Not all joint pain is arthritis

As a rheumatologist, I’m becoming an expert in evaluating all types of joint pain.  My adult patients are wonderful at describing how their joints feel: burning, stabbing, pressure, stiffness, crushing, aching, throbbing.  Children use more creative language: the joint feels like ice cream, like aliens are poking at them with needles from the inside, like bugs are crawling over them.

Pain in a joint is one of the most common reasons why patients are referred to a rheumatologist, often with the suspicion that the pain is due to arthritis.   Although there are many causes of joint pain, one simple question can help to differentiate between arthritis and most of the other conditions.

Arthritis is a term that refers to inflammation of a joint.  There are two basic types of arthritis: inflammatory arthritis (like rheumatoid arthritis) and osteoarthritis.  It’s easy to see inflammatory arthritis: it causes joint swelling, warmth, redness, and pain. Osteoarthritis, on the other hand,  does not  cause much joint inflammation and usually only presents pain.

So how is one to tell the difference between all of the entities that cause joint pain?   Just ask this question: “when do your symptoms occur?”

Morning symptoms are most common in inflammatory arthritis.  Patients describe significant stiffness in their joints when they wake up.  This is referred to as the “gelling phenomenon,” which occurs because the fluid inside the joint becomes thickened, like a gel, and makes movement difficult.  Patients with inflammatory arthritis have a hard time getting out of bed; it may take them over an hour before their joints begin to feel better.  This stiffness improves as they pursue different activities (when the “gel” is warmed up), but if they sit for prolonged periods of time, their symptoms will return.  One of my patients with active rheumatoid arthritis tells me that in the morning, her hands feel clumsy and weak, and she finds it difficult and painful to button her blouse, open jars for breakfast, or drive to work.  Her symptoms improve later in the day.

In children, who are  rarely able to describe “stiffness,” it is usually the parents who first notice the symptoms of juvenile arthritis (kids get arthritis too!).  Parents say that their child has a limp that is worse in the morning, and improves throughout the day.  They may also notice a swollen knee or ankle.  However, even with a limp and active arthritis, children  usually  continue to do most of their activities,  including sports.  I had a patient with juvenile arthritis affecting her legs, who continued to run cross-country despite active disease.  She would do well in races at “home,” when she was able to warm up well before a race.  However, whenever she went to an “away” race, she became stiff after the long bus ride, and as a result her speed suffered.

In contrast, osteoarthritis and diseases caused by damage to the joint, such as sprains, strains, and fractures, usually present with symptoms that are worse later in the day.  Pain is exacerbated when patients are involved in activities: climbing stairs, running, walking, writing, cooking, cleaning, etc.  When they sit down to rest, pain improves.   In osteoarthritis, the pain is due to joint damage as a result of wear-and-tear.  Osteoarthritis is the kind of arthritis that people usually talk about  when they say that “Aunt Bertha had arthritis of the hips and needed a hip replacement,” or “I can’t play golf with you, Lenny, the arthritis in my back is killing me!”     As you can imagine, this type of arthritis becomes more common as people age, and predominantly affects weight-bearing joints such as the knees, hips, as well as the fingers.  Stiffness is not a predominant symptom in patients that have non-inflammatory causes of joint pain.

Finally, I evaluate patients that have severe pain in multiple joints “all the time.”  These patients don’t have the warm, swollen joints that are seen in inflammatory arthritis.  They  are often young, and don’t have evidence of wear-and-tear, as seen in osteoarthritis.  They weren’t involved in an accident, and they didn’t sustain strains, sprains, or fractures to multiple joints.  How can they have so much pain, if all of their joints look so normal?  This is a topic that we are only beginning to understand.   It appears that some patients develop abnormalities in the way in which their nervous system is wired, and as a result, they experience pain due to abnormal processing of pain signals.  These patients are often given the diagnosis of chronic pain syndrome or fibromyalgia.  The most puzzling aspect of these conditions is that the pain is real–and often excruciating–even though the joint looks normal.  Treatment for these conditions are aimed at correcting the nervous system abnormalities, not at the joint.   This includes aerobic exercise, cognitive behavioral therapy, and medications that help to reduce pain sensitivity.

Take-home points:

  • Inflammatory arthritis (such as rheumatoid arthritis) usually causes joint swelling, stiffness, and pain that is worse in the morning and improves with activity.
  • Osteoarthritis and other causes of joint damage (strain, sprain, fracture) present with pain that worsens with activity, and improves with rest.
  • Pain amplification syndrome and fibromyalgia cause persistent pain without any visible abnormalities to the joint as a result of abnormalities in the nervous system.

68 thoughts on “Not all joint pain is arthritis”

      1. I know this article was posted in 2014 but I puzzled. I really need an expert opinion.
        My situation is that I’ve been having really bad joint pain. My body feels like when having the flu, the aches and pains. I have stifness when I hold a cup of coffee for a few minutes, then my fingers are stiff in that position and is painful to straighten them.
        There is no visible inflammation but every joint hurts.My RA factor is high and all the other blood tests to check the information in the body, are also high. My primary doctor told me that he does not think I have RA and he said that I don’t have fibromyalgia. So what else can it be?
        Is it possible to have rheumatoid arthritis without inflammation? I just need an opinion please. It would help me a lot.786-372-5242
        Text me because my email does not let me open my mail.

      2. I need help I see an old Rheumatologist that said nothing was wrong….my fingers are so swollen with my toes…too it aches in the am and throughout the day 🙁 its crippling my fingers.

        1. You need to see another Rheumatologist. You have the right to choose your health care provider as part of your patient rights and responsibilities. As a nurse of some 30+ years as sufferer of OA and Firbromyalgia after a car wreck, I too had to follow my own advice until I found a Rheumatologist who would accurately diagnose and treat me.

  1. Thank you for your article – it was a good read …..well – not that I am asking for “free” advice — BUT =) —I am 31 (young patient but not a child or teen) I have anterior osteophytes in the thoracic area of my spine as well as DDD in the lumbar region – and 5 herniations (T 3/4 t/67 t7/8 L3/4 L4/5) Two of the thoracic ones deform the cord and the l4/5 cause a “stenosis” narrowing the canal there to less than 9mm — my Neurologist sent me to see a rheumy b/c i was also having specific joint pain outside of the spine (ankles/knees/pinky and ring finger/ wrists and shoulders) negative for RA — and it isn’t worse in morning so i guess a non inflammatory type — but i would say it hurts consistently through out the day but much more by night (my spine and resulting nerve pain hurt more at night as well) — I am seeing a different rheumy in May (long story but the first rheumy i saw disregarded the info i gave him and radiology reports of my spine) but I see a neurosurgeon specialist next week regarding calcification of the herniations in my thoracic causing more severe cns issues — -anyhow since I don’t have a “specific” cause of my spine issues and already have “osteophytes” there — is it possible at 31 that i have osteoarthritis in my other joints ?? Is there a specific type of osteoarthritis that affects younger people??

    1. Hi Julie. It’s difficult for me to comment on your specific disease, not being able to examine you and look at your imaging. However, you’re exactly right, the fact that you don’t have morning symptoms likely means that you don’t have an inflammatory arthritis. Also, if your joints are not swollen, that’s another reason to think it’s not inflammatory. It’s very difficult to interpret back pain based on an MRI, since it’s hard to say that the abnormalities on the MRI are actually causing your symptoms. For example, there are many people that have horrendous-looking MRIs and have no back pain whatsoever, whereas you can have somebody with a normal MRI and have horrible back pain. Nevertheless, if you have pain for any reason, it is possible for the pain to spread to other sites. This doesn’t mean that the osteophytes spread, only the pain. We call this a pain syndrome. The body basically becomes sensitized to pain, so that even minor movements cause severe pain. Again, it’s impossible for me to comment on your specific disease, but a good rheumatologist should be able to confirm this. Good luck, and let us know how you do!

      1. Thank you for responding! My visits to other specialists (Rheumy / cardiologist) have all been to more or less pin point that my neurological and pain issues are stemming from my spine – because as you know neurological and rheumatological symptoms and illnesses can overlap. Obviously one does not want to have spine surgery to find out my pain/problems was from some underlying condition. It can be hard on people that are perfectly healthy one day and then enter an alternate reality of pain and sickness daily that is hard to explain and hard to diagnose — Glad there are Good doctors like you who are advancing information and education on things the people around us suffer with all the time — Keep up the Good work sir! And I will leave a blurb or two along the way that you can post or not about my battle!! Thank you Again <3

          1. Ohh man what a journey so far. I got worse ill wise and pain wise. Turns out in 2015 I got dx’d by a geneticist that I had Ehlers-Danlos Syndrome type 3 — but what had triggered the worsening pain and sickness and tremors etc is that I had developed dysautonomia — common in EDSers apparently. I have IST (inappropriate Sinus Tachycardia) and Hyperadrenergic POTS and this year have developed gastroparesis with it. So mystery solved with my spine damage and joint issues — I am just moving my joints too far with out realizing it and they are , in general, not as stable as the average persons. — Again, thank you for your post in general. It is good to see doctors out there still seeking answers for patients that aren’t “standard” patients.

      2. Hi My name is judy I have spinal stenosis and my lower lumbar spine most of the cartilege is worn away exposing nerves. I also have disc bulging of the spine and dics displacement. I was seeing a doctor which helped the pain with medications and therapy. Now my pain has moved to my legs which pains everyday and is swollen also by the knee areas. All my blood reports came back normal but i still dont understand this pain swollen legs and i have to limp and walk i also have heel spurs. Please i need some answers. Thank you

  2. Thank you this is helpful, but leaves many questions unanswered, so what of the person who first was diagnosed with RA then develops Osteoarthritis and despite -ve RA factor for many years continues to see deterioration and caught between moving to relieve morning stiffness and overdoing it and getting overuse pain from Osteo and then the unexplained fusion of joints such as the Elbow. Knee replacement takes care of one joint as does Hip but there seems no answer for the Elbow…..Hope someone is looking into that. Confused in Radium Hot Springs CA

    1. Hi Nazir, thanks for your comments. You’re totally right that patients with RA can also have OA, especially in common joints such as the knee and hip. In general, we recommend exercise for everyone, including people with OA and RA. However, you should be mindful about what kind of activity to do. We generally recommend low-impact activities, such as swimming, elliptical, cycling, etc. This should help for both RA and OA. Regarding the elbow, this is can sometimes be affected by RA, more likely than OA. Medication for RA and physical therapy can often help improve function.

  3. Not all inflammatory arthritis causes warmth and swelling. You say yourself that intlammatory arthritis ‘usually’ causes joint swelling, stiffness, and pain. I have inflammatory arthritis. Rheumatoid Arthritis. Inflammation is visible on ultrasound and nuclear bone scans. Yet because my joints are not visibly warm and swollen, (they are swollen to me) I am constantly told by uneducated rheumatologists that I have fibromyalgia or a chronic pain syndrome. This is rubbish! Looking at a joint is a very unreliable way to detect inflammation. After 8 years of uncontrolled disease I now have erosions and much cartilage damage. Not to mention severe pain. Through all this time my disease has gone undertreated because my joints are not warm and swollen, and rheumatologists have told me they can’t see any swelling! Clearly they were wrong, and this thinking that non-swollen joints mean fibromyalgia is to blame!

    1. Thanks for your comments. You are right, a small minority of patients can have subtle evidence of inflammation on ultrasound or MRI, yet have little evidence of arthritis on exam. I usually get at least X-rays if the story is good for RA but there is no swelling on exam. Sometimes you can see early erosions despite normal exam. But for the great majority of patients, no swelling means no arthritis. I would hope that good rheumatologists would be able to tell the difference. It looks like you’ve found one who made the right diagnosis!

      1. It’s not really a small minority, rather a large minority, where there is no visible or palpable swelling. There have been several studies now that show that MRI is far more sensitive in detecting synovitis in early RA than physical exam, usually in the order of 50%, which means many patients are going undiagnosed. Many rheumatologists still think they can detect synovitis and swelling via physical exam in all cases, and don’t order an MRI. Ultrasound is also a far better choice than a physical exam alone. So many patients are being denied treatment because this idea that there must be swelling, persists!!! There IS swelling, but it can be seen or felt, by even the most experienced of rheumatolgists.

        1. I agree with you about the increased specificity of MRI or ultrasound to detect synovitis. What we don’t yet know is how to use this in clinical practice. The problem is that if you perform MRI or ultrasound on healthy individuals, you will likely detect synovitis in a large number of patients, even when they don’t have any symptoms. It’s the same challenge we have with mammography or PSA screening for prostate cancer…you may pick up a large number of false positives. I think the potential use of these technologies is great, but we have to be careful how we use them!

  4. I would like to add that patients with autoimmune diseases such as lupus, scleroderma, and MCTD, can often have joint pain without swelling, which is not fibro. I have MCTD, and my rheumy never blames my joint pain on fibro even though I have no visible swelling. I do have the stiffness as you described, from sitting too much and exercise helps. Plaquenil has worked wonders for my joint pain.

    1. Thanks for your comments. I agree with you, once you have an underlying rheumatologic disease, it’s more difficult to figure out the cause of joint pain, even without swelling. Patients with chronic rheumatic diseases, such as rheumatoid arthritis, can still develop fibromyalgia as a result of the joint pain that they live with every day. On the other hand, I often hear patients with lupus or other connective tissue diseases, like you, complain of joint pain, while their exam remains normal. Is it that there is some underlying swelling that I’m unable to see on exam? Possibly. Treating these symptoms with Plaquenil is entirely appropriate and often very helpful. I’m glad you’re feeling better with this medication!

    2. I too, have the same diagnosis of MCTD, Scleroderma, Raynaud’s, and Sjorgren’s. Also have painful, stiff joints with edema and am being treated with Plaquenil, Gabapentin and Methotroxate. I do not have arthritis or fibromyalgia. My Rheumy is also very good, but I’m still having difficulty opening my hands and can never fully extend my fingers.

  5. Can erratic hormone fluctuations during the perimenopause years, specifically the last 12 months leading up to the actual menopause be the culprit for increased “generalized” inflammation and joint issues, including carpal tunnel-like symptoms. And would it be best to wait until the hormonal fluctuations dissipate before trying to determine if other causes exist?

    1. You are right that hormones seem to affect the development of arthritis. Take, for instance, the finding that rheumatoid arthritis is more common in women than in men. Also, children hardly ever get rheumatoid arthritis, it becomes more common after menarche. Gout, uncommon in premenopausal women, becomes more common after menopause. Osteoarthritis, generally thought as due to “wear and tear” is also more common in women. In summary, hormones probably do play a role in the development of arthritis, but exactly HOW they do this is unclear.

      However, I’d be careful to specify whether what you are experiencing is, in fact, inflammation of the joints (“arthritis”), versus join pain WITHOUT inflammation, versus carpal tunnel which can be due to repetitive injury, among other reasons. Your primary care doctor may be able to help figure this out.

      1. It would seem, then, that it becomes complicated as to what direction a woman should go with regards to medication. If declining hormones can play a role. Which medication delivers the least side effects in some cases (ie, HRT, versus arthritis meds). It would be interesting to know if there has been a rise in arthritis since the HRT study caused so many women to forego HRT. Perhaps am I thinking about this incorrectly. Personally, I prefer to avoid all prescriptions (HRT and beyond) but not sure that would be unadvisable with RA. (As a previous post mentioned, not looking for free advice, but was intrigued to find some answers here that I was searching for). As for my GP, quote: “we have to wait until you’re through menopause and just manage your symptoms until then.”

  6. Hi! I am 25 and since I was 22 that I have been feeling several joint pain. It started with my wrist and then my shoulder, then my toes and then my ankle and my knees.I went to several doctors and they cant find what’s wrong with me. I wake up with several pain like my joints are being pressure and feel hot and hurts, but its not actually nothing wrong with then beside that it hurts a lot. I have done exams and blood tests and everything is normal. I am feeling really tired of this, because the pain is constant, sometimes worse then other days.

    1. cc, i know you posted this just over a year ago, but I am wondering if you have been able to find an answer. I have been suffering from the same thing for almost 10 years now. At least it sound the same. I suffer from roaming joint pain that gets quite severe. It can be in my wrist at noon, then by evening it is moving into my fingers. It will hit literally any joint, and usually 2-3 joints at a time with swelling, hot and painful to touch or move. I did find that cutting nightshades (potatoe, tomato, peppers, eggplant are the main) out of my diet has helped a bit but I still have more pain than I care to have… My rheumatologist insists its rheumatoid arthritis and wants to keep giving me pills that actually seem to make it worse. I do have osteoarthritis in my hips and during a recent visit with my bone doctor, he commented that I should get checked for Ehlers Danlos syndrome due to my very mobile joints. I think that will be my next step.
      I have been wondering for years if there is anyone else that suffers from this kind of joint pain. I am actually rather amused by the response I get from some doctors. One actually tried to tell me that the pain is not really moving around, I just think it is!! wow. Needless to say, that was the last time I went to see him!
      Anyhow, I hope you have found some answers and some relief. It is tough to carry on day to day activities when a joint is so painful it feels as though it is shattered.

  7. Having a balanced, nutritious diet is an important part of achieving and maintaining a healthy weight. That’s good news for your joints, not just your wardrobe. A small study published in Arthritis in 2015 reported on a 6-week intervention of 40 individuals with osteoarthritis who were placed on a plant-based diet of fruits, vegetables, legumes (beans, peas, lentils) and whole grains. The group experienced significantly reduced pain and improved physical function. https://www.healthclues.net/blog/en/poor-mans-rich-calcium-diet/

  8. Thank you for this information it was very helpful. I have a few questions and it would mean a lot if you replied. I am a seventeen year old male and about last july i started doing cross country during the summer and i noticed my knee started aching and every time i would bent it it would make a popping/cracking sound and it would hurt but not to the point where i couldn’t walk but i stopped running. And now i still don’t run because i feel the same pain with my other knee now even though i don’t run or put stress on it, it doesn’t hurt when i walk (it actually feels better unless it’s a lot of walking)but if i’m just standing still i start to feel my knees getting shaky and they get really tender and i feel like i could easily be pushed down to the ground it’s hard to keep them straight(i used to run a lot throughout all of my highschool years except this one my senior year and never had problem with my knees). Also most of my joints seem to ache for some reason my elbows feel the same as my knees they pop/crack a lot and hurt even if i just do 10 push ups my elbows begin to hurt (i weigh 135 and would regularly lift weights and do about 50 push ups with no problem)with every crack and they sometimes get locked. Lately my fingers and toes have been aching really bad too especially my thumbs and my big toes to the point that it hurts sometimes to walk and i try to avoid using my big toe when i walk, also when i brush my teeth or button my shirt the pain from my thumb increases and its hard to just do simple things because everytime i apply pressure to my thumb or try to bend it it makes a grinding feeling/noise before it would just crack but now it doesn’t and it hurts even more. I have been playing guitar for over 4 years but now i’ve had to stop since my thumbs have been hurting so bad and it’s not just my thumbs it’s also most of my fingers (the distal interphalangeal joints including the ones for my thumbs). there are also other joints that ache when i apply pressure to them but they don’t ache as bad as the ones i mentioned. I went to the doctor because one day i just sat down on the floor and i put pressure on my knee and it felt as if though i had dislocated it it immediately started to hurt and i couldn’t bend it or straighten it and for the next week it was swollen. The doctor told me it was just inflamed and he made some blood test and he told me that i don’t have rheumatoid arthritis and that it was just reactive arthritis and that it will go away, i also found out i have scoliosis. I don’t know if he just said that because he didn’t want to do another test but i hope that he is right even though i’ve felt this pain for about a year now and i don’t remember getting any fever, i still don’t get fevers and the pain is there everyday and in most of my joints. My parents tell me that it’s all in my mind and that i should stop worrying, and at this point i don’t know what to do i’ve been feeling really down lately because of all the things that i want to do but can’t anymore what do you recommend that i do, do you have any advice? Thank you and sorry that this is too long.

    1. Sounds like a complicated history. I would recommend that you see a rheumatologist for further workup and management. Certainly it’s not normal for an otherwise healthy young man to have so many joints hurting that prevent you from doing activities that you enjoy!

    2. Dont know if you will see this as your post is an old one but I would investigate connective tissue disorders, namely Ehlers Danlos Syndrome. This is often unrecognised by doctors, even rheumatologists who should be aware of it by now. A post in July mentioned this issue too. Good luck x

  9. These have all been very useful messages. I am a 60 year old female living in AZ and during the summer when the temps get high outside my joints and muscles start aching really bad, the hotter it is outside the worse I feel, even when I am inside. Do you have any idea what would cause this, or what I can do to help the pain?

    1. Puzzling symptoms…I’m not sure what to make of this. Coming from Boston, most patients complain of how cold weather affects them…haven’t had many people complain about the heat!

  10. I’m 46 year old male in the Boston area. Gradual onset of pain over the past 2 years. Started as stiff neck, to lower back, to mid back, to fingers, to feet, to now hips and knees. All blood normal (lots of blood work from inflammation to Lyme). Narrowing and FAI pincer on hip xrays, all other normal. Pain is mostly an achy, sore feeling. Stiffness. No swelling anywhere. Tried Celebrex and Prentazone trial. Doing aqua PT to increase flexibility. Have seen Rheumy, Neuro, Podiatrist. Rheumy is puzzled. Haven’t been able to figure out any patterns. Exercise doesn’t increase pain, normal getting around (sitting, standing) seems most painful. Any thoughts?

    1. Challenging case. I can tell you that it is not uncommon to have patients whose symptoms we can’t explain. The most important thing is to have a group of doctors who continue to follow you closely, consider different methods of treatment even if the diagnosis is still unclear, and be alert for any changes. It can often take years to make a clear diagnosis in many patients.

      1. Sounds like me as well. Did the other two people on here happen to have a diagnosis now? I had a positive ANA but everything else was negative. Rheumatology wrote me off and I don’t know where else to go.

  11. Dr. Hausmann,

    Perhaps you could help me with something that has been happening to my knees. I’m a generally healthy 29 year old male that rode a stationary bike every night. I started noticing my knees would be red/hot after playing basketball… then at night after biking… and now it’s pretty much every night ONLY in evening when standing. It’s red and warm on the kneecap, not sides and back of knees. I rarely feel that much pain, but it happens sometimes in one joint and fades after 10 min. RICE helps. Even aloe vera helps. Heat causes it. It feels very aggravated when driving in traffic (I commute). I use a standing desk now at work and I feel great until around 6PM, and suddenly red/hot knees once I’m home. I did tests for RA and other autoimmune diseases, everything came out negative.

    What do you think I should do? An MRI? Ignore it? Have you seen anything like this?

    1. I have had some patients that complain of color changes in their joints, similar to what you’re describing. Some of those patients just have skin that is sensitive to temperature changes, so they see these color changes on their skin. For them, since it’s not causing pain or discomfort, there’s nothing that needs to be done.

  12. Thank you for the reply. My husband has had something similar to Raynaud’s (even though his rheumatologist does not think so), joint stiffness, mild carpel tunnel syndrome in both hands, elevated IgE (1400) and eosinophils (fluctuating between 19% and 21%) in the last 4 months, but has tested normal for ESR, CRP and ANCA. Skin biopsy didn’t reveal anything out of ordinary as the pathologist attributes the presence of one “peculiar” eosinophil to my husband’s eczema. Now the rheumatologist seems to think that my husband’s symptoms are not rheumatological, but it seems that ESR, CRP and ANCA are not necessarily definitive in diagnosing any particular rheumatological diseases. Are autoimmune issues always this difficult to diagnose?

    1. Yes, some autoimmune conditions can be very challenging to diagnose because of nonspecific symptoms, lack of diagnostic tests, and the fact that they may mimic a host of other conditions. Sometimes it takes weeks, months, or years to make a diagnosis. At the same time, there are many patients that live without a clear explanation for their symptoms.

  13. I am male of 57 years. Had been visiting GP since late forties with joint pain in feet and hands which has latterly spread to elbow, some years left others right, or both. Pain was accompanied by morning stiffness until I started taking vitamin D (2000 i.u.) daily, but the pain remains. I have pelvic pain syndrome, migraines, a brief history of TMD, restless legs syndrome and suffered from chronic fatigue in my thirties, although that appears to be completely resolved. Pain and stiffness spread to back several years ago and became very debilitating but intermittent. MR scan revealed minor abnormality at T6 but minimal wear, DEXA scan suggested osteoporosis. Started taking alendronate and Vitamin D/ calcium. That’s when joint stiffness improved. My own research has convinced me that I have fibromyalgia. My father was diagnosed in his fifties but then it was called fibrositis. Pain is worst between October and March, it worsens and improves in a few days around the Equinox. Tried light therapy using powerful daylight bulb for that reason. Minor improvement at best. Tried experimenting with diet as that has helped with migraines, have discovered that avoiding wheat products and potatoes has significant impact on symptoms. I have control at last. Slight discomfort at moment as it is October, but I barely notice it. Hope this information might help other sufferers.

  14. Hi Jonathan. I am a 30year old male. I have had lower left back pain for over a year. I only have back pain at night I’d say it starts around 4/5am and won’t go until I get up. Then the pain is usually gone within 20 minutes or so. For the last 8 weeks I have had on and off pain in my fingers and wrists (aching and stiffness) no swelling, some days the pain is worse than others. Blood test says I have a borderline rheumatoid factor (not really sure what that means) Doctor referred me to rheumatologist, but they cancelled my referral as they said I didn’t meet the criteria? Doctor has told me to keep a diary of pain/problems and make another appointment in 6 weeks.

    Thanks.

    1. It can be difficult to determine the cause of joint pain. In general, a diagnosis is made based on a careful history, physical exam, and selected blood tests. Keeping a close record of symptoms can help your doctors find out what’s going on. Primary care doctors have a lot of experience in evaluating patients with joint complaints. However, when symptoms persist, when the cause is not readily discernible, or when immune-modulating treatment is required, a rheumatologist can help.

  15. Dr. Hausmann: Thank you for a very informative and to the point article. I’ve been seeing many doctors the past couple of years, and your short article helped me understand my symptoms more than any of them have. Not that I have a diagnosis yet or anything, but at least now I feel like I can rule out the first two categories in your article. I truly hope to one day overcome this battle and resume being able to live a normal healthy life and work again. I guess I’ll leave as short a medical history here as I can, as others have, and maybe something will come out of it. My primary question to you though, is does it make sense that if I fall into your third category, that my sudden onset of excruciating pain in my joints accompanied by excruciating sciatica of my lower body would all be helped significantly by IV steroids rather than pain meds? I just had my third bout of this severe joint pain which sends me to the ER, after never having had joint pain at all prior to 6 months ago. The pain and stiffness increase over a matter of days and get so unbearable that I feel like dying would be a better option, until the steroids work their magic. Until… this third time when I received the IV steroids and the pain still remained a little and now has returned much sooner than the past two times. I’m terrified the steroids are losing their efficacy and nothing is going to stop this pain that none of the doctors have been able to figure out. Yikes.

    Now to the hard part. Summarizing med history of past few years. I’m 38 and have always been a healthy weight and had NO medical problems at all until 3 years ago when I developed a c. Diff infection after taking antibiotics. Life has been a living hell ever since. I went from being a new lawyer to completely disabled and barley able to function at all (although the govt denied that claim so my daughter and I get to enjoy being homeless now (husband passed away)). Anyway, back to this… after the c. Diff, I was hospitalized multiple times for colon inflammation and then early last year, I woke up in ICU after having emergency surgery for a perforated bowel. I woke up with a foot less of bowel, a colostomy bag, and one less ovary since they said when I was opened up they found severe endometriosis that fused most of my organs in the abdominal area together. I then had a post surgical DVT and PE. Three months later they opened me up to do the colostomy reversal and i woke up to find they needed to do an emergency fully complete hysterectomy due to even more spreading of the endometriosis. So obviously I was thrust into early menopause and couldn’t take hormones because of the blood clot history. Then 3 months later (exactly a year ago), I had yet another emergency surgery for a blockage. Thank goodness, no surgeries since then. Thought maybe I’d actually be able to get back to work and be able to properly parent my poor kid again, but then I developed c diff like symptoms in March of this year. Went to the ER and tested positive for vibrio cholarae. Yep. Put on antibiotics to treat it and as a result, developed c diff again. Then a month later, in May of this year, I wake up feeling like the tin man and can’t even sit up and lift myself out of bed due to severe lower back and all over joint pain.

    I’ve had numerous tests and consults. Been to the ER several times. Rheumatologist was dismissive. But did do an X-ray and found a “vacuum phenomena of the SI Joint.” Pain management doc dismissive. Inflammatory bowel disease specialist found nothing. Orthopedist did MRI of lower back and found minor bulging disc and anular tear but said my severe pain and sciatica wouldn’t result from that alone. Oredered physical therapy but the good old state of MO won’t cover the hippy dippy alternative (but highly proven) practice of physical therapy via Medicaid. I’ve had a referrral for a neuro but it takes months to get in to any specialist doc that actually takes Medicaid. So unsure on that area just yet. I have a good PCP but since we became homeless, I had to move 2 hours from him so it’s resulted in very poor communication with all the other docs and really a zero ability to treat me. He felt maybe I have “reactive arthritis” from the c diff but other docs thought no on that. Even if that is what I have, he doesnt seem to know how to treat it or where to send me. My poor kid. On the positive side, this whole mess has motivated her to want to go to med school and be a doctor so she can actually help people like me. And like herself. She too has been ill and diagnosed with eosinophilia gastroenteritis/colitis and it’s very debilitating and auto-immune in nature. I wonder if ours are connected at all. You seem to be one of those great doctors so many of us wish we could find. Thanks so much for reading this long note and if you could address the steroid question, I’d greatly appreciate it!!

    1. I’m so sorry to hear about your case. Sounds like you’ve been through a lot recently! Deciding when to use steroids is difficult. Certainly it’s a good medication that acts quickly and we often use it for short periods of time to decrease inflammation. This can include inflammation from inflammatory arthritis, but sometimes physicians use it to decrease inflammation of the spine (for example, with sciatica), or even inflammation of the brain from trauma. However, for longer periods of time, it has significant side effects including bone loss, high sugars. problems with anxiety, sleep, weight gain, etc. Whether or not this medication should be used in specific patients–and for how long–is a tough question that I’m unable to answer. At the same time, a response to steroids doesn’t always mean that the cause of symptoms was inflammatory in nature…Steroids often help people feel better, even in conditions such as osteoarthritis, which is not considered significantly inflammatory. However, any benefits for steroids must be weighed against their significant long-term risks.

  16. Hello, I hope you can help clear this up for me. I’m 21 years old and I’ve been having joint pain in my fingers and wrists for 2 years now. Sometimes it is worse than others. For the last few months it has been hurting so bad that I can barley move my fingers. My thumbs and middle fingers seem to hurt the most, when I apply pressure to my joints (like squeezing them) it provides a little bit of relief. I don’t seem to have swelling so I’m not sure what is wrong. My family does have a large history of rheumatoid arthritis and my mom seem to think I have it as well. What are your thoughts about this? And what are your recommendations? Thank you so much!

  17. Can “gelling” happen at other times of the day, not just after sleeping? If I sit cross legged for a while, when I stand up my knees and lower back are so stiff I have to ease into straightening up. After a minute I’m ok, no pain.

  18. I am 60 year old femail. Physically fit and not over weight. My knees started hurting in the summer after playing soccer with my grandson. We frequently play these types of constant motion games! My left knee is now inflammed and I have a lump in the back. When I walk the knee clicks and pops also locks! This is very painful and so far no answers from tests. The knee itself is very unstable and walking is kind of scarry! Doctor is now wanting an MRI! Do you think this test will show anything or is it just a waiste of time. What could be going on or is this normal aging for an active person.

  19. Hi Jonathan, I’m so glad to have found this site. My 17 year old daughter has had on-off flare-ups of acute elbow and wrist pain (bilateral) for the last year. Her recent flare-up has lasted a week so far and is so painful she literally can not sleep at night and so is too exhausted (and in pain) to go to school. She definitely comes in to your third category. Arthritis has been ruled out with blood tests, plus there is no swelling. Her rheumatologist doesn’t think it’s fibromyalgia, as the pain is very specific to elbow and wrist joints and nowhere else (is he right?). He’s sending her for tests on cubital tunnel syndrome, but I don’t think it’s that as she doesn’t get numb or painful hands (plus the pain is on the outside of her elbows and not the insides).
    Do you have any ideas? It’s so awful to watch a young person suffer to badly at the prime of their life. Also, for the pain she’s taking naproxen and cocodamol, but it’s not really working; can you advise better pain relief meds?
    Thankyou, Karen.

  20. I am confused about what my GP has called inflammatory arthritis. I have had, for about 18 months, a swollen, painful, warm left ankle/foot. It Is always warm. It is only this one area. Ruled out gout, cellulitis and DVT, an xray concluded inflammatory arthritis. Is it possible to only have this in one spot for such a prolnged period? I do have OA in other areas.

  21. I am a 31 years old male, very active. I do multiple sports and I began to have pain in my left pinky finger and then it developped to all my fingers excepted thumbs on both hands within few days. After that, it the toes become to “hurt” too. It doesn,t really hurt but it’s not comfortable to walk.

    Now my hips, elbows, knees and shoulders hurt. The only place it doesn’t hurt, it is in my wrists and ankles. I must say that now when I turn my head to the right, I hear a tic back and forth every single time. It’s driving me crazy. I stoped every sport activities since then. I still go to gym when I feel like it and pain doesn’t increase while lifting weights. I used to go 3 times every week but now it’s more like 2-3 times per month.

    All these symptoms appeared since mid october. I went to my GP 3 times and he ordered an xray on my left pinky finger but it came back as normal. I don’t have any swelling or redness. I do wake up with soreness in feets and hands but it go away when I activate my joints within seconds. When I get out of bed, my feet feels Like I ran a marathon during the night but it fade away within seconds of walking.

    I do have anxiety and I’ve had a lot of unexplicated help problems during the last years. Sometimes I think it’s all in my head but I am skeptical that it can persists to 3 months with consistent spreading pain every day.

    Do you think this can be a case of RA, do you think it can be more like mental illness and I am able to make up all this pain?

  22. Hello! I read this with interest because I thought I was developing OA in my thumbs and big toes (I do have OA in both knees) but now I’m not sure. The pain in my thumbs is only when I try to open something or grip something large. The other day I had to have someone open a container for me! None of my fingers are affected. The pain is just at the top portion of my thumbs, and is mainly on my left hand. It also comes and goes. Same with my big toes although I’m not opening anything with them, just when I’m walking and push off with my toes I’ll feel the pain. Also, comes and goes. I’m 57 and have not mentioned this to my doctor yet because this only started happening in the past year. No swelling, no stiffness.

  23. Hi, I am near,y 60 and up until a few years ago, .I would say I was pretty healthy. I suffered for a couple of years with undiagnosed gallstones eventually having my gall bladder removed. After that I noticed that I was getting pains in both shoulders. Within that year it had spread to groin pain, hip pain, elbow and wrist pain and the most paonful was finger pain.
    Some days seem worse particilatly cold, damp days. I wake up aching all over but it does improve with movement. I have had various blood test and various scans and the only significant thing that appears on my X-rays is that I have a calcium hook on one shoulder.
    These pains have been put down to auto immune fibromyalgia. I am progabbalin three times a day but to be honest, I don’t think it is helping. Is fibromyalgia a term that is bandied about when there is no other diagnosis or reason for the Iain and symptoms.
    Is this something I will always have? Is there no cure or help for this condition?

  24. Hi.. I got rashes all over my body 5 days before ..those rashes were not itchy though but had a little burning sensation.. from d same day I was feeling a bit week and with some body ache. I consulted a dermatologist she diagnosed it with viral rashes.. after 3 days of taking that medicine my rashes are gone.. but now I have started having pain and stiffness in all joints.. fingers ankle wrist shoulders and knees.. this pain persist whole day. Other than this I have sore throat.. doctor says that it is due to viral infection only and will take some more time.. I don’t have fever.. I do feel feverish though.. but temperature is normal.. I am worried

  25. I’ve been to a couple different doctors and had some labs, but so far, no diagnosis for chronic joint pain. It sounds similar to what you’ve described in the end of your article, but my doctor is pretty sure I don’t have fibromyalgia because I don’t have any muscle pain or specific tender spots that are apparently common in the disease. I’m wondering if it’s still a possibility though based on what you’ve mentioned in your article.

    I’m a 22 y.o. white female with chronic, recurrent joint pain. The joint pain started about a year ago following a 2-week upper respiratory illness. I initially had pain in my right shoulder blade and elbow that kind of came and went but was severe enough to wake me up at night (anywhere from 5-7/10). It comes and goes and now primarily occurs in both elbows and knees, though not every joint is affected every time I have pain. Although the pain doesn’t occur every day, I rarely go more than a week without having one of my joints hurt. The pain is dull and diffuse and doesn’t radiate anywhere. I’ve had tendonitis in my wrist before and the pain feels like that, but in my elbows and knees. I don’t have swelling, redness, fever, muscle aches, redness, or rash with the joint pain. I don’t usually have any stiffness except for when I don’t move the joint for a very long period of time – I sometimes notice this if I wake up in the middle of the night, but it doesn’t occur very often or during the day. Not sure whether this is related, but sometimes my skin is tender/painful to touch when I have joint pain (swelling, or redness) and follow pretty closely with dermatomal organization (though it occurs in different dermatomes each time). The joint pain seems to be worse when it’s cold out, when I’m sick, or after I have any alcohol. I’ve used Ibuprofen, heat packs and a TENS unit, which all seem to help in the short-term.

    I’ve been tested for Lyme’s and Celiac disease and both came back negative. I’m always borderline anemic with low RBC, hematocrit, ferritin etc and have started taking iron supplements and vitamin C and eating more meat, which hasn’t seemed to help at all. The rest of the CBC was normal. ESR was elevated over the course of 4 months when the joint pain started (28, 40, 25). Vitamin D levels were low and I now take a supplement for that as well. CRP was normal. TSH was normal.

    My doctor doesn’t think it’s arthritis because there’s no swelling/redness/inflammation. Ehlers-Danlos was suggested – I have slight hypermobility in my elbows and knees but PT said it wasn’t anything significant. I don’t have any of the classic EDS signs – no stretchy or thin, velvety skin or excessive scarring, no extreme hypermobility etc.

    I take sertraline (depression) and ortho tricyclen (birth control). No tobacco or recreational drugs. Pretty healthy diet and moderate exercise. No significant medical history. Mom dx with hypothyroidism, rosacea. Dad dx with hypertension.

    Could this still be an autoimmune problem even though I don’t have any of the signs of inflammation in any of my joints? Potentially fibromyalgia or some type of arthritis?

  26. Autoimmune type response with gouty reactions in the big toe/ankle/knee and hip. had an injury ending with 12 stitches in my Left hand and within 3 weeks had a nuclear flare up.
    First round during this flare up I received 2 steroid shots and more steroidal pills and it took about a week and a half before being close to normal. Although it never really went completely away leaving some tenderness.
    Second round.A week later I ended up back at the Dr’s with another round of steroids.
    I eat a very clean diet almost vegan. I don’t smoke and rarely drink. Active work schedule. Not a big fan of exercising conventionally.
    About 3.5 years ago I injured the same hand resulting in 2 stitches and had the very exact thing happen.

    Both times had blood work done and both times had the tests come back with everything in normal ranges.

    I am 49 and have been treated for gout since the age of 27 and not once had any synovial fluid drawn to verify that it is gout.

    At my witts end!

    What causes this. What is this and how do I avoid it happening again?

    Looking for insight
    Brian

  27. Hi I’m a 13 year old girl with shooting foot pain. It gets worse when I walk or bend down. It is hard to explain but sometimes while walking, my muscles seem to tighten and I trip or having stabbing pain. I have scoliosis and I am going for a back appointment in a week so my parents won’t let me go to the doctor. My right leg is also shorter than the other, which is the one causing me pain. Sometimes the pain will spread to my leg but quickly goes away. This has been going on for 2 months on and off and I need help. If anyone can help or direct me to any information that would be great.

  28. hello i have pain on my second finger. it all started two weeks ago. it starts in the afternoon it swells up and start feeling pain. i am right handed and its on my left hand. i wonder what it is causing it. could it be from food. the next day i dont feel anything then it starts again the next day and always in the afternoon.

  29. This was a comforting read for me this morning. I have extreme pain in my fingers, toes, and both knees pretty much all the time. In the mornings my fingers are very stiff and sore and difficult to move. The stiffness typically gets better as the day progresses, but the pain typically does not.

    Long story short, I’ve spent the past 5+ years trying to get doctors to take the pain seriously even though there is little to no evidence of joint damage. Last year I was diagnosed as having sero-negative RA, but now that’s in question. As much as I didn’t like the idea of having arthritis at 34 (35 now), the diagnosis itself was comforting because at least I could identify why I was hurting so much. Now that my rheumatologist is starting to explore other possibilities, even that slim comfort is gone.

    I think, for me, the biggest frustration other than the pain is just not knowing why I’m hurting.

  30. I’ve experience sharp pain in my knees since I was about 7 years old. I’m 24 now & still happens. Not often but when it does it’s either one knee or both. I’ve never been athletic or had any kind of knee injuries. Sometimes it’s as bad to where I can’t sleep at night. The pain will also go as far to where my hip is. Usually gets better when heat is applied. It doesn’t really get stiff, it’s more of just a sharp pain. It also gets worse in the cold or when it’s about to rain (oddly) it’s almost as if my knees can predict when it’s about to rain!

    I’ve never really gone to the doctor about it since I’ve had it all my life & never thought much of it. I always just tell myself it’s arthritis but I’m no doctor. Anyone else have this same problem? What could this be?! ?

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