symptoms of musculoskeletal disorders
bone, joint, and muscle disorders
Joint Pain: Many Joints
In evaluating joint pain, doctors first try to decide whether joint pain is caused by a disorder of the joints or a serious bodywide (systemic) illness. Serious bodywide disorders may need specific immediate treatment. The following information can help people decide when to see a doctor and know what to expect during the evaluation. In people with pain in more than one joint, symptoms that should prompt rapid evaluation include Joint swelling, warmth, and redness New skin rashes, spots, purple blotches, or nail pitting Sores in the mouth or nose or on the genitals Chest pain, shortness of breath, or new or severe cough Abdominal pain Fever, sweats, weight loss, or chills Eye redness or pain People with warning signs should see a doctor right away. People without warning signs should call a doctor. The doctor decides how quickly they need to be seen based on the severity and location of pain, whether joints are swollen, whether the cause has been diagnosed previously, and other factors. Typically, a delay of several days or so is not harmful for people without warning signs. Doctors first ask questions about the person's symptoms and medical history. Then they do a physical examination. What doctors find during the history and physical examination often suggests a cause for joint pain and guides the tests that may need to be done (see table). Doctors ask about pain severity, onset (sudden or gradual), how symptoms vary over time, and what increases or decreases pain (for example, rest or movement or time of day when the symptoms worsen or abate). They ask about joint stiffness and swelling, previously diagnosed joint disorders, and risk of exposure to sexually transmitted infections and Lyme disease. Doctors then do a complete physical examination. They check all joints (including those of the spine) for swelling, redness, warmth, tenderness, and noises that are made when the joints are moved (called crepitus). The joints are moved through their full range of motion, first by the person without assistance (called active range of motion) and then by the doctor (called passive range of motion). This examination helps determine which structure is causing the pain and if inflammation is present. They also check the eyes, mouth, nose, and genital area for sores or other signs of inflammation. The skin is examined for rashes. Lymph nodes are felt and the lungs and heart examined. Doctors usually test function of the nervous system so that they can detect disorders of the muscles or nerves. Some findings give helpful clues as to the cause. For example, if the tenderness is around the joint but not over the joint, bursitis or tendinitis is likely the cause. If tenderness is present in many areas besides the joints, fibromyalgia is possible. If the spine is tender as well as the joints, possible causes include osteoarthritis, reactive arthritis, ankylosing spondylitis, and psoriatic arthritis. Findings in the hand can help doctors differentiate between rheumatoid arthritis and osteoarthritis, two particularly common types of arthritis. For example, rheumatoid arthritis is more likely to involve the large knuckle joints (those that join the fingers with the hand) and wrist. Osteoarthritis is more likely to involve the finger joint near the fingernail. The wrist is unlikely to be affected in osteoarthritis, except at the base of the thumb. The following tests are the most important overall: Tests of joint fluid Blood tests for autoantibodies Erythrocyte sedimentation rate (ESR) and C-reactive protein If joints are swollen, doctors usually insert a needle into the joint to take a sample of the fluid in the joint for testing (a procedure called Joint aspiration (arthrocentesis) or arthrocentesis). Doctors numb the area before taking a sample, so people experience little or no pain during the procedure. Doctors generally do a culture on the fluid to see whether infection is present. They look under a microscope for crystals in the fluid, which indicate gout or related disorders. The numbers of white blood cells in the fluid indicate whether the joint is inflamed. Doctors also often do Laboratory Tests for autoantibodies. Examples of such tests are antinuclear antibodies, anti–double-stranded DNA, anticyclic citrullinated peptide, and rheumatoid factor. Autoantibodies in the blood may indicate an autoimmune disorder such as rheumatoid arthritis or systemic lupus erythematosus. The ESR is a test that measures the rate at which red blood cells settle to the bottom of a test tube containing a blood sample. Blood that settles quickly typically means that bodywide (systemic) inflammation is likely, but many factors can affect the ESR test including age and anemia, so the test is sometimes inaccurate. To help determine whether bodywide inflammation is present, doctors sometimes do another blood test called C-reactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation). Imaging tests are sometimes necessary, especially if there is a possibility of bone or joint tumors. X-rays are done first, but sometimes If a particular disorder is suspected, other tests may be required (see table). 