAID therapy (e.g., celecoxib, naproxen) rather than intermittent use 1
• For patients with GI risk factors: use selective COX-2 inhibitors or non-selective NSAIDs plus gastroprotective agents 1
• Consider cardiovascular risk profile when selecting NSAIDs, as both coxibs and traditional NSAIDs carry cardiovascular risks 1

Non-Pharmacologic Interventions (Essential for All Patients)

Regular exercise and physical therapy are as important as medications and should be initiated immediately 1:

• Home exercise programs: Daily stretching when pain/stiffness minimal, holding stretches 10-30 seconds 1
• Supervised group physiotherapy: Superior to home exercise alone for patient global assessment, though not necessarily for pain reduction 1
• Isotonic strengthening exercises: Preferred over isometric for functional improvement 1
• Warm-up and cool-down: 5-10 minutes each, with static stretching during cool-down 1

For Spasticity-Related Stiffness (Post-Stroke, Neurological)

Use a stepwise approach starting with positioning and range of motion, progressing to oral antispasmodics only if causing pain, poor hygiene, or decreased function 1:

• First-line: Positioning, passive stretching, range of motion exercises several times daily 1
• Oral medications (if conservative measures fail): Tizanidine or baclofen preferred; avoid benzodiazepines due to deleterious effects on recovery 1
• Botulinum toxin or phenol: For selected patients with disabling or painful spasticity 1
• Intrathecal baclofen: For chronic cases with severe spasticity 1

For Musculoskeletal Pain (Osteoarthritis, Soft Tissue Injury)

Acetaminophen is first-line for mild-to-moderate pain; NSAIDs for inadequate response 4, 5:

• Acetaminophen: Up to 3-4 grams daily (reduce dose in hepatic disease, malnutrition, or alcohol use disorder) 4, 5
• Topical NSAIDs: Recommended for non-low back musculoskeletal injuries 5
• Oral NSAIDs: If acetaminophen inadequate; use lowest effective dose for shortest duration 5, 6
• Tramadol: Consider for patients with inadequate relief from acetaminophen who are at risk for NSAID complications 4, 5

For Aromatase Inhibitor-Associated Musculoskeletal Symptoms

Assess at each clinical encounter and offer acupuncture, physical activity, or physical therapy referral 1:

• These symptoms affect up to 50% of patients and cause 20% to discontinue therapy 1
• If intolerable: switch to different aromatase inhibitor (40% tolerate alternative) or tamoxifen 1
• NSAIDs and acetaminophen often ineffective for this specific etiology 1

Common Pitfalls to Avoid

• Do not use diazepam or benzodiazepines in stroke recovery patients due to negative effects on neurological recovery 1
• Do not combine SERMs with aromatase inhibitors for osteoporosis prevention, as this blunts breast cancer recurrence reduction 1
• Do not prescribe NSAIDs without assessing GI, cardiovascular, and renal risk factors 1, 5
• Do not delay vascular surgery consultation if acute limb ischemia suspected—this is a limb-threatening emergency 2
• Do not overlook medication-induced causes: Aromatase inhibitors, statins, and other medications commonly cause musculoskeletal symptoms 1

When to Escalate Care

• Immediate vascular surgery referral: Acute limb ischemia with salvageable limb 2
• Rheumatology referral: Persistent inflammatory symptoms despite NSAIDs, elevated inflammatory markers, or radiographic erosions 1
• Physical medicine and rehabilitation: Severe functional impairment, spasticity requiring advanced interventions, or need for orthotics 1
• Multidisciplinary pain management: If psychosocial factors (catastrophizing, fear of movement) impede recovery 1