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Chronic joint pain/stiffness 🦴

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🦴 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.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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