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Narrowing the differential diagnosis
When evaluating joint pain, it useful to consider six key concepts during the
history and physical examination that help to narrow the differential diagnosis.
By narrowing the differential, one can focus the work-up in a more expedient and
cost efficient manner.
The six key concepts are:
* Is the condition acute or chronic?
* Is the problem inflammatory or noninflammatory?
* What is the pattern of joint involvement?
* Are there associated systemic features?
* What are the demographics of the patient that might make one diagnosis more
tenable?
* Is the joint pain really an arthritis?
Periarticular, articular, or nonarticular?
There are a variety of structures that can become painful and might be
interpreted as an arthritis by patients. Causes of joint pain from outside the
joint (structures inside the joint capsule) can be from periarticular
structures. The following is a list of structures around a joint that might
present to you as joint pain.
Periarticular causes of joint pain
Bursitis
Faciitis
Tendonitis
Ligament Injury
Epicondylitis
Myofacial Pain/Fibromyalgia
There are also a variety of nonarticular abnormalities affecting bone, nerve, or
blood vessels that may present as joint pain. Below is a list of such causes.
Nonarticular causes of joint pain
Tumors of Bone
Radiculopathy
Osteomyelitis
Neuroma
Nerve Entrapment
Vasculopathy
Physical examination to differentiate these problems should include:
*Inspection of the joint area for evidence of swelling or redness
*Passive range of motion of the joint(s) in the area noting pain, reduction of
motion, or instability
*Active range of motion of the joint(s) in the area noting pain that was not
there when the joint(s) were passively moved
*Resisted range of motion of the joint(s) in the area again noting pain
*Palpation of the joint line(s) and surrounding structures noting tenderness,
joint effusion(s), and boney changes.
*Most soft tissue problems do not hurt with passive motion while most forms of
arthritis do.
*Tendonitis is typically painful with active or resisted motion.
*A bursitis is usually painful only with palpation.
*Myofacial pain is also painful to palpation and may be widespread as in
fibromyalgia.
Acute vs. chronic
Acute refers to conditions lasting less than 8 weeks while chronic signifies
conditions that persist for a longer period of time. Acute also suggests a rapid
onset. Many acute disorders are also self-limited. This division of acute and
chronic can help focus the evaluation especially for conditions that have been
present for more than 8 weeks.
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