What is the appropriate workup and management for a patient presenting with polyarthralgia?

Workup and Management of Polyarthralgia

Begin with a systematic clinical assessment to distinguish inflammatory from non-inflammatory causes, then obtain targeted laboratory tests and imaging based on the pattern of joint involvement, reserving advanced serologic testing for cases with clear inflammatory features or atypical presentations.

Initial Clinical Assessment

Establish the presence or absence of inflammation through specific clinical features:

• Document joint swelling, warmth, and erythema on examination, as palpable synovitis indicates inflammatory disease rather than mechanical pain 1, 2
• Assess morning stiffness duration—prolonged stiffness (>1 hour) suggests inflammatory arthritis, while brief stiffness (<1 hour) points toward osteoarthritis 2, 3
• Examine all peripheral joints systematically for tenderness, range of motion limitations, and crepitus to differentiate inflammatory synovitis from bony hypertrophy of osteoarthritis 1, 2
• Evaluate for true muscle weakness (not pain-limited strength), as objective weakness with elevated creatine kinase suggests myositis rather than isolated arthralgia 4, 1

Characterize the pattern of joint involvement:

• Note symmetry versus asymmetry and whether the pattern is migratory or persistent, as symmetric involvement suggests rheumatoid arthritis while asymmetric patterns may indicate spondyloarthropathies 1, 2
• Identify which joints are affected—small joints of hands (MCPs, PIPs) favor rheumatoid arthritis, while large joint involvement may suggest reactive arthritis or polymyalgia rheumatica 5
• Assess spine involvement including range of motion and tenderness to screen for axial symptoms 1

Screen for critical systemic features that require urgent evaluation:

• Fever, weight loss, or constitutional symptoms warrant immediate workup for infection, malignancy, or systemic vasculitis 5, 1
• Recent infections or travel history to endemic areas raises concern for arboviral infections (chikungunya, dengue) or reactive arthritis 5, 1
• Cardiac symptoms in the setting of muscle weakness require troponin measurement to exclude myositis with cardiac involvement 1

Exclude High-Priority Diagnoses First

Rule out septic arthritis immediately if any joint shows severe pain, swelling, and warmth:

• Perform urgent arthrocentesis with synovial fluid analysis including cell count, Gram stain, culture, and crystal examination 1, 2

Consider alternative diagnoses that mimic polyarthralgia:

• Crystal arthropathies (gout, pseudogout), polymyalgia rheumatica, psoriatic arthritis, spondyloarthritis, systemic lupus erythematosus, vasculitis, reactive arthritis (parvovirus B19, rubella, HBV, HCV), paraneoplastic syndromes, osteoarthritis, and fibromyalgia all can present with polyarticular pain 5
• Misdiagnosis is more common in seronegative disease, so maintain a broad differential especially when initial serologies are negative 5

Laboratory Workup

Obtain inflammatory markers in all patients:

• ESR and CRP should be measured, though normal values do not exclude inflammatory disease 4, 1
• Elevated ESR (>40 mm/hr) is associated with higher relapse rates in polymyalgia rheumatica and may guide treatment decisions 4

Order a focused autoimmune panel based on clinical suspicion:

• Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies are essential when rheumatoid arthritis is suspected; anti-CCP is particularly useful in seronegative presentations 4, 1, 6
• Complete blood count to assess for anemia of chronic disease or other causes of inflammation 4, 1
• Comprehensive metabolic panel including glucose, creatinine, and liver function tests establishes baseline organ function 4, 1
• Creatine kinase (CK) should be normal in polyarthralgia; elevation indicates myositis rather than isolated joint pain 4, 1

Reserve extended serologic testing for atypical presentations:

• ANA and ANCA testing should be obtained when patients are younger than 60 years, have constitutional symptoms (unexplained weight loss, fever), peripheral inflammatory arthritis, low/normal inflammatory markers despite active symptoms, or fail to respond to appropriate therapy within 2 weeks 4
• HLA-B27 may be necessary when spondyloarthropathy is suspected based on axial involvement or enthesitis 1
• Protein electrophoresis excludes paraproteinemia that can mimic inflammatory symptoms 4
• Thyroid-stimulating hormone (TSH) rules out thyroid disorders with similar presentations 4

Consider infectious workup when indicated:

• Tuberculosis testing is necessary before initiating immunosuppressive therapy or in high-risk patients 4
• Viral serologies (parvovirus B19, HBV, HCV, rubella) when reactive arthritis is suspected 5

Imaging Studies

Start with plain radiography:

• X-rays of affected joints evaluate for erosions, joint space narrowing, or metastatic lesions when symptoms persist 1, 7
• Chest radiograph may be performed to exclude malignancy or alternative diagnoses 4

Use advanced imaging selectively:

• Ultrasonography should be considered when there is doubt about the presence of inflammatory activity based on clinical assessment, as it can detect synovitis not apparent on examination 5, 1
• MRI is highly sensitive for erosive changes and inflammation but should be reserved for cases where diagnosis remains uncertain after initial workup 7

Management Approach

For inflammatory polyarthralgia with confirmed synovitis:

• Refer to rheumatology for patients with joint swelling, persistent symptoms despite initial management, or severe pain with signs of inflammation 1
• Do not escalate DMARD therapy in the absence of confirmed inflammatory activity, as concomitant fibromyalgia, osteoarthritis, psychological conditions, or non-adherence may contribute to symptoms 5

For suspected polymyalgia rheumatica in patients >50 years with bilateral shoulder/hip pain:

• Initiate prednisone 15-20 mg daily (within the guideline range of 12.5-25 mg) and monitor for dramatic improvement within 1-2 weeks 4
• Higher doses (20-25 mg) may be required in patients with high ESR (>40), female sex, or peripheral arthritis 4
• Failure to respond within 2 weeks should prompt dose escalation up to 25 mg/day or diagnostic reassessment 4

For non-inflammatory polyarthralgia:

• Provide patient education about staying active and sleep hygiene 5
• Recommend physical activity and exercise, with referral to physiotherapy for individually tailored programs if patients cannot initiate activity independently 5
• Consider orthotics (splints, braces, assistive devices) if pain impedes activities of daily living 5
• Address psychological factors such as catastrophizing or fear of movement through cognitive-behavioral therapy if these underlie disability 5
• Offer weight management for obese patients, as obesity contributes to pain and disability 5

Monitoring Strategy

Schedule serial assessments:

• Follow-up every 4-6 weeks after treatment initiation with rheumatologic examination and inflammatory markers to monitor disease activity and treatment response 1
• Monitor CK, ESR, and CRP if myositis remains in the differential diagnosis 1

Common Pitfalls to Avoid

• Do not assume normal inflammatory markers exclude inflammatory disease—some patients with active inflammatory arthritis have normal ESR/CRP 1
• Avoid attributing all symptoms to pre-existing osteoarthritis in older adults, as inflammatory arthritis can coexist and present with atypical migratory patterns 6
• Do not overlook giant cell arteritis in patients with polymyalgia rheumatica; screen for headache, jaw claudication, visual symptoms, and temporal artery tenderness 4
• Recognize that early RA management approaches emphasizing rapid DMARD initiation can lead to misdiagnosis if inflammatory arthritis is not truly present 5