What is the appropriate initial management for a patient with swollen and tender joints, particularly when bending, and a potential history of autoimmune conditions or infections?

Initial Management of Swollen, Tender Joints

Patients with swollen and tender joints affecting more than one joint must be referred to and seen by a rheumatologist within 6 weeks of symptom onset, as earlier treatment initiation significantly improves outcomes and prevents irreversible joint damage. 1

Immediate Clinical Assessment

Key History Elements to Obtain

• Duration of morning stiffness: Stiffness lasting >30-60 minutes strongly suggests inflammatory arthritis rather than mechanical joint problems 1
• Pattern of joint involvement: Note which specific joints are affected and whether symptoms migrate between joints 2
• Response to medications: Improvement with NSAIDs or corticosteroids (but not opioids) suggests inflammatory arthritis 1
• Systemic symptoms: Fever, weight loss, or rash may indicate infection or systemic autoimmune disease 1
• Recent infections or exposures: Critical for identifying acute rheumatic fever, disseminated gonococcal infection, or Lyme disease 2

Physical Examination Priorities

• Assess for true synovitis: Joint swelling accompanied by warmth or erythema indicates active inflammation 1
• Perform the "squeeze test": Lateral compression of the metatarsophalangeal joints causing pain suggests inflammatory arthritis 3
• Examine all peripheral joints systematically: Document the number of swollen and tender joints, as this guides prognosis and treatment decisions 1
• Check for skin findings: Look for psoriatic plaques, nail dystrophy, or dactylitis ("sausage digits") that suggest psoriatic arthritis 1

Critical caveat: Joint tenderness alone without swelling may not indicate active inflammation, especially in established disease where it more likely reflects joint damage and malalignment 4, 5

Essential Laboratory Tests (Order Immediately)

The following tests must be obtained to exclude alternative diagnoses and assess disease severity 1:

• Complete blood count: Assess for systemic inflammation and anemia
• Inflammatory markers: ESR and CRP (elevated levels support inflammatory arthritis)
• Rheumatoid factor and anti-CCP antibodies: Predict persistent and erosive disease
• Antinuclear antibodies (ANA): Screen for systemic lupus and other connective tissue diseases
• Urinalysis and transaminases: Exclude renal and hepatic involvement
• Antistreptolysin O titer and throat culture: If acute rheumatic fever is suspected 2

Initial Imaging Strategy

First-Line Imaging

Obtain plain radiographs of the affected joints immediately (hands, wrists, feet as appropriate), as this is the standard initial imaging study and can identify early erosions or joint space narrowing 1, 3

Advanced Imaging When Diagnosis Unclear

• Ultrasound with power Doppler: Highly sensitive for detecting synovitis and joint effusions, can be performed at bedside 1, 6
• MRI without IV contrast: Most sensitive for identifying early erosions and bone marrow edema (the strongest predictor of disease progression), recommended when radiographs are normal but clinical suspicion remains high 1, 3

Urgent Diagnoses to Exclude

Septic Arthritis

• If joint effusion is present: Aspiration with synovial fluid analysis is mandatory and cannot be replaced by imaging alone 6
• Transfer to hospital if: Significant effusion requiring drainage, systemic signs of sepsis, multiple joints involved, or prosthetic joint present 6
• Laboratory clues: CRP >2.0 mg/dL or ESR ≥40 mm/hr support septic arthritis 6

Acute Rheumatic Fever

• Migratory polyarthritis of large joints is a hallmark manifestation requiring urgent evaluation 2
• Treatment: NSAIDs or salicylates for symptomatic relief; systemic glucocorticoids if carditis present; penicillin prophylaxis to prevent recurrence 2

Crystal Arthropathies

• Gout: Look for tophi, first metatarsophalangeal joint involvement; ultrasound shows "double contour sign" 1
• Pseudogout: Radiographs demonstrate chondrocalcinosis in fibrocartilage (wrist triangular fibrocartilage, knee menisci) 1

Initial Symptomatic Treatment

NSAIDs (First-Line for Symptom Control)

• Evaluate contraindications first: Assess gastrointestinal, renal, and cardiovascular status before prescribing 1
• Naproxen dosing: 375-750 mg twice daily has been shown to reduce joint swelling, morning stiffness, and improve mobility in rheumatoid arthritis 7
• Onset of relief: Pain relief begins within 1 hour for naproxen, with effects lasting up to 12 hours 7
• Safety consideration: Naproxen causes significantly less gastric bleeding than aspirin in comparative studies 7

Glucocorticoids (Adjunctive Therapy)

• Systemic glucocorticoids: Reduce pain and swelling; should be considered as temporary adjunctive treatment as part of the DMARD strategy 1
• Intra-articular injections: Appropriate for relief of local inflammatory symptoms in large joints 1

Important warning: Avoid corticosteroid injections until diagnosis is established, particularly to exclude septic arthritis 3

Disease-Modifying Treatment (If Inflammatory Arthritis Confirmed)

Indications for Early DMARD Therapy

Patients at risk of developing persistent or erosive arthritis should be started with DMARDs as early as possible, even if they do not yet fulfill established classification criteria 1

Risk factors for persistent disease include 1:

• High number of swollen and tender joints
• Elevated ESR or CRP
• Positive rheumatoid factor or anti-CCP antibodies
• Radiographic erosions present

DMARD Selection

• Methotrexate is the anchor drug and should be used first in patients at risk of developing persistent disease 1
• For psoriatic arthritis: Mild disease managed with NSAIDs alone; if unresponsive after 2-3 months, initiate methotrexate; moderate-to-severe disease requires methotrexate, TNF-α blockade, or combination therapy 1

Treatment Goal and Monitoring

• Primary goal: Achieve remission 1
• Monitoring frequency: Assess disease activity every 1-3 months until remission achieved, using tender/swollen joint counts, patient/physician global assessments, ESR, and CRP 1
• Structural monitoring: Obtain radiographs of hands and feet every 6-12 months during the first few years 1

Common Pitfalls to Avoid

• Do not delay rheumatology referral: The 6-week window is critical, as treatment started earlier leads to better outcomes 1
• Do not rely on tender joints alone: Swollen joints are strongly associated with ultrasound-detected synovitis, while tender-but-not-swollen joints may reflect joint damage rather than active inflammation 4, 5
• Do not miss septic arthritis: Always aspirate significant joint effusions before initiating immunosuppressive therapy 6
• Do not combine NSAIDs with aspirin: This combination increases adverse events without additional benefit and aspirin increases naproxen excretion 7