What is the best initial evaluation and treatment strategy for a patient presenting with joint pain?

Approach to Joint Pain: Evidence-Based Evaluation and Management

Initial Clinical Assessment

Begin by determining the number of joints involved (monoarticular vs. polyarticular) and whether the pain is inflammatory or mechanical in nature, as this fundamentally directs your diagnostic pathway. 1, 2

Key Clinical Features to Identify

Inflammatory vs. Non-Inflammatory:

• Morning stiffness lasting >30 minutes (or ideally >1 hour) strongly suggests inflammatory arthritis rather than mechanical causes like osteoarthritis 1, 3, 2
• Joint swelling, warmth, and redness indicate synovitis and active inflammation 4
• Mechanical pain (osteoarthritis) typically causes brief stiffness (<30 minutes) that worsens with activity 3

Pattern of Joint Involvement:

• Perform the "squeeze test" by compressing the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints laterally—pain indicates inflammatory arthritis 1, 3, 2
• Symmetric small joint involvement (MCPs, proximal interphalangeals, MTPs) suggests rheumatoid arthritis 3
• Asymmetric oligoarticular pattern with enthesitis suggests seronegative spondyloarthropathy 2

Mandatory Initial Laboratory Workup

Order these tests on every patient with suspected inflammatory arthritis: 1, 2

• Complete blood count (exclude systemic disease, assess for anemia of chronic disease) 1, 2
• ESR or CRP (quantify inflammation and predict erosive disease) 3, 2
• Rheumatoid factor (RF) and anti-CCP antibodies (predict severe disease and poor prognosis in RA) 3, 2
• Antinuclear antibodies (ANA) (screen for lupus and connective tissue diseases) 1, 2
• Urinalysis and transaminases (exclude non-rheumatologic diseases) 1, 2

Imaging Algorithm

Plain radiographs of affected joints are mandatory as the first imaging study for all suspected inflammatory arthritis (ACR appropriateness rating 9/9) 1, 2

Advanced imaging indications:

• Ultrasound with power Doppler when clinical examination is equivocal—detects synovitis, erosions, and tophi not visible on X-rays (sensitivity 65%, specificity 80% for gout tophi) 1, 2
• MRI without contrast when radiographs are normal but pain persists—superior for detecting early erosions and synovitis 1, 2

Critical Red Flags Requiring Immediate Action

Refer to rheumatology within 6 weeks of symptom onset if: 1, 3, 2

• Arthritis involves more than one joint with swelling not caused by trauma 1, 2
• Positive squeeze test of MCPs or MTPs 3, 2
• Morning stiffness >30 minutes 1, 2

This 6-week window is critical because early DMARD initiation (within weeks of symptom onset) significantly improves long-term outcomes and prevents irreversible joint damage. 1, 3

Initial Symptomatic Management (While Awaiting Rheumatology)

NSAIDs for symptomatic relief:

• Consider naproxen 500 mg twice daily after evaluating GI, renal, and cardiovascular risk 2
• Do NOT start DMARDs (like methotrexate) before rheumatology consultation—these require specialist-directed monitoring protocols 2

Adjunctive measures:

• Systemic or intra-articular corticosteroids for severe flares 5
• Protection, rest, ice, compression, elevation (PRICE) for acute symptoms 6

Specific Diagnostic Considerations

For suspected gout:

• Look for erosions with overhanging edges on radiographs 1, 2
• Dual-energy CT or ultrasound can detect tophi and urate crystals 1
• Joint aspiration with synovial fluid analysis is definitive 1

For suspected pseudogout (CPPD):

• Target radiographs of wrists (triangular fibrocartilage), knees (menisci), and pelvis (symphysis pubis) for chondrocalcinosis 1
• Ultrasound shows "icing" of cartilage (double contour sign with 83% sensitivity, 76% specificity) 1

For suspected septic arthritis:

• Joint aspiration is mandatory—this is a medical emergency requiring immediate diagnosis and treatment 7
• Synovial fluid analysis with cell count, Gram stain, and culture 1

Common Pitfalls to Avoid

• Do not rely solely on RF or anti-CCP negativity to exclude rheumatoid arthritis—seronegative RA exists and still requires early DMARD therapy 3
• Bilateral structural abnormalities on imaging (especially in patients >70 years) poorly discriminate painful from non-painful joints—clinical correlation is essential 1
• Normal radiographs do not exclude inflammatory arthritis—early disease may show no radiographic changes, necessitating ultrasound or MRI 1, 2
• Bone scans have low specificity and poor anatomic resolution—they are not routinely indicated for chronic joint pain evaluation 1