Multiple Joint Pain
The range of causes of multiple joint pain spans acute, chronic and chronic relapsing conditions. The difficulty for the primary care clinician is sifting through the wide differential and spotting early significant disease that requires prompt referral.
Differential diagnosis
Common Diagnoses
- Rheumatoid Arthritis (RA)
- Psoriatic Arthropathy
- Viral Polyarthritis (e.g. Hepatitis, Rubella)
- Connective Tissue Diseases (e.g. SLE, Systemic Sclerosis, Polyarteritis Nodosa, Giant Cell Arteritis)
- Multiple Osteoarthritis (OA)
Occasional Diagnoses
- The Spondoarthritides: Ankylosing Spondylitis, Reiter’s Disease, Enteropathic Arthritis, behçet’s Syndrome, Juvenile Chronic Arthritis
- Henoch–Schönlein Syndrome
- Malignancy (Usually Secondary)
- Iatrogenic: Corticosteroid Therapy, Isoniazid, Hydralazine
- Hypertrophic Pulmonary Osteoarthropathy (Due to Lung Cancer)
- Sarcoidosis
Rare Diagnoses
- Sickle-Cell Crisis
- Amyloidosis
- Rheumatic Fever
- Atypical Systemic Infections (e.g. Lyme Disease, Weil’s Disease, Brucellosis, Syphilis [Secondary])
- Decompression Sickness (the Bends)
Ready reckoner
Key distinguishing features of the most common diagnoses
| RA | Psoriasis | Viral | Connective Tissue | OA | |
|---|---|---|---|---|---|
| Symmetrical | Yes | Possible | Possible | Possible | Possible |
| Rash | No | Yes | Possible | Possible | No |
| Fever, Malaise | Possible | No | Yes | Possible | No |
| Young Patient | Possible | Possible | Possible | Possible | No |
| Self-Limiting | No | No | Yes | No | No |
Possible investigations
Likely: FBC, ESR/CRP, autoantibodies.
Possible: Urinalysis, U&E, HLA-B27, joint X-rays, synovial fluid aspiration.
Small Print: Blood film, serology, CXR, bone scan, bronchoscopic biopsy or nodal aspiration.
- FBC, ESR/CRP, blood film: WCC and ESR/CRP raised in acute inflammation and infection. Anaemia of chronic disease may be seen, and blood film will reveal sickle cell.
- Autoantibodies: Rheumatoid factor is positive in most cases of RA (if negative, consider measuring anti-CCP), but is also positive in many autoimmune diseases and chronic infections; antinuclear factor is positive in 98% of cases of SLE but a similar result is obtained in 30% of cases of RA and also in many other diseases.
- Urinalysis: May reveal proteinuria or haematuria if there is renal involvement in connective tissue disease.
- U&E: To check for renal failure via renal involvement in multisystem connective tissue disease.
- HLA-B27: A high prevalence in spondoarthritides.
- Serology: May be useful to diagnose viral, or atypical systemic, infections. ASO titres, if rising, suggest recent streptococcal infection (e.g. in rheumatic fever).
- Joint X-rays: Hand X-rays may show characteristic features helping to distinguish between RA and psoriatic arthritis; pelvic and lumbar spine X-rays may show the typical changes of ankylosing spondylitis (if negative, and clinical suspicion high, a bone scan may be helpful); X-rays of affected joints may confirm clinical diagnosis of OA.
- CXR: May reveal lung malignancy.
- Synovial fluid analysis: Helps distinguish inflammatory from infective and crystal arthropathies.
- Bronchoscopic biopsy or nodal aspiration: For sarcoidosis.
Top Tips
- The connective tissue diseases can all affect almost every organ system. Take a full history so as not to miss a clue or complication.
- Check the skin as this may contribute to the diagnosis (e.g. scaly rash in psoriasis, butterfly rash in SLE, thickening of skin in sclerosis).
- Don’t overvalue autoimmune blood tests. Most diagnoses of arthritis are clinical, blood tests simply providing confirmatory or prognostic information.
Red Flags
- Suspect Reiter’s syndrome in a young male with an inflammatory oligoarthritis of the lower limbs.
- An insidious onset of symmetrical polyarthritis in the 30–50 age range, with early morning stiffness, pain and swelling of hands and feet, suggests RA.
- Pain in the wrists and ankles of a middle-aged or elderly smoker with clubbing and chest symptoms strongly suggests hypertrophic pulmonary osteoarthropathy caused by underlying lung cancer.
- Don’t overlook the patient’s occupation as this may be relevant in certain cases – for example, in vets and farm workers, brucellosis and Weil’s disease are possible infective causes.