🦴 Chronic joint pain and stiffness is a common presentation in both primary care and rheumatology clinics. 👉 It can result from mechanical wear-and-tear, systemic inflammatory diseases, infection, or metabolic/autoimmune causes. The challenge is distinguishing inflammatory vs non-inflammatory pathology, as this guides investigations and management.

📖 About

Chronic joint pain: Pain lasting >6 weeks, may be constant or intermittent.
Stiffness: Inflammatory conditions → prolonged morning stiffness (>30 min). Mechanical conditions → brief stiffness (<30 min), worse with activity.
Important to assess joint distribution (small vs large joints, symmetrical vs asymmetrical).

⚡ Causes of Chronic Joint Pain & Stiffness

Degenerative (Mechanical):
- Osteoarthritis (OA) – most common; worse with use, improves with rest.
- Previous trauma or joint injury.
Inflammatory:
- Rheumatoid arthritis (RA) – symmetrical small joint pain, morning stiffness >1 hr, systemic features.
- Spondyloarthropathies (psoriatic arthritis, ankylosing spondylitis, reactive arthritis).
- Crystal arthropathies (gout, CPPD/pseudogout).
Infective: Chronic septic arthritis (TB arthritis, Lyme disease).
Metabolic/Endocrine: Haemochromatosis, acromegaly, thyroid disease.
Other systemic causes: Lupus, connective tissue diseases.

🩺 Clinical Features

History: Onset, duration, pattern, morning stiffness, effect of activity, systemic symptoms (fatigue, fever, rash, weight loss).
Exam:
- Joint swelling, warmth, effusion.
- Deformities (ulnar deviation in RA, Heberden’s nodes in OA).
- Reduced range of motion and functional limitation.
- Check for extra-articular features (skin, eyes, nails, spine).

🔎 Investigations

Bloods: FBC, ESR, CRP, U&E, LFTs.
Autoantibodies: RF, anti-CCP (RA); ANA, dsDNA (SLE); HLA-B27 (spondyloarthritis).
Joint aspiration: Microscopy & culture (exclude infection, crystals).
Imaging:
- X-ray: OA → joint space narrowing, osteophytes. RA → periarticular osteopenia, erosions.
- MRI: Early synovitis or sacroiliitis.
- US: Synovial thickening, effusions, power Doppler activity.

📝 Comparison of Common Chronic Joint Disorders

Condition	Typical Age	Pattern	Key Clinical Features	Investigations	Management
Osteoarthritis (OA) 🦴	>50 yrs (esp. elderly)	Asymmetrical, large joints (knees, hips, spine, DIP, PIP)	• Pain worse on activity, better on rest • Short (<30 min) morning stiffness • Bony nodes (Heberden’s, Bouchard’s) • Crepitus, reduced ROM	• X-ray: joint space narrowing, osteophytes • Bloods: normal inflammatory markers	• Analgesia, NSAIDs • Physio, weight loss, joint protection • Steroid injections, arthroplasty in severe cases
Rheumatoid Arthritis (RA) 🔥	20–50 yrs, F>M	Symmetrical, small joints (MCP, PIP, wrists)	• Morning stiffness >1 hr • Swelling, warmth, tenderness • Deformities (ulnar deviation, swan neck) • Systemic: fatigue, nodules, lung/eye involvement	• ↑ ESR/CRP • RF & anti-CCP positive • X-ray: erosions, periarticular osteopenia	• DMARDs (methotrexate, sulfasalazine) • Biologics (anti-TNF, IL-6) • Steroids for flares • MDT: rheum, physio, OT
Spondyloarthritis 🧍	Teenage–40 yrs, M>F	Axial spine, SI joints ± asymmetrical oligoarthritis (knees, ankles)	• Inflammatory back pain (night pain, improves with activity) • Enthesitis (heel pain) • Dactylitis ("sausage digit") • Extra-articular: psoriasis, uveitis, IBD	• HLA-B27 positive • MRI: sacroiliitis • ESR/CRP may be ↑	• NSAIDs first-line • Physiotherapy, exercise • Biologics if severe (anti-TNF, IL-17)
Gout 🍖	Middle-aged men, post-menopausal women	Monoarthritis (classically 1st MTP "podagra")	• Sudden, severe joint pain + swelling • Red, hot, tender joint • May have tophi (chronic) • Often linked to alcohol, red meat, diuretics	• Joint aspiration: needle-shaped, negatively birefringent crystals • ↑ Serum urate • X-ray: "punched out" erosions	• Acute: NSAIDs, colchicine, steroids • Long-term: allopurinol/febuxostat (urate-lowering therapy) • Lifestyle: reduce alcohol, purines

💊 Management Principles

General measures: Weight loss, physiotherapy, exercise programmes, joint protection advice.
Analgesia: Paracetamol, NSAIDs (use with PPI cover), topical agents.
Disease-specific:
- OA → conservative + joint injections; arthroplasty if severe.
- RA & inflammatory arthritis → DMARDs (methotrexate, sulfasalazine, leflunomide), biologics (anti-TNF, anti-IL-6).
- Gout → acute: NSAIDs/colchicine/steroids; long-term urate-lowering therapy (allopurinol, febuxostat).
- Spondyloarthropathies → physiotherapy, NSAIDs, biologics if severe.
Multidisciplinary care: Rheumatology referral, orthopaedics, pain clinics, occupational therapy.

🚩 Red Flags

Rapidly progressive monoarthritis → suspect septic arthritis or crystal disease.
Systemic features (fever, weight loss, night sweats) → possible infection or malignancy.
Back pain + neurological deficit → urgent spinal assessment.
Unexplained chronic pain with constitutional symptoms → consider TB, endocarditis, malignancy.

📚 Exam Pearls

Morning stiffness >1 hr → inflammatory arthritis (RA, spondyloarthropathy).
Stiffness <30 min, worse on activity → OA.
Asymmetrical oligoarthritis in young male → reactive or psoriatic arthritis.
Always aspirate acutely swollen joint before giving steroids.

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Chronic joint pain/stiffness 🦴