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S2D: The Symptom to Diagnosis Podcast - Episode 08: Joint Pain
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S2D: The Symptom to Diagnosis Podcast - Episode 08: Joint Pain
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Segment:0 .
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we are back with episode 8 of the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. Each episode is divided into four parts. We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites.
DR. STERN: Okay, so our topic this week is joint pain. And Adam, you are the expert of the day. Do you have a case to present to me?
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: This is a very recent case for me. It's a 60-year-old guy, he's a plumber by profession who came to see me for an initial visit, with complaints of, sit down, hand pain. He says that he's had hand pain stiffness for the last 10 years. He says, it's always troublesome, but he says that occasionally, may be every few months, his hands really flare up and then they're really painful. During these periods, his wrists, his MCPs are warm and swollen with a lot of morning stiffness during those periods.
DR. CIFU: Morning stiffness is not a part of his hand pain otherwise. NSAIDs help during these periods, and he usually says he goes a little bit crazy with ibuprofen during the periods. Otherwise he sort of manages the pain with Tylenol or nothing at all. He also reports some kind of chronic unchanging knee pain. And it's gotten to the point where actually during the flare ups, it actually makes his work difficult.
DR. CIFU: He, you know, he's a Chicago plumber. So he works with a lot of cold pipes. He's got no past medical history, but he actually admits he hasn't seen a doctor he said, possibly since his pediatrician, thus, he takes no medications. And on exam, he's got sort of, you know, a hard enlargement of the wrist, the MCPs and also the PIPs and DIPs.
DR. CIFU: I didn't find anything else on exam. The joints weren't inflamed, there were no synovial changes, nothing like that. Just kind of, you know, hard, enlarged, somewhat deformed joints on his hands.
DR. STERN: Okay. Well, that's an interesting case and a little worrisome. I guess, one thing that jumps out to me right away, is I always worry about patients that haven't seen a doctor in 30 years. Because that means they never go unless they're dying.
DR. CIFU: Exactly.
DR. STERN: So, you know, it totally worries me, but putting that aside and knowing you're going to have to work this guy up, how would you think about him? So, one thing is we, I will just say at the outset, we often see a lot of osteoarthritis, and this doesn't sound like that. Tthe fact that's so episodic and sounds somewhat inflamed and the wrong joints are involved.
DR. CIFU: Yeah.
DR. STERN: You know, people often have OA in the hands, but it's often the DIPs and the PIPs and you're really talking about MCPs and wrists. So we have to step back right away and say, right away, this doesn't strike us as the most common entity. It does sound like it's polyarticular rather than monoarticular or one one-sided. And it sounds like it's inflammatory, associated with morning stiffness.
DR. STERN: So I have to say at the top of my list would probably be RA. It's a little indolent, you know, it's been 10 years, and then you're not describing deformities, which is a little peculiar. And you're also not describing, you know, soft tissue swelling at those joints, but rather hard deformities, which is a little peculiar.
DR. STERN: But I would certainly say RA would be high on my list. You know, what are some of the other inflammatory polyarthropathies to think about? Many of them don't apply here, 'cause the duration is 10 years and he's been well. So, you know, hepatitis B could do it though it would be unusual to be going on for so long and not be diagnosed. It's possible. HIV could do it, but not 10 years without him being diagnosed with an HIV-related problem.
DR. STERN: Lyme disease can cause a chronic polyarthritis, although this seems very symmetrical, and I don't think that would tend to be so symmetrical. I would just expect if this was psoriatic arthritis, we'd have, you know, better clues about that. It's too long for endocarditis, really. Lupus is a possibility, I suppose, he's a man, he's older, he's not the typical demographic, but it's possible. And CPPD is possible, it's much more common than most of those.
DR. STERN: It's very symmetrical and it's more inflammatory than many of the patients I've seen and more polyarticular than many of the patients I've seen, but I suppose, that too is possible.
DR. CIFU: Yeah, that's great. I mean, that's really where my thoughts were too. You know, you hear old guy coming in with chronic hand pain. You immediately think OA, but as I sort of heard this story more, RA, CPPD were kind of high up on the list for me. Where would you start his evaluation?
DR. STERN: Well, I would certainly get hand X-rays. 'Cause we may see joint erosions and things that would help us with RA regardless of whether or not they're obvious clinically. I would certainly get a sed rate and a CRP to look for measures of inflammation. I would also get a rheumatoid factor and a CCP, rheumatoid factor is as you know, much less specific, CCP is much more specific. You know, this does not sounds like gout, I don't really think a uric acid level is going to be helpful in this situation.
DR. STERN: And probably because he's never been seen, I'd get a chemical survey and a CBC. If we see anemia that can be a marker of chronic inflammation, it might be helpful. And the chemical survey to make sure his liver tests are normal. That's probably what I would start with for him.
DR. CIFU: Yeah, that sounds great. I'm going to throw out one of my suspicions, which is completely unfounded. So if this turns out to be wrong in 10 years, nobody can blame me. But it's the difference in the specificity between the rheumatoid factor and the anti-CCP. You know, rheumatoid factor has been around forever. It's been studied in all different populations, right? And I always use it as an example of specificity because the sensitivity of rheumatoid factor is pretty stable study to study, right?
DR. CIFU: And that's the likelihood of getting a positive test in someone with disease. The specificity of the rheumatoid factor varies from study to study from as low as 15% to as high as 95%. And that depends on what your controls are, right? If it's healthy looking, you know, young men walking around on the street, it's going to be very specific.
DR. CIFU: If it's, you know, achy women in the rheumatology clinic, it's going to be much less specific. I wonder if what's happened is that, you know, there have been fewer studies of the CCP in much more controlled groups. And I wonder if it really is as much better as we think it is.
DR. STERN: Well, come back in 2030 for our next version of the podcast that we can find out whether Dr. Cifu's prediction is correct.
DR. CIFU: We'll both have bad skin turgor by that time.
DR. STERN: Totally. That was from our last podcast. Anyway, Adam, I think we're going to take a deep dive into joint pain. Do you want to give us five key points about evaluating patients who have joint pain?
DR. CIFU: Sure. So my five key points, they're a little bit different, all sort of get to the differential diagnosis, just because I think joint pain is one of those topics that you just have to hammer into yourself, the organization of the differential diagnosis. So point one, is just that, is that more than most the framework of the differential diagnosis is just so important. And that the main categories, when you see someone who's presenting with joint pain is to ask yourself, is this periarticular joint pain?
DR. CIFU: Is this monoarticular joint pain? Or is this polyarticular joint pain? There's a little bit of crossover between monoarticular and polyarticular. But for the most part, those do a really good job of isolating different diseases.
DR. STERN: And help us a little bit with the periarticular versus the monoarticular. That seems like that could be tricky.
DR. CIFU: Beautiful. You set me up for point two, thank you very much. So my second point is the importance of differentiating periarticular from monoarticular. And this can be really hard, right? 'Cause just about all periarticular joint pain is someone coming in and saying, you know, my elbow hurts or my ankle hurts, and that may be a periarticular syndrome, or it might be a monoarticular syndrome.
DR. CIFU: Ways of differentiating on exam, is to look at range of motion. Often if you have the person completely relaxed, move the joint, especially if you've treated their pain or if they've treated their pain before they've come. 'Cause even some polyarticular syndromes will limit range of motion. If there's a lot of pain associated with it.
DR. CIFU: You know, you've certainly seen people with, I don't know, cellulitis of their ankle, who have trouble moving their ankle because it's in so much pain. Probably the biggest thing for me is that as you go through your career, for each joint, you should get very familiar with the periarticular syndromes that affect that joint. And so you can very easily say, huh, here's a person, let's use elbow pain for instance, here's a person coming in with elbow pain.
DR. CIFU: What are the periarticular syndromes that affect the elbow? And for me, I think about ulnar neuropathies, median neuropathies and radial neuropathies, right? Radial nerve compressions. Probably in today's world, it's mostly going to be ulnar nerve compression because we're all sitting at our desk, typing, leaning on our ulnar nerves all the time. There's medial or lateral epicondylitis, right?
DR. CIFU: Golfer's elbow and tennis elbow, respectively. And then there's olecranon bursitis. And those are the things that really stick out to me. And so if someone says, you know, "I'm having elbow pain." I'll say, "Huh, is it one of these periarticular syndromes?" And if it's really not that, then I'm sort of all about the joint.
DR. STERN: Don't you also find that joint pain, if the person's not moving it, is often not exquisitely tender to palpation, whereas the periarticular syndromes, many of them are very tender, just touching it.
DR. CIFU: Right. And often, specifically tender, right?
DR. STERN: Right, one spot.
DR. CIFU: Exactly. That you'll be able to say, "Oh look, you know, this is lateral epicondylitis," or "This is subacromial bursitis," right?" And you'll be able to say that's a periarticular syndrome rather than a joint syndrome. That's a great addition. So my third point is that when you get to a monoarticular arthritis, so we've said this isn't periarticular, this is clearly the joint that's the problem. The most important next thing is to differentiate inflammatory from non-inflammatory.
DR. CIFU: And fortunately this is generally easy. I think a student who's been through, you know, their first physical diagnosis class, kind of gets the fact, the whole rubor, calor, or whatever they are, [chuckles] that if it's red, hot, painful, you know, that's an inflamed joint. And if it's not, it's not.
DR. CIFU: And the great thing about the human body being symmetric is if you're, you know, comparing two knees, you can easily put your two hands on the patient's two knees and compare the heat radiating from those joints.
DR. STERN: Wait, touch the patient?
DR. CIFU: Yeah, you know.
DR. STERN: Aren't you kind of old fashioned?
DR. CIFU: It's old school.
DR. STERN: Old school.
DR. CIFU: Fourth key point, if it's monoarticular inflammatory arthritis and it's not definitely gout, it needs to be tapped. I made this t-shirt a long, long time ago to teach our third year students, which I think said monoarticular arthritis requires arthrocentesis, just to jam it into their head. We'll talk a little bit later about how you know it's definitively gout, but if it's not, you really, really, really have to have a good reason for not tapping a joint.
DR. CIFU: 'Cause that's the way you're going to make the diagnosis. And of course not making the diagnosis risks missing septic arthritis, which can be a joint destroying disaster.
DR. STERN: It does seem like there's a lot of reticence to tap a joint.
DR. CIFU: There is, there is. And I think it's because, you know, most of these people come into, let's say primary care, right? So whether it's family medicine, internal medicine, emergency medicine, and most of us are pretty good at, you know, tapping knees.
DR. STERN: Right.
DR. CIFU: Maybe, you know, an elbow here or there, but not very good at anything else. And so if it's any other joint, it's like, "Ah, we've got to call the rheumatologists, the rheumatologist is going to be mad at us."
DR. STERN: Right.
DR. CIFU: But you got to do it.
DR. STERN: All right, do you have one more key point for us?
DR. CIFU: I got one more. And of course we've done periarticular, we've done monoarticular, we've done monoarticular inflammatory versus non-inflammatory. The last one is polyarticular. And for me, when you think about polyarticular arthritis, what really helps is time course, it's differentiating sub-acute versus, sorry, acute or subacute polyarticular arthritis from chronic polyarticular arthritis.
DR. CIFU: And I got to say, this is hard. This is, this is kind of like intrarenal AKI for me. You know, you really got to think, you got to learn the differential to get this. So if you're seeing polyarticular arthritis, which is acute or subacute, it is very likely that that's infectious or post-infectious. And you think about things like bacterial endocarditis, rheumatic fever, parvo-related arthritis, or other viral arthritides versus chronic, which is really much more likely to be, you know, one of the rheumatologic diseases, one of the connective tissue diseases, might be rheumatoid arthritis, might be psoriatic arthritis.
DR. CIFU: Maybe one of those seronegative arthritides. Now of course, those can present acutely, right? So it can be, it can be confusing. But if a patient comes in and says, you know, I've been struggling with this for six months, you know, that's not bacterial endocarditis because that person would be dead if it was bacterial endocarditis.
DR. STERN: Yeah, I like that framework. That's really helpful. I mean, we were alluding to that in the case, right? He'd had it for 10 years.
DR. CIFU: Absolutely.
DR. STERN: So infection was less likely, but that's a nice framework to think about.
DR. CIFU: Right, and it is what, you know, listening to you think about it, it's what sent you away from so many of those diagnoses that you were entertaining.
DR. STERN: Right. All right, well, let's go back to the case. Do you want to tell us what happened to this poor plumber?
DR. CIFU: Yeah, so he was actually, I got to say, it was easier than, than I thought it was going to be because I sent pretty much all the tests that you asked for, besides the normal lipids and A1C that I needed, just because this guy hadn't seen a doctor in a million years, I sent a CBC, a BMP, ESR, CRP, and rheumatoid factor, anti-CCP. And I sent the guy for X-rays and I did both hands and I actually did his left knee because his left knee was more painful than the right knee.
DR. CIFU: And I got back the radiology read, you know, before I finished my clinic. And what the read was that the guy has some osteoarthritis in all the joints, but more striking is that he had clear findings of calcium pyrophosphate deposition disease, so CPPD. And that's the linear calcifications along the cartilage seemed clearly, clearly, clearly in his knee, in his wrists, and actually in his MCPs.
DR. CIFU: And that actually in retrospect, really fits with his diagnosis because we think a lot about CPPD presenting as like pseudogout, right? One inflamed joint, but actually CPPD presents more commonly as sort of an osteoarthritic looking arthritis with occasional inflammatory flares. And actually there is a presentation of CPPD, which is actually called pseudo RA.
DR. CIFU: 'Cause it can look so much like rheumatoid arthritis. And though for the reasons you pointed out, there are a lot of reasons that this wasn't really right for RA, you know, you could definitely confuse the two.
DR. STERN: Totally, I mean, I think that was the first thing that came to my mind was RA for him.
DR. CIFU: Mine too, mine too, same. The rest of his labs were actually unremarkable.
DR. STERN: Well that's reassuring as well.
DR. CIFU: Even his sed rate and CRP, I was seeing at a time that he was not inflamed. And so we don't get a lot into treatment on this podcast on purpose, but you know, chronic CPPD usually you're treating Tylenol, NSAIDs, colchicine actually have a role in chronic disease and actually hydroxychloroquine works pretty well in people who you have a hard time controlling their inflammatory symptoms.
DR. STERN: So in this condition it works.
DR. CIFU: Right. And the great thing is it keeps people out of the hospital for COVID. That's a joke.
DR. STERN: All right, so let's go on to fingerprints, common misconceptions, our favorite pet peeves, and other random bits of knowledge. So Adam, do you want to start us off with some fingerprints?
DR. CIFU: Yeah, I will definitely. And so I alluded to this before, so there are really good fingerprints for gout. So if you have six classic features for gout when someone presents, the likelihood ratio of that is 22. So you've sort of made the diagnosis. What are the classic features? So they're outlined very clearly in Symptom to Diagnosis, but I'm going to run you through the ones that at least I remember very easily and that's that the arthritis is recurrent, there's maximal inflammation in less than a day.
DR. CIFU: I've heard people refer to gout as thunderclap joint pain. It really, truly people will go to bed saying I felt fine, and will wake up at one o'clock in the morning with pain so severe they can't put a sheet over their foot. So recurrent maximal inflammation in less than a day. Monoarthritis, joint erythema, right? You're saying it's, monoarticular inflammatory. And then things which really pertain to gout. So involvement of the first MTP and unilateral MTP arthritis, so that's podagra, unilateral tarsal arthritis.
DR. CIFU: So, you know, forefoot and ankle arthritis, presence of tophi on exams, or hyperuricemia which is really hyperuricemia in the past, because uric acid levels when someone's in a gout flare are not terribly reliable.
DR. STERN: That's great. I think the other thing that's interesting about gout that people who haven't seen it won't appreciate it is the foot is so inflamed you often wonder if there's an infection on the dorsum of the foot. I mean, it's swollen, the whole foot looks horrible.
DR. CIFU: Right. It's often hard to isolate that it's MTP arthritis, right? 'Cause it looks like, boy, half this patient's foot is swollen and it's not until you start touching it that you get to the MTP and you touch it and the person flies off the bed.
DR. STERN: Right, exactly. Nobody likes that. All right, well, my fingerprint is the presence of subcutaneous rheumatoid nodules in a patient who has polyarthritis is very specific for RA, with a likelihood ratio of over 30, which is actually why they call them rheumatoid nodules. So not terribly common, but very helpful when they're there.
DR. CIFU: Right, for me these days, it's something I generally point out to students on my patients who have bad rheumatoid arthritis, like "Okay, and these are rheumatoid nodules."
DR. STERN: That's awesome. All right, how about some misconceptions?
DR. CIFU: Okay. This actually sounds like one of your misconceptions.
DR. STERN: [chuckles]
DR. CIFU: So the misconception is that if the patient is not febrile, they do not have a septic joint and that's just not true. And that gets back to the idea that, you know, fingerprints are often very helpful. So a positive finding may actually drive you in the diagnosis of an infection, but the converse is not true. So the absence of a finding is generally not helpful. And in fact, about half of patients who present with a septic joint are afebrile, and a good number of patients who present with really bad gout are febrile.
DR. CIFU: So whatever, it just doesn't help you. Certainly, if someone comes in with a very high fever and one very inflamed joint that makes septic gout likely, but--
DR. STERN: You said makes a septic gout likely.
DR. CIFU: Sorry, makes a septic joint likely. Septic gout's a whole 'nother ball of wax. [both chuckle]
DR. STERN: Septic gout, we have a new animal. The misconception I want to point out was brought out by a patient I saw recently who had an infected prosthetic joint and this doesn't come up terribly often, but I just thought it was worth mentioning that these are very hard to diagnose. Infected prosthetic joints, a person who's already had a joint replaced, and then comes in with not an immediate postoperative infection, but an infection down the line are often subacute and rarely have the erythema and the inflammatory signs that you might see in a native joint.
DR. STERN: And so if you see a patient who has a prosthetic joint and there's new problems with that knee or joint, and it's more swollen and it doesn't really look exactly like a septic joint, boy, you need to get that patient evaluated preferably by their orthopedist and quickly.
DR. CIFU: I agree. I think we actually-- we talked about this patient when you were seeing the patient. Right, for me, it's like, you know, is there a hardware malfunction that I can see on an X-ray? And if not, you know, I don't know what I'm doing with this because you know, sometimes it's healing, sometimes it's the patient's previous arthritis that's flaring, you know, around a prosthetic joint.
DR. CIFU: Sometimes it's an infection. And I just, I can't figure it out.
DR. STERN: It's really tricky because the whole joint's inflamed for a long time after they replace it.
DR. CIFU: Right, absolutely.
DR. STERN: In a shocking way actually.
DR. CIFU: And I think people who are not orthopedist doing joint replacements just don't have the experience following joints for a long time, and seeing what the natural history of recovery is in a wide way range of patients.
DR. STERN: Right, exactly. All right, our favorite pet peeves, Adam.
DR. CIFU: So my pet peeve is definitely the ANA. So, it's sending an ANA in someone who doesn't really have reasons for you to have suspicion for lupus. So like, just sending an ANA in every person who comes in who says like they're a little bit achy and fatigued. The specificity of ANA in people who are actually at risk for disease is 45%, okay? And so that means that 55% of the people in whom you might send the ANA who do not have lupus will have a positive ANA, right?
DR. CIFU: So that's a lot of positive ANAs, and what have you done for that person? Nothing, except told them that they have a positive ANA that they should probably worry about for the rest of their life. On the other hand, we all know the ANA is quite sensitive, usually quoted around 96%. So if you get a negative ANA you're in good shape, you know, you've done a pretty good job of ruling out lupus, but so, you got to think, when you're sending an ANA on a low-risk person, you're really just taking a gamble that you're going to get lucky and it's going to be negative.
DR. STERN: So when I come to see you for my physical, I won't ask you for an ANA then.
DR. CIFU: I often do yearly ANAs on healthy people just, just to try to, you know, break Medicare.
DR. STERN: All right. So my pet peeve is examining a person who has a joint complaint through their clothes. It's shocking how often people do this actually, and don't actually look at the joint. And the last time I remember this happening in urgent care, one of our residents looked-- a patient came in with knee pain, and they examined them through their clothes, and when I actually asked the patient to take off her blue jeans she had zoster, not osteoarthritis as the resident had thought.
DR. STERN: So do me a favor, when somebody says it hurts somewhere, look at it, look at the skin, and see what you see.
DR. CIFU: That resident will probably avert their glance every time you walk by them in the hall.
DR. STERN: Totally.
DR. CIFU: Yeah, and you go back to physical diagnosis and just remember, you know, it's inspection, auscultation, percussion, palpation, palpation, percussion, and often just looking at something is really helpful.
DR. STERN: All right, so our last section is clinical pearls, Adam?
DR. CIFU: You know, my first one, this wasn't intentional, but may go nicely after your last one is that often the clue to the cause of joint pain is actually found not examining the joint, but on the general exam. Think about, you know, you're seeing a patient who comes in with joint pain, but they also have, I don't know, fever, rash, a heart murmur, nail changes, a pleural rub, you know, that's going to be hugely effective on what your differential and maybe what your diagnosis is.
DR. CIFU: If you just focus on rash, right? Rash and joint pain, that might be suggestive of endocarditis, of psoriatic arthritis, of SLE, of reactive arthritis, of viral arthritides, and you know, sometimes those rashes are non-specific, but sometimes they're actually quite specific and will really help you make a diagnosis in the setting of everything else that's going on with the patient.
DR. STERN: Yeah, it would totally change your organizational thinking about that patient.
DR. CIFU: Absolutely, absolutely.
DR. STERN: Well, my clinical pearl turns once again to gout, which is gout can affect various joints in the body, but it almost always starts in the big toe. I don't know if you have doubt about that, but I'd be curious if you do. But if I saw a patient who never had gout in the big toe and came in with an inflamed knee, I'd be very suspicious that this is gout, meaning, I would not think it's very likely, and evaluate that patient thoroughly.
DR. CIFU: Right, you know, I think it's, it's interesting if you go back to, what was it, my first fingerprint, when I talked about, you know, six classic features of gout with a likelihood ratio of 22. So, you know, a bunch of the things I mentioned there, right? Was recurrent, first MTP arthritis, unilateral MTP arthritis, right? So if you're talking about someone presenting with a first episode in another joint, you immediately take away three of those classic findings.
DR. CIFU: It's going to be very hard to make a diagnosis of gout on a first presentation in a non-MTP joint.
DR. STERN: So basically neither of us would do that.
DR. CIFU: Neither. I would not, I would not.
DR. STERN: Right, I agree.
DR. CIFU: On the other hand, you know, if someone comes in with acute podagra and you see someone who's going to tap that joint, you should probably throw your body in front of the needle. And say, like, don't do that, that's not necessary, right?
DR. STERN: Well, I don't know that I'd throw my body. It might be worse than them getting a tap, but that's okay, the point's taken.
DR. CIFU: Come on, this is your vocation, sacrifice yourself for it.
DR. STERN: Indeed.
DR. CIFU: So we hope you found this episode of the Symptom to Diagnosis podcast useful, and a bit enjoyable. As a reminder, our textbook "Symptom to Diagnosis: An Evidence-Based Guide" takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places, on your handheld device, and also available and fully searchable via the Access Medicine website available worldwide from McGraw Hill.
DR. CIFU: Thanks a lot.
DR. STERN: Thank you. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.