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Chronic mono- or oligoarticular pain (>6 weeks) is unusual. Degenerative disease (osteoarthritis) presents
without inammation or effusion. Inamed joints are likely septic with fungus or TB as the most likely
organisms.
Polyarthritis: Involves both small and large joints in a symmetric fashion.
Acute polyarthritis is often self-limited and resolves within 6 weeks without clear-cut diagnosis (viral, post-viral
or post-vaccination arthritis).
If the process last >6 weeks it is most commonly rheumatoid arthritis.
Oligoarthritis: (arthritis of very few joints)
The spondyloarthropathies, or vertebral arthritides, share common features of asymmetric oligoarthritis, inam-
matory back pain, mucocutaneous lesions, and inammation of attachment tendons and ligaments. The
group includes ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and the arthritis associated with
inammatory bowel disease. Reactive arthritis typically follows an infection of the genitourinary tract or
bacterial dysentery.
Inammatory low back pain awakens patient at night, causes profound morning stiffness lasting > 1 hr,
localizes to sacroiliac joint with tenderness, improves with exercise, radiates into the buttocks, posterio
thigh and knee (not below the knee) and may alternate buttocks.
Reiter’s syndrome begins with an infection, often a nonspecic urethritis, a post gonococcal urethritis or a
bacterial bowel infection with bloody diarrhea. In the weeks following the infection the patient develops
conjunctivitis and/or shallow, painless oral ulcers. These symptoms may be mild and overlooked or not
reported. Shortly after the patient develops an asymmetric oligoarticular inammatory arthritis, usually
involving large joints of the lower extremity, e.g. knee or ankle. There is also a tendency for the Achilles
tendon and plantar fascia to be involved. Small joints of the hands and feet may be involved with
inammation of every joint in a digit as well as the tendons and ligaments of that digit (a dactylitis,) giving
a sausage digit appearance.
Ankylosing Spondylitis presents as insidious onset of inammatory low back pain in young men (onset < age
40 yr.) and is often mistaken for mechanical lumbar sprain or strain for years before the diagnosis of
inammatory arthritis disease is entertained. Also involves uveitis of the eyes.
Mechanical low back pain: Common syndrome of pain, which may radiate into the buttocks or legs and
is often associated with sensory derangement (numbness, tingling, etc.), history of trauma, morning stiffness
which improves, and pain with lifting.
Arthralgias/myalgias without physical findings:
Acute arthralgia/myalgia is seen in viral illness, overuse. Chronic polyarthralgias/polymyalgias may be seen
with fibromyalgia, overuse syndromes, hypothyroidism, diabetes and more rarely, metabolic bone disease
such as hyperparathyroidism. Myositis, or inflammatory muscle disease, presents with insidious onset
proximal muscle weakness and elevated muscle enzymes. Rhabdomyolysis, the massive breakdown of
muscle cells due to a variety of causes (trauma or compression, ischemia, infection, drug toxicity, metabolic
disease, heat injury), may be associated with muscle swelling and pain. Myoglobin release into the blood
stream is toxic to the kidneys. Patients may present with brown urine and renal failure. This illness,
presenting with acute onset muscle pain is a medical emergency.
Plan:
Treatment
General (mechanical, as well as some inflammatory causes of arthritis):
- Rest, compress and elevate inamed joints.
- Apply ice and/or heat (alternating for 20 min each). Heat may feel better on a sore joint, but do not use
within 48 hours of an acute injury. - Immobilize and protect joint with splint, brace or cast and crutches or cane, as appropriate.
- Perform (active or passive) gentle range of motion exercises bid/tid early in treatment to retain mobility.
- Later, perform strengthening and isometric exercises for supporting muscles followed by isotonic and
weight bearing exercises as soon as tolerated.