What is the diagnosis for a patient with bilateral joint pain, wrist pain, elbow pain, and intermittent left flank and back pain?

Differential Diagnosis for Bilateral Joint Pain with Wrist, Elbow, and Flank/Back Pain

This constellation of bilateral joint pain affecting multiple sites (wrists, elbows) combined with axial symptoms (flank and back pain) strongly suggests a systemic inflammatory arthropathy, most likely rheumatoid arthritis or seronegative spondyloarthropathy, rather than isolated mechanical joint pathology.

Initial Diagnostic Workup

Immediate Imaging

• Obtain radiographs of bilateral hands, wrists, and elbows immediately as the best initial imaging study for polyarticular chronic joint pain 1
• Radiographs can identify early erosions, joint space narrowing, or other bony abnormalities suggestive of inflammatory arthritis 1
• The bilateral and polyarticular nature of symptoms makes localized mechanical causes (epicondylalgia, isolated tendinopathy) much less likely 2

Critical Clinical Features to Assess

• Morning stiffness duration >30-60 minutes strongly suggests an inflammatory process rather than mechanical joint disease 1
• Symmetric joint involvement is characteristic of rheumatoid arthritis 1
• Examine for soft tissue swelling around joints even without visible erythema 1
• The combination of peripheral joint pain (wrists, elbows) with axial symptoms (back, flank) raises concern for seronegative spondyloarthropathy 1

Essential Laboratory Evaluation

• Obtain comprehensive rheumatologic workup immediately, including:
  • Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies 1
  • Antinuclear antibodies (ANA) to evaluate for other connective tissue diseases 1
  • Inflammatory markers: ESR and C-reactive protein (CRP) 1
  • Complete blood count to assess for systemic inflammation 1

Advanced Imaging Strategy

When Radiographs Are Normal or Nonspecific

• MRI without IV contrast is the preferred next study when radiographs show only nonspecific findings and inflammatory arthritis is suspected 1
• Bone marrow edema (osteitis) on MRI is the strongest predictor of future disease progression and functional deterioration in early rheumatoid arthritis 1
• MRI is much more sensitive than radiographs for identifying early erosions 1
• MRI can quantify active synovitis, especially with IV contrast administration, allowing confident early diagnosis and treatment guidance 1

For Isolated Wrist or Elbow Pain (If Unilateral)

• If symptoms were truly unilateral wrist pain, MRI without IV contrast would assess ligaments, triangular fibrocartilage complex (TFCC), tendons, and bone marrow abnormalities 2
• For isolated elbow pain, radiographs remain the initial study, with MRI reserved for soft tissue evaluation 2

Most Likely Diagnoses (In Order of Probability)

1. Rheumatoid Arthritis

• Bilateral symmetric polyarticular involvement of wrists and elbows is classic 1
• Morning stiffness, if present, supports this diagnosis 1
• Early aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) can prevent irreversible joint damage 1

2. Seronegative Spondyloarthropathy

• Combination of peripheral arthritis (wrists, elbows) with axial symptoms (back, flank pain) is characteristic 1
• May be RF and anti-CCP negative but have elevated inflammatory markers 1

3. Systemic Lupus Erythematosus or Other Connective Tissue Disease

• Polyarticular involvement with systemic symptoms 1
• ANA testing is critical for evaluation 1

Critical Management Principles

• Early referral to rheumatology is critical, as up to 50% of patients with inflammatory arthritis may develop persistent inflammation with progressive joint damage if left untreated 1
• NSAIDs for pain control if no contraindications 1
• Avoid corticosteroid injections until diagnosis is established 1
• Activity modification to reduce joint stress 1

Common Pitfalls to Avoid

• Do not attribute bilateral polyarticular pain to isolated mechanical causes like epicondylalgia or tendinopathy—these are typically unilateral and activity-related 2
• Do not delay rheumatologic workup waiting for radiographic changes—MRI can detect disease months to years before plain films 1
• Do not dismiss normal initial radiographs as excluding inflammatory arthritis—early disease may show no radiographic abnormalities 1
• The flank/back pain component should not be dismissed as unrelated musculoskeletal pain—it may indicate axial involvement in spondyloarthropathy 1