First Presentation of Joint Pain
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1 First Presentation of Joint Pain Andrew Harrison Rheumatologist Wellington Regional Rheumatology Unit, HVDHB Bowen Centre, Crofton Downs, Wellington Assoc. Prof. in Medicine, University of Otago Wellington Clinical Leader, Research, CCDHB
2 Disclosures Advisory board member for AbbVie NZ and Pfizer NZ Research grants from Roche and Abbvie Sponsorship to attend conferences from AbbVie, Roche and Pfizer Consultancy work for AbbVie to develop educational materials for GPs and rheumatologists
3 Disclaimer No qualifications or experience in primary care
4 Learning Objectives To provide a structured approach to the assessment of newonset arthritis To review the important data needed to inform diagnosis and prognosis To understand the influence of different patterns of clinical and laboratory features on diagnosis and prognosis To recognise the cases that require urgent referral and/or treatment to optimise long-term outcome
5 Why Bother?
6 Why Bother?
7 Rationale for Early Immunomodulatory Treatment In RA, early use of corticoteroids improves long-term outcome DMARDs reduce symptoms reduce erosive progression reduce need for NSAIDs and long-term corticosteroids Early treatment associated with drug-free remission
8 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue
9 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS
10 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal? objective synovitis swelling/tenderness MTP squeeze RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA
11 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal? objective synovitis swelling/tenderness MTP squeeze RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Limb girdle Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA
12 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal? objective synovitis swelling/tenderness MTP squeeze Limb girdle Large joint / proximal Knee/ankle RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated
13 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
14 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
15 Effective Use of Investigations
16 Effective Use of Investigations
17 Effective Use of Investigations
18 Effective Use of Investigations
19 Effective Use of Investigations
20 Effective Use of Investigations
21 Effective Use of Investigations
22 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
23 Effective Use of Investigations
24 Effective Use of Investigations
25 Effective Use of Investigations
26 Effective Use of Investigations
27 Effective Use of Investigations
28 Effective Use of Investigations
29 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
30 Effective Use of Investigations
31 Effective Use of Investigations
32 Effective Use of Investigations
33 Effective Use of Investigations
34 Effective Use of Investigations
35 Effective Use of Investigations
36 Effective Use of Investigations
37 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
38 Effective Use of Investigations
39 Effective Use of Investigations
40 Effective Use of Investigations
41 Effective Use of Investigations
42 Effective Use of Investigations - Summary Base the choice of tests on the differential diagnosis Different patterns of presentation require different tests Avoid requesting irrelevant tests
43 Determining Urgency Rationale for early immunomodulatory treatment In RA, early use of corticoteroids improves long-term outcome DMARDs reduce symptoms reduce erosive progression reduce need for NSAIDs and long-term corticosteroids Early treatment associated with drug-free remission Urgency of treatment or referral determined by prognostic indicators value of early intervention potential consequences of delaying treatment current impact on patient
44 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
45 Determining Urgency Small joint / distal inflammatory symptoms poor functional status objective synovitis MCP/MTP squeeze test extra-articular features (including systemic) acute phase response Rheumatoid factor and/or anti-ccp other lab features (e.g. ANA/ENA/dsDNA, ANCA/MPO/PR3)
46 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
47 Determining Urgency Large joint / proximal limb girdle inflammatory symptoms poor functional status extra-articular features (including systemic) GCA symptoms visual, jaw claudication acute phase response
48 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
49 Determining Urgency Large joint / proximal knee and ankle inflammatory symptoms poor functional status extra-articular features (including systemic) acute phase response (less important) need for arthrocentesis
50 A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
51 Determining Urgency Axial inflammatory symptoms poor functional status HLA-B27+ acute phase response
52 Early Interventions Suspected RA evidence to support early use of corticosteroids e.g. prednisone 20 mg daily tapering over 4 8 weeks while awaiting results or assessment for DMARDs
53 Early Interventions Suspected RA evidence to support early use of corticosteroids e.g. prednisone 20 mg daily tapering over 4 8 weeks while awaiting results or assessment for DMARDs Can also be applied to other peripheral inflammatory arthritides, e.g. PsA, ReA, viral
54 Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help
55 Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help Suspected GCA discuss with rheumatology registrar immediately if unable to contact, prednisone can be started before biopsy ideally CRP and ESR before stating treatment biopsy within 3 weeks of commencement of prednisone
56 Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help Suspected GCA discuss with rheumatology registrar immediately if unable to contact, prednisone can be started before biopsy ideally CRP and ESR before stating treatment biopsy within 3 weeks of commencement of prednisone Suspected PMR prednisone 15 mg daily 1/52, then 12.5 mg 1/52, then 10 mg reducing by 1 mg every 2/52 to 5 mg
57 Early Interventions Suspected gout three options: NSAIDs, colchicine, prednisone colchicine regimen: 1 g stat and 0.5 mg 1 hour later
58 Early Interventions Suspected ankylosing spondylitis / axial spondyloarthritis Full dose long acting NSAID nocte to bd refer for confirmation of diagnosis and monitoring corticosteroids seldom used Suspected OA can mimic inflammatory arthritis NSAIDs now favoured over paracetamol
59 Summary early intervention can reduce the long-term impact of inflammatory arthritis different patterns of involvement require different investigations urgency for intervention determined by clinical and laboratory features treatment can be started before diagnosis is confirmed.
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