Taking a patient history
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The history is the critical part of the assessment. If the story is consistent with inflammatory joint pain, you should consider further action even if there are few or no signs on physical examination.
There are no clear-cut methods of assessment to produce a diagnostic algorithm, but the diagram below shows some typical features of inflammatory arthritis compared with other joint pain:
Key questions to cover in the history
Where's the pain?
How did the problem start and how has it developed?
Is there any stiffness?
Is there any swelling?
How do the symptoms relate to activity?
Are there any extra-articular features?
Red flags Where's the pain?
Different patterns of joint involvement tend to be associated with different diseases.
Joint involvement is usually symmetrical in rheumatoid arthritis. The small joints of the hand and feet are often affected, although in the elderly the larger joints may be mainly affected in a clinical presentation similar to polymyalgia rheumatica. The number of affected joints usually increases over a period of time.
Other types of inflammatory arthritis may present symmetrically or asymmetrically (for example psoriatic arthritis) and with poly-, mono- or oligoarthritis.
If the arthritis flits from one joint to another in a migratory pattern, this is known as palindromic rheumatism.
Typically in palindromic rheumatism, inflammation can arise fairly suddenly in one joint, last for a few hours to days, and then spontaneously resolve, before arising again in a different joint.
Back pain may suggest a spondyloarthritis, although rheumatoid arthritis may also affect the neck.
In the hands:
rheumatoid arthritis usually doesn't affect the distal interphalangeal (DIP) joints
psoriatic arthritis may affect any of the joints
osteoarthritis rarely affects the metacarpophalangeal (MCP) joints.
key questions. How did the problem start and how has it developed?
In general, inflammatory conditions tend to have an acute or subacute onset. Pain of a non-inflammatory origin such as osteoarthritis or fibromyalgia is likely to have a more gradual onset over a period of months or even years.
Attacks of gout are likely to have a very sudden onset, while polymyalgia rheumatica often develops quite rapidly over a few weeks.
key questions. Is there any stiffness?
Early morning stiffness is a common and important symptom of inflammatory arthritis. Stiffness lasting longer than 30 minutes is significant, and patients frequently report stiffness that lasts several hours, or even most of the day. A diurnal variation with stiffness in the evening is also common.
Viral arthropathies, though self-limiting, typically have a similar pattern of morning stiffness to rheumatoid arthritis.
Stiffness typically occurs after periods of rest or inactivity in osteoarthritis. This ‘gelling’ often becomes worse as the day goes on but is relatively short-lasting (less than 30 minutes).
Osteoarthritis is more likely to cause localised stiffness in specific joints. Stiffness in rheumatoid arthritis may be more generalised.
key questions. Is there any swelling?
A history of joint swelling often suggests an inflammatory disease process. It's important to follow this up in the
soft ‘squidgy’ swelling is typical of inflammatory conditions
hard, bony and non-tender swelling, for example of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) finger joints, is often seen in nodal osteoarthritis.
Swelling of the knee or ankle is less helpful in identifying inflammatory disease. Knee swelling could be associated with osteoarthritis or trauma while ankle swelling is commonly due to oedema.
key questions. How do the symptoms relate to activity?
In general, pain of a non-inflammatory origin is more directly related to use. Pain resulting from inflammation tends to flare up and then ease unpredictably, sometimes from one day to the next.
Severe bone pain is often persistent and unremitting, causing sleep disturbance. Fibromyalgia pain is often associated with poor sleep patterns.
Look out for symptoms like:
Skin – rashes, nail changes, bruising, ulcers
Bowel – abdominal pain, change in bowel habit
Eye symptoms – dry eyes
Circulatory problems – Raynaud’s phenomenon, ulcers
Systemic features – fatigue, malaise.
key questions. Red flags
The following red flag features should always prompt consideration of serious pathology and can be indicative of any inflammatory, infective or neoplastic process:
fever or other systemic manifestation
single joint involvement
neurological symptoms and signs.
Kim's history shows the pain in her hands and knees came on over the last month. She's also experiencing swelling and morning stiffness.
Fahmida's history shows her pain started in her shoulders and back, but it's now spread. She hasn't noticed any swelling but is experiencing fatigue and poor sleep.
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