JOINT PAIN

Resident Author: Mustafa Mohamedali MD

Faculty Advisor: Gilchrist, Christopher, MD, CCFP 

External Reviewer: Alessandro Francella, MD, CCFP (SEM), Dip. Sport Med.
Created: October 2020

Diagnosis
Table 1: Differential diagnoses to consider in all patients with monoarthropathy1-10
Infection Crystal Induced Hemarthrosis: 
 Tumor
Septic arthritis, post- Gout - most commonly knee/1st MTP (podagra). Chondrosarcoma, Metastatic
infective arthritis, Severe pain, erythema, swelling, When to suspect: cancer, osteoid osteoma, etc.

Trauma,
When to suspect: When to suspect: Anticoagulation, When to suspect:
Acute atraumatic swelling, clotting disorder, Large new mass at the joint,
warmth, tenderness Pseudogout (CPPD) - can present similarly to fracture
pain gradually increasing over
systemic fevers/chills. Pain gout time with joint stiffness,
on passive joint movement nighttime pain, fevers, chills,
Always consider primary night sweats, unexplained
STI weight loss

Next step: Next step: Next step: Next step:

-Send to ER for septic
workup including
aspiration of joint fluid
-Gout: Counsel on risk factors Obesity, significant X-ray to r/o acute X-ray of joint to start
EtOH use, Thiazide diuretic, etc. fracture Biopsy for confirmation
-Colchicine, NSAIDS acutely (see table 3) Can aspirate joint if Can proceed to other imaging
-Allopurinol 4-6 weeks post acute flare significant fluid (CT, PET, MRI as clinically
-If first presentation, aspirate to confirm diagnosis
present indicated)

Systemic Rheumatic Intraarticular Derangement MSK


Disease 
 Meniscal Tear, fracture, Acute ACL rupture, Ligament/Tendon injury - clear mechanism of injury that
RA, SLE, Sarcoidosis Loose Body, Joint Dislocation correlates with physical exam (varies based on joint)

Spondyloarthritis When to suspect: Osteoarthritis flare - advanced age, previous trauma/
JIA, etc. etc. Acute trauma and point tenderness on palpation injuries to area, diagnosis of exclusion 

Unable to weightbear for lower extremity joints Always keep differential broad and examine joint
See figure 1 for details “locking sensation”, pain with movement above and below

Next steps: Next step: Next step:

See below, bloodwork as
indicated. If suspect
inflammatory cause, refer
to rheumatology and/or
place patient on therapy
(see treatment section for
details)
To ER if open fracture, or unstable Minimize investigations in lieu of physio unless specific
X-ray to r/o fracture indications present
f/u MRI to r/o meniscal tear or other concomitant Note, an x-ray is not needed to diagnose ligamentous
injuries injury.
X-ray can be done to r/o fracture and/or confirm
presence of OA.

Figure 1: Approach to Polyarthropathy11

When considering a patient

with joint pain of unclear
etiology, do a full review of
systems and keep systemic
conditions on the differential
(Wegener’s granulomatosis,
lupus, ulcerative colitis,
fibromyalgia, etc.)
Prevention and Treatment12-21
Table 2: Analgesia options for joint pain
Class Indications Side Effects Monitoring Parameters

Non-Pharmacological:
1st line treatment for
Massage, Ice, Heat, Physical Activity,
Physiotherapy,
Arrange for community resources
and gait aids (walker, cane, etc) PRN
Increased life satisfaction! Physical activity guidelines:
joint pain Moderate to vigorous aerobic
physical activities such that there is
an accumulation of at least 150
minutes per week
Muscle strengthening activities
using major muscle groups at least
twice a week

Acetaminophen 1st line treatment for Hepatotoxic. Max dose 2-3g in

Tylenol 650-975 mg q4-6h prn fever and analgesia elderly, hepatic impairment/
Max: 4g in 24 hours cirrhosis, malnutrition

NSAIDS
Meloxicam 7.5-15 mg once daily
Naproxen 250-500 mg BID-TID to
max 1500 mg/day
Diclofenac 50 mg BID-TID, max 150
mg in 24 hr
Celecoxib 200 mg once daily or 100
mg BID
For pain related to GI ulcers +/- bleeding Baseline blood pressure should be
inflammation. No Renal impairment taken and screening bloodwork
evidence for one Diarrhea, Hepatotoxicity, should be ordered before
type over another. Cardiovascular events, prescribing (CBC, LFTs,
Use lowest dose for Bronchospasm, Pulmonary Creatinine), repeat bloodwork and
shortest time not for edema BP at one month after starting
long-term daily treatment and q3months thereafter
therapy * Do not use in renal failure or if
patient has known gastric ulcers

Topical NSAIDS Can be used for mild Can cause skin irritation
Diclofenac gel available OTC to moderate joint
Capsaicin apply TID-QID to unbroken inflammation
skin

Table 3: Specific Rheumatologic Treatments

Medications Indications Side Effects Monitoring Parameters

Colchicine Treatment of Diarrhea Treatment should be initiated within 24

Day 1 oral: 1.2 mg at the first sign of flare, followed gout, off hours of onset
in 1 hour with a single dose of 0.6 mg or 0.6 mg 3 label for (Narrow therapeutic window)
times daily on the first day of flare; maximum total pseudo-gout
dose: 1.8 mg on day 1 of flare
Day 2 and thereafter: Oral: 0.6 mg twice daily until
flare resolves

Prednisone Gout, Fluid retention, Blood pressure, serum glucose,

(dosage and varies based on clinical situation) myopathies, electrolyte electrolytes, signs/symptoms of infection
other disturbances,
inflammatory arrhythmias,
disorders cushingoid
(situation appearance (adrenal
dependent) suppression), weight
gain

Methotrexate* (should be started ASAP when Rheumatoid Headache, dizziness, CBC with differential and platelets, serum
diagnosis of RA is made) Arthritis fatigue, cirrhosis, creatinine, and LFTs: Baseline and every 2
Contraindica azotemia, to 4 weeks for 3 months after initiation or
10 to 15 mg once weekly, increased by 5 mg every ted in nephropathy, following dose increases
2 to 4 weeks to a maximum of 20 to 30 mg once Pregnancy, thrombocytopenia, Chest x-ray (to check for TB) - annual TB
weekly alcoholism, mucositis, Nausea/ test (high risk)
alcoholic vomiting, confusion If high risk, Hepatitis B and C serology +/-
liver disease Liver biopsy

*Note: Other DMARDs are also available including hydroxychloroquine, leflunomide, sulfasalazine, minocycline and others.
Methotrexate is the most common DMARD used, and typically if using other DMARDs, consider referral to a Rheumatologist. 

Note: This is not an exhaustive list of therapies for rheumatologic conditions. Additional therapies are beyond the scope of most family
medicine practices.
Key Treatment Pearls for Rheumatologic Conditions
Actively ask patients about their comorbid conditions routinely, as they may change the overall management plan
Do a thorough exam to check for extraarticular manifestations of rheumatologic conditions (see below for a non exhaustive
list):

Figure 2: Extraarticular manifestations of common rheumatological conditions15



Key Treatment Pearls for MSK conditions
Remember to always ask patients about the impact of pain on their daily function.
Other non-pharmacological resources that are available to patients in the community include: splints, walking canes, walkers,
etc.