Skip to content

From the American College of Rheumatology

Rheumatology for Primary Care
  • Symptoms
    • Fever
    • Joint Pain
    • Muscle Pain and/or Weakness
    • Rashes
    • Raynaud’s Phenomenon
  • Diseases
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Drug and Medication-Induced Rheumatic Diseases
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Idiopathic Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Multisystem Inflammatory Syndrome in Children
    • Myositis
    • Polyarteritis Nodosa
    • Polymyalgia Rheumatica
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Case Studies
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Inflammatory Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Myositis
    • Pediatric Fevers
    • Polyarteritis Nodosa
    • Polymalgia Rheumatica
    • Raynaud’s Phenomenon
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sicca/Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Labs
  • Meds
    • Commonly Used Rheumatology Meds
    • Treatment Considerations
    • Addressing Patient Fears About Rheumatology Medications
    • Medications by Diseases
  • Resources
    • Resources
    • Vaccination Considerations – Pediatrics
    • Vaccination Considerations – Adults
    • Glossary of Terms
    • ACR Clinical Guidelines
    • ACR Education Center
    • Rheumatology Provider Directory

Joint Pain

Home ยป Joint Pain
Joint PainPrimary Care2024-05-21T14:41:29+00:00
  • Diagnostic Workup

  • Clinical Pearls

  • Special Considerations for the Pediatric Population

  • Diagnostic Workup

When a patient reports symptom of “joint pain,” it is very important to differentiate if the pathology is truly within the joint (intra-articular) or an issue with structures around the joint (extra-articular).

  • INTRA-ARTICULAR:
    • Pain on ACTIVE range of motion or when the patient does the movement, and
    • Pain on PASSIVE range of motion or when the provider does the movement
  • EXTRA-ARTICULAR:
    • Pain on attempted ACTIVE range of motion
    • Commonly painless on PASSIVE range of motion or when the provider does the movement
    • Tenderness on palpation of peri-articular structure

An important factor in developing a more focused differential is to determine whether the joint problem is inflammatory versus non-inflammatory in nature:

  • INFLAMMATORY:
    • On history: AM stiffness usually ≥60 min, improves with activity
    • On physical exam: swelling, effusion, warmth, and erythema of joint
    • If joint fluid available (look for WBC amount, gram stain, culture, and crystals): WBC ≥2k (and not hemarthrosis)
  • NON-INFLAMMATORY:
    • On history: AM pain usually ≤ 30 min, worsens with use
    • On physical exam:
      • Crepitus +/- locking, clicking
      • Bony hypertrophy (longstanding OA) or effusion may be present, but the joint will not be warm and soft tissue swelling will be absent.
    • If joint fluid available: WBC <2K

Given the above, the following approach is recommended for diagnosing patients with joint pain.

Flowchart that walks through how to best diagnose joint pain, starting with intra-articular joint pain vs. extra-articular joint pain.

  • Clinical Pearls

  • Chronicity
    • Acute onset: crystal arthropathy (in adults), infection
    • <6 weeks: parvovirus, Epstein Barr virus, Lyme, post-streptococcal reactive arthritis
    • Chronic (≥6 weeks): osteoarthritis, rheumatoid arthritis, spondyloarthropathies, systemic lupus erythematosus and related connective tissue disorders, sarcoid, juvenile idiopathic arthritis (in children), polymyalgia rheumatica
  • Septic arthritis
    • Sexually active: gonococcal infection
    • IV drug use: staph or strep septic arthritis
    • Sickle cell: salmonella
  • Diarrhea: consider enteropathic arthritis or reactive arthritis
  • Urinary tract infection symptoms: reactive arthritis
  • Anticoagulated: hemarthrosis
  • Long-term steroid use: infection, avascular necrosis, fragility fracture
  • Distribution
    • 1st MTP arthritis: gout, “podagra”
    • 5th MTP erosion: rheumatoid arthritis
    • DIP arthritis +/- erosions or fluffy periostitis: Psoriatic arthritis
    • CMC arthralgia: osteoarthritis
    • MCPs 2/3: CPPD, hemochromatosis, rheumatoid arthritis
    • Sacroiliac joint: ankylosing spondylitis, axial involvement with IBD-associated arthritis, psoriatic arthritis or reactive arthritis
  • Rheumatoid arthritis does not involve:
    • DIP
    • Thoracolumbar spine
  • Osteoarthritis does not involve:
    • MCP
    • Elbow
    • Rarely glenohumeral  shoulder joint
  • Gout does not involve the axial spine.
  • Special Considerations for the Pediatric Population

The cause of a swollen joint or limp in a child varies from benign to serious and distinguishing characteristics can be elucidated from the history, examination, laboratory, and imaging studies.

History

  • Trauma
  • Duration, location, frequency, intensity, quality, exacerbating/alleviating factors
  • Symptoms that may be associated with inflammatory joint pain: 
    • Morning stiffness, swelling, stairs, weakness, pain with chewing, number of joints involved
    • Associated symptoms: rashes; fevers; oral/nasal ulcers; Raynaud’s phenomenon; eye problems such as conjunctivitis, iritis, or uveitis
  • Symptoms associated with chronic pain syndromes:
    • Evening pain
    • Pain without swelling, or limited ranges of motion
    • Missed school
    • Association with poor quality of sleep
    • Allodynia
    • Associated symptoms: headaches, stomachaches, IBS symptoms, POTS

Physical Exam

  • Limitation of motion: best appreciated at ENDPOINTS of range and compared to contralateral side; contractures can also be seen
  • Warmth
  • Swelling: best appreciated from midline while looking at both sides to compare 
  • Growth discrepancies: leg length discrepancy, muscle atrophy on affected side
  • Gait with walking, running, toe walking and heel walking; assess for equal time on each side and foot/ankle positioning, knee flexion/extension

Differential Diagnosis

Inflammatory Arthralgia
  • Systemic rheumatic diseases (including Kawasaki disease, chronic nonbacterial osteomyelitis/chronic recurrent multifocal osteomyelitis)
  • Reactive and post-infectious arthritis (including rheumatic fever)
  • Hematologic disorders (leukemia, bleeding diatheses, hemoglobinopathies)
  • Septic arthritis and osteomyelitis (including parvovirus-associated arthritis and Lyme arthritis)
Non-inflammatory Arthralgia
  • Avascular necrosis and epiphyseal disorders (Legg-Calve-Pertes)
  • Traumatic arthritis including hypermobility associated with microtrauma
  • Metabolic and endocrine disorders (including Rickets)
  • Tumors
  • Idiopathic pain syndromes (including complex regional pain syndrome and fibromyalgia)
  • Vitamin C deficiency
Joint Pain Without Joint Swelling
  • Legg-Calvé-Perthes disease (hip pain)
  • Slipped upper femoral epiphysis/slipped capital femoral epiphysis (hip pain)
  • Benign hypermobility syndrome
  • Inherited metabolic disorders (e.g., Gaucher disease)
  • Osgood-Schlatter disease
  • Scheuermann disease
  • Growing pains
  • Complex regional pain syndrome
  • Amplified musculoskeletal pain
Single Joint Involvement
  • Bacterial infections (e.g., septic arthritis, osteomyelitis, abscess and pyomyositis)
  • Lyme disease in endemic areas
  • Trauma
  • Hemarthrosis due to vascular malformation, or bleeding diathesis
  • Malignancies such as acute lymphoblastic leukemia and malignant tumors
  • Benign tumors such as osteoid osteoma, pigmented villonodular synovitis
Multiple Joint Involvement
  • Reactive arthritis
  • Viral arthritis
  • Systemic lupus erythematosus
  • Juvenile dermatomyositis
  • Juvenile idiopathic arthritis
  • IgA vasculitis (Henoch-Schönlein purpura)
  • Scleroderma
  • Lyme disease
  • Malignancy
  • Immunodeficiency-associated arthritis
  • Inflammatory bowel disease-associated arthritis
  • Chronic recurrent multifocal osteomyelitis

We Want Your Input

Find what you needed? We would love your feedback so that we can ensure the site meets the needs of primary care providers.

Give Feedback

American College of Rheumatology Information

About ACR

ACR Contacts

Authors

This product was funded by a medical grant from Pfizer. The content was written by a physician work group. See Authors

© Copyright American College of Rheumatology 2025 | All rights reserved | See ACR Policies

Page load link
Go to Top