Name:
Joint Pain
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Joint Pain
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Upload Date:
2022-09-15T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DR. SMITH: Welcome back to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only, and should not be understood as medical advice under any circumstances.
DR. SMITH: [upbeat music] [upbeat music] [upbeat music]
DR. ZHOU: Welcome to another rheumatology episode of Run the List. My name is Joyce Zhou, and again with us here today to discuss an approach to joint pain is Dr. Eli Miloslavsky who's a rheumatologist at MGH and a fantastic medical educator. As a sneak peek on some future episodes we're really excited to have him once again, to share about his career as both a rheumatologist, as well as a medical educator in an upcoming careers episode.
DR. ZHOU: We're thrilled to have you back on our podcast, Dr. Miloslavsky, thanks again for your time. [Dr. Miloslavsky] It's great to be here.
DR. ZHOU: With that let's start talking some joints and let's Run the List. [Dr. Miloslavsky] Let's do it.
DR. ZHOU: As usual, we will start our episode off with a case, so we have a 34-year-old female who has a medical history of obesity, diabetes, as well as hypertension and she comes into outpatient clinic with the chief concern of two months of intermittent pain in her fingers and swelling of the first digit of her right hand. She notes that the swelling affects her ability to type, and it's really troublesome to her because she works as an administrative assistant and every morning she feels like she has trouble doing her job.
DR. ZHOU: She also tells you that she's noticed some odd changes in her fingernails, which she initially thought was due to a fungal infection, but over-the-counter medication hadn't helped. She's also noted some peeling skin, as well as what she considers to be scaly red splotches at the hairline of her neck. She denies any pain with urination, vision changes, eye changes, or any oral ulcers.
DR. ZHOU: She also doesn't know any preceding trauma either to her hand or to her neck, and she hasn't had any new sexual partners, though, a month or so ago she had a about of food poisoning. On exam, you notice onycholysis of the fingernails as well as mild erythema in pain with palpation of the first and second DIPs on both hands, the first and second PIPs on her right hand only, and prominent third to fifth MCP swelling on her left hand.
DR. ZHOU: You don't find any other joint or finger swelling or pain with range of movement of her larger joints. You do also see what she means with the skin changes. She has scaly plaques that look dry and also parts that look like they have recently bled with scratching. So prior to diving in, I would love if we can define some terms before we get started.
DR. ZHOU: Can you help us define arthritis versus arthralgia, as well as this idea of synovitis, tenosynovitis and enthesitis, so lots of itises, and then one last term, this idea of boggy joints, what does that mean? [Dr. Miloslavsky] Absolutely. So I think a lot of terms are sometimes used interchangeably and they add to the confusion in what's an already confusing specialty, so thanks for starting off with that question.
DR. ZHOU: So arthralgia just means joint pain, and arthralgia can have inflammatory features or non-inflammatory features, but when you say arthralgia, that means that it's just pain without finding anything objective on exam or imaging. Arthritis is joint pain with something objective on exam or imaging. So for example, joint pain with swelling on exam would be arthritis or joint pain with changes, say osteoarthritis on X-rays would also be called arthritis.
DR. ZHOU: Synovitis means inflammation of the synovium and we often refer to that when we talk about joint inflammation, because an inflamed joint is always inflamed because the synovium is the part of the joint that's inflamed. And when people describe a joint that feels boggy, that's essentially synonymous with synovitis, but synovitis can not only affect the joints, it can affect the tendons because tendons are lined by a synovial sheath.
DR. ZHOU: So when there's a tendon that's involved with synovitis, we call that tenosynovitis. And then finally there's a term called enthesitis, which is inflammation of the insertion of tendon onto bone. That doesn't involve the synovium and it's a different process that's only associated with a subset of conditions that cause inflammatory joint pain.
DR. ZHOU: Let's turn now towards our general framework for patients who come in with new joint pain. I would like to hear how you approach joint pain, as well as how you think through this particular patient who has come into primary care clinic. [Dr. Miloslavsky] Absolutely. I like to bucket things as much as I can and joint pain, I think can be bucketed into four categories. Is it something mechanical? So things like osteoarthritis or tendonitis or bursitis.
DR. ZHOU: So things like osteoarthritis or tendonitis or bursitis. Is it inflammatory? And that's basically all of the rheumatologic diseases because all of our diseases can present with inflammatory joint pain. Is it an infectious process like a septic arthritis? Or is it none of the three, which would usually fall into a pain syndrome bucket, whether that's fibromyalgia or say, a neuropathy of some type.
DR. ZHOU: So I think there's like four things that are really helpful for cutting this list of four down to a list of perhaps two. So I'll give you an example. Time course and number of joints is really important. So for example, osteoarthritis is never acute onset, whereas if you had an injury and you have an acute pain in one area, you know, that can be consistent with the mechanical process. Infectious arthritis is usually one joint or sometimes two, and it's usually an acute onset, right?
DR. ZHOU: So infectious arthritis is very rarely chronic or polyarticular. There are some exceptions, like Lyme arthritis kind of has a subacute onset and it's usually one joint, but that's an exception rather than the rule. And then fibromyalgia is usually a diffuse pain process, so it's not usually in one area and it's also not of acute onset. So time course and number of joints can be really helpful in limiting that down.
DR. ZHOU: The other frame that's really important is, is the pain inflammatory or non-inflammatory? So inflammatory joint pain is usually patients experience a lot of stiffness and pain in the morning and as they get going that tends to improve. So I often ask, when you wake up, do you feel stiff or do you have a lot of pain? If the answer is yes, I ask, does that improve as you get going?
DR. ZHOU: And if the answer to that is yes, I ask, how long is it until you feel as good as you're going to feel that day? And the longer that time is, the higher likelihood there is of an inflammatory arthritis. So usually I use a cutoff of 30 minutes as the lower limit of something that could possibly be inflammatory and the longer it is, the higher the likelihood ticks up. If there's presence of swelling that's another thing that gives you points for inflammatory arthritis.
DR. ZHOU: And then time of onset in terms of, did you get multiple joints all at the same time or come close? Like for this patient multiple joints over the course of two months, definitely sounds like it could be inflammatory. And then finally, the pattern of the joints in terms of the location of which joints are involved can be helpful.
DR. ZHOU: So let me apply this framework to this patient. She has multiple joints that came on over the course of two months. So that does not seem that consistent with something that's mechanical, although possible, but it's not so acute that I think this is likely to be infectious, so that leans me a little bit towards inflammatory. She has morning stiffness, so that leans me a little bit towards inflammatory.
DR. ZHOU: And then in terms of her involvement, she has joints that are typically involved in osteoarthritis, like PIPs and DIPs but she also has joints that are not typically involved in osteoarthritis, such as the MCPs, which are involved very prominently on one hand. So all that leads me towards an inflammatory arthropathy, and then I try to think about, well, which one is it? So there are three, I would say, four sort of common ones, rheumatoid arthritis, the spondyloarthropathies of which there are four, one of them is psoriatic arthritis.
DR. ZHOU: And then there's polymyalgia rheumatica, which only happens in patients over 50, and crystal arthropathy like gout and pseudogout. So PMR and crystal arthropathy is very unlikely in a young person, so you're down to rheumatoid arthritis and the spondyloarthropathies. Rheumatoid arthritis is typically a symmetric arthritis that affects both the small and large joints. So the PIPs, and the MCPS, those are all consistent with rheumatoid, but rheumatoid does not typically involve the DIPs like this patient has.
DR. ZHOU: And also this patient's involvement, I would say leans towards the asymmetric rather than symmetric side. So I'm wondering if it could be a spondyloarthropathy and this patient also has rash and nail involvement that both sound like they could be psoriasis. So from the history that's given, I'm worried about psoriatic arthritis in this case.
DR. ZHOU: So it sounds like overall in terms of the approach, you want to first think through these four common buckets of causes of joint pain, and you can use some other differentiators to help you figure out which of these buckets seem more likely. So in terms of diagnostic steps, what would you consider to be the next things to do, to figure out what's going on with this particular patient? And specifically in terms of diagnosis, we tend to talk about arthrocentesis to be helpful in joint disease.
DR. ZHOU: Would you do an arthrocentesis in this case? [Dr. Miloslavsky] So I probably wouldn't because arthrocentesis is helpful for three things. One is if you're not sure if it's inflammatory or not. So for example, osteoarthritis, when it affects the knees can often cause swelling and joint effusion, and if you're not sure if you're dealing with something inflammatory or osteoarthritis, an arthrocentesis can help.
DR. ZHOU: If you're worried about a crystalline arthropathy like gout or pseudogout, the gold standard of diagnosis is an arthrocentesis. And if you're worried about an infection, like a septic arthritis, you have to, have to, have to do an arthrocentesis to investigate that diagnosis. But in this case, we're pretty confident that it's an inflammatory arthritis.
DR. ZHOU: We're not worried about a crystalline process, and we don't think this is an infection. And also small joints are usually very hard to aspirate fluid from, but even if it was technically feasible, I don't think it would help that much in this case.
DR. ZHOU: Got it. [Dr. Miloslavsky] But there are two other kind of buckets of things that we have at our disposal. One is lab testing and the other is imaging. So in terms of lab testing for the entire inflammatory arthritis category, only rheumatoid arthritis is what we call seropositive, in other words, has antibodies associated with it. And so in this case, even though rheumatoid arthritis doesn't typically affect the DIPs, once in a while it can, so it would be reasonable to check a rheumatoid factor and an anti-CCP antibody, but I would expect them to be negative.
DR. ZHOU: I would also check a sed rate and a CRP. I would though caution you not to use those as rule-out markers because in patients with inflammatory arthritis, whether it's rheumatoid arthritis or a spondyloarthropathy, about one third of patients with active untreated disease will have normal inflammatory markers, but they're helpful to follow the disease. And then I would get some basic labs, like a CBC and a BMP to make sure that there are no cytopenias and that the creatinine is normal and that's helpful for A. making sure that you're not missing something else that's going on, but also that you know of all the medical problems before you start treatment.
DR. ZHOU: Great, that's really helpful. It sounds like no arthrocentesis unless you're very concerned about specific things such as septic joint disease or a crystalline disease, or if you need some help figuring out if it's inflammatory or not, which is not particularly relevant in this case. And then you also want to do some other labs, both general labs, as well as some antibodies, specifically RF as well as anti-CCP.
DR. ZHOU: So I'll give a little update in terms of our case. The CBC and BMP were both within normal and the ESR and CRP were slightly elevated and not particularly high. ANA titer was 1:80 and because of this concern for possibly RA the RF and the anti-CCP were checked, but both were negative. So can you then interpret these particular labs for this patient and synthesize it in combination with what you learned of her H and P?
DR. ZHOU: [Dr. Miloslavsky] Absolutely. So the inflammatory markers were elevated, which goes along with our thinking that this is an active inflammatory arthritis, but if they were normal, I don't think that would move me very much. It was interesting that the antinuclear antibody was checked. It was not totally inappropriate because sometimes we check on the antinuclear antibody for an inflammatory arthritis, not because the antinuclear antibody helps us diagnose rheumatoid arthritis or a spondyloarthropathy, but because the antinuclear antibody is very sensitive for connective tissue diseases like lupus, and once in a blue moon lupus will present with an inflammatory arthritis as a first manifestation, but in this case, you could even argue not to check it because asymmetric involvement with DIP involvement would just be so atypical for lupus.
DR. ZHOU: But it's low in this case and so that would support my assumption that this is probably psoriatic arthritis rather than lupus presenting with arthritis. Negative rheumatoid factor and CCP make RA less likely. I will mention that it doesn't rule it out because about 4 out of 10 patients with RA have a negative rheumatoid factor and CCP. So that's why the clinical presentation and the exam is really important.
DR. ZHOU: In this case, rheumatoid arthritis was not the highest on our list, so negative RF and CCP supports that assumption further.
DR. ZHOU: So if we're thinking about psoriatic arthritis, I just wanted to clarify one thing. Do they typically present with skin lesions, without skin lesions, will they have had psoriasis for a long time before they then presented with joint symptoms? What does that look like? [Dr. Miloslavsky] Most patients with psoriatic arthritis do have psoriasis at the time of diagnosis, although a small minority of patients present with joint symptoms first, but the duration and the severity of psoriasis actually doesn't have great correlation to the presence of psoriatic arthritis.
DR. ZHOU: So in my mind, when I'm evaluating someone with joint pain, I really want to know whether they have psoriasis and if they do have psoriasis, it increases my pre-test probability of an inflammatory arthritis and makes me look for patterns that are consistent with psoriatic arthritis but the time of onset and extent of psoriasis doesn't help me that much.
DR. ZHOU: Once you have an inflammatory arthritis in a patients with psoriasis, it basically doesn't matter what the pattern of that inflammatory arthritis is because psoriatic arthritis can cause almost any pattern of joint involvement. So once you have inflammatory arthritis and you're sure that it's not osteoarthritis like in this case, and you have psoriasis and you have a negative rheumatoid factor and CCP, you're basically done, it's psoriatic arthritis.
DR. ZHOU: So we essentially clinched the diagnosis given the history, especially given the skin findings that came with these joint symptoms, and then these labs continued to confirm our suspicion that it was probably psoriatic arthritis. So I want to turn now a little bit to treatment and without diving in too deeply, what is your approach to treatment for psoriatic arthritis? And to what end do you tend to treat your patients? And then I think another question that's built into this is when do we need to consult a rheumatologist or refer to rheumatology?
DR. ZHOU: [Dr. Miloslavsky] Usually someone with a diagnosis of a chronic inflammatory arthropathy, whether it's RA or a spondyloarthropathy could really benefit from being referred to rheumatology. But that doesn't mean that in the primary care setting or in the hospital treatment can be started. So for psoriatic arthritis, you could start with NSAIDs, those usually need to be used in a [unintelligible] at a high dose, and sometimes, especially for very mild disease, that can be enough.
DR. ZHOU: But I would say that most patients need a disease-modifying anti-rheumatic drug, a.k.a. DMARD, the most common of which is methotrexate, and if that doesn't work, we will often move on to biologics like TNF inhibitors, such as adalimumab, which is Humira or etanercept that is Enbrel. And the last couple of years have seen an explosion in treatment options for psoriatic arthritis, with multiple new very effective biologics coming to market.
DR. ZHOU: So I say that to just emphasize that we really treat to remission. We feel like we can get many patients back to feeling We feel like we can get many patients back to feeling almost the way they were before they developed the disease. And certainly, how active the person is or what their personal goals are, is really important. Someone who's sedentary, who may not be that bothered by their joint pain may choose to have less aggressive treatment than someone who's a marathon runner, and really wants to continue doing that.
DR. ZHOU: That's incredible. I think that speaks to the progress that we've made from the pharmacologic end in treating some of these diseases that used to be pretty morbid and affected people's quality of life quite a bit. Steroid injections, would you use them? When do you use them? [Dr. Miloslavsky] The important thing to know is that there are few things that we have that work quickly, like NSAIDs, systemic steroids and joint injections.
DR. ZHOU: Whereas our DMARDs usually take weeks to sometimes months to start working, so sometimes we'll use a short prednisone course while the DMARD starts to work. And we tend to use steroid injections when one or maybe two joints are involved and we don't want to give systemic prednisone. So you could inject one or two joints. In this case, this is a patient who has more than five involved joints and injecting more than five small joints is just not that practical, so we would try NSAIDs first and then maybe steroids if she was still very symptomatic while starting a DMARD.
DR. ZHOU: Last question, before we wrap up the case, I know we didn't perform an arthrocentesis for synovial fluid in this particular patient, but in general, do you want to walk us through how you interpret an arthrocentesis? I think that's always something that comes up. [Dr. Miloslavsky] Absolutely, so there's three things that you want to send when you aspirate joint fluid, the white cell count, and you'll get a diff with that as well; crystals, looking for gout and pseudogout; and a culture if you're concerned for septic arthritis.
DR. ZHOU: So the latter two are self-explanatory if they're positive or negative and the part that needs interpretation is the cell count. So generally speaking, non-inflammatory joint fluid, like from a meniscal tear or osteoarthritis has less than 2,000 cells in it, and it will usually be monocyte predominant. Between 2,000 and 50,000 cells that's where most of the inflammatory arthropathies come in, rheumatoid arthritis, spondyloarthropathies, crystalline arthropathy, and that will usually be poly predominant.
DR. ZHOU: And then when the cell count is more than 50,000 cells, usually with a very, very high neutrophil predominant that's when infectious arthritis is more likely. Although I will say that infectious arthritis could happen with less than 50,000 cells, so that higher number, that 50,000 is not so cut and dry.
DR. ZHOU: Hm, okay, so it sounds like there might be some overlap, especially in these in-between number ranges. So always good to combine with our clinical history and everything else, all the other data that we have. To wrap up this case, the patient was referred to a rheumatologist and was counseled on weight loss, exercise, as well as joint protection.
DR. ZHOU: She was started on Naprosyn, which mildly improved her symptoms but not fully, and so she was also started on methotrexate and her liver function was carefully monitored given her metabolic syndrome co-morbidities and the knowledge that methotrexate can affect the liver. Fortunately, this greatly improved her symptoms and she actually could get back to work with very minimal symptoms.
DR. ZHOU: Prior to wrapping up, Dr. Miloslavsky, do you have any pearls for listeners to leave them with about an approach to joint pain? [Dr. Miloslavsky] Yeah, I think I would leave you with two pearls, I think number one, it's important not to get caught up in figuring out exactly what disease the joint pain is from, but to really get comfortable with making I would say the more important call of is this joint pain inflammatory?
DR. ZHOU: Does it sound like an inflammatory arthritis? And then figuring out exactly what's causing that is sort of, I would say almost a lesser task. And then two, I would just highlight that the diagnosis relies on history, physical, labs, plus/minus imaging, but negative labs do not rule out an inflammatory arthritis nor does normal imaging. And so the history and the physical, especially when it comes to evaluation of joint pain, is really important.
DR. ZHOU: Thank you, and maybe as a third pearl, to consult your friendly rheumatologist, if you have any questions about these things, because they are very confusing sometimes, but I think what you left us with was a great first approach to how we should think through these things on our own and that we can always come to people like you for further questions. Thank you so much for your time today. Thank you for sharing this approach to joint pain and for our listeners, we'll see you again on the Run the List.
DR. ZHOU: [outro music] [outro music]