Evaluation of the adult with polyarticular pain
- Robert H Shmerling, MD
Robert H Shmerling, MD
- Section Editor — Diagnostic Issues in Rheumatology
- Associate Professor of Medicine
- Harvard Medical School
- Section Editor
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
Polyarticular pain in an adult is encountered frequently in clinical practice. The causes include various self-limited illnesses and others that are potentially disabling and life-threatening. The history and physical examination generally provide the most useful diagnostic information; supporting or confirmatory data are obtained from laboratory and imaging studies or, more rarely, from tissue biopsy. A complete history and physical examination are appropriate for all patients presenting with polyarticular joint pain, since this symptom may be the initial manifestation of a systemic illness.
The list of causes of polyarticular pain is lengthy [1,2] and includes:
●Polyarthritis (table 1)
●Viral arthritis (table 2)
●Postinfectious or reactive arthritisTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Pinals RS. Polyarthritis and fever. N Engl J Med 1994; 330:769.
- Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:1.
- El-Gabalawy HS, Duray P, Goldbach-Mansky R. Evaluating patients with arthritis of recent onset: studies in pathogenesis and prognosis. JAMA 2000; 284:2368.
- El-Gabalawy HS, Goldbach-Mansky R, Smith D 2nd, et al. Association of HLA alleles and clinical features in patients with synovitis of recent onset. Arthritis Rheum 1999; 42:1696.
- Sox HC Jr, Liang MH. The erythrocyte sedimentation rate. Guidelines for rational use. Ann Intern Med 1986; 104:515.
- Kushner I. C-reactive protein in rheumatology. Arthritis Rheum 1991; 34:1065.
- Kay J, Morgacheva O, Messing SP, et al. Clinical disease activity and acute phase reactant levels are discordant among patients with active rheumatoid arthritis: acute phase reactant levels contribute separately to predicting outcome at one year. Arthritis Res Ther 2014; 16:R40.
- Miller A, Green M, Robinson D. Simple rule for calculating normal erythrocyte sedimentation rate. Br Med J (Clin Res Ed) 1983; 286:266.
- Sox HC Jr. Probability theory in the use of diagnostic tests. An introduction to critical study of the literature. Ann Intern Med 1986; 104:60.
- Woolf SH, Kamerow DB. Testing for uncommon conditions. The heroic search for positive test results. Arch Intern Med 1990; 150:2451.
- Juby A, Johnston C, Davis P. Specificity, sensitivity and diagnostic predictive value of selected laboratory generated autoantibody profiles in patients with connective tissue diseases. J Rheumatol 1991; 18:354.
- Shmerling RH, Delbanco TL. How useful is the rheumatoid factor? An analysis of sensitivity, specificity, and predictive value. Arch Intern Med 1992; 152:2417.
- Nishimura K, Sugiyama D, Kogata Y, et al. Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med 2007; 146:797.
- Whiting PF, Smidt N, Sterne JA, et al. Systematic review: accuracy of anti-citrullinated Peptide antibodies for diagnosing rheumatoid arthritis. Ann Intern Med 2010; 152:456.
- Hadler NM, Franck WA, Bress NM, Robinson DR. Acute polyarticular gout. Am J Med 1974; 56:715.
- Schlesinger N, Norquist JM, Watson DJ. Serum urate during acute gout. J Rheumatol 2009; 36:1287.
- Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA 1990; 264:1009.
- Baillet A, Gaujoux-Viala C, Mouterde G, et al. Comparison of the efficacy of sonography, magnetic resonance imaging and conventional radiography for the detection of bone erosions in rheumatoid arthritis patients: a systematic review and meta-analysis. Rheumatology (Oxford) 2011; 50:1137.
- Howard RG, Pillinger MH, Gyftopoulos S, et al. Reproducibility of musculoskeletal ultrasound for determining monosodium urate deposition: concordance between readers. Arthritis Care Res (Hoboken) 2011; 63:1456.
- Ramírez J, Ruíz-Esquide V, Pomés I, et al. Patients with rheumatoid arthritis in clinical remission and ultrasound-defined active synovitis exhibit higher disease activity and increased serum levels of angiogenic biomarkers. Arthritis Res Ther 2014; 16:R5.
- Gamon E, Combe B, Barnetche T, Mouterde G. Diagnostic value of ultrasound in calcium pyrophosphate deposition disease: a systematic review and meta-analysis. RMD Open 2015; 1:e000118.
- Visser H, le Cessie S, Vos K, et al. How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum 2002; 46:357.
- Alves C, Luime JJ, van Zeben D, et al. Diagnostic performance of the ACR/EULAR 2010 criteria for rheumatoid arthritis and two diagnostic algorithms in an early arthritis clinic (REACH). Ann Rheum Dis 2011; 70:1645.
- Ha YJ, Park YB, Son MK, et al. Predictive factors related to progression toward rheumatoid arthritis in Korean patients with undifferentiated arthritis. Rheumatol Int 2012; 32:1555.
- de Rooy DP, van der Linden MP, Knevel R, et al. Predicting arthritis outcomes--what can be learned from the Leiden Early Arthritis Clinic? Rheumatology (Oxford) 2011; 50:93.
- Musculoskeletal emergencies
- Joint symptoms
- Associated symptoms
- Other clues from the history
- PHYSICAL SIGNS
- Joint examination
- General examination
- LABORATORY STUDIES
- Erythrocyte sedimentation rate
- Antibody tests
- - Antinuclear antibody
- - Rheumatoid factor
- - Antibodies to citrullinated peptides
- Serum uric acid concentration
- Synovial fluid analysis
- IMAGING STUDIES
- TISSUE BIOPSY
- DISEASE COURSE
- INFORMATION FOR PATIENTS