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 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 can one tell the difference between all 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 called the “gelling phenomenon,” which occurs because the fluid inside the joint becomes thickened, like a gel, making movement difficult.  Patients with inflammatory arthritis have difficulty getting out of bed; it may take 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, their symptoms will return.  One of my patients with active rheumatoid arthritis tells me that her hands feel clumsy and weak in the morning, 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,” the parents usually 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 limp and active arthritis, children usually continue to do most of their activities,  including sports.  I had a patient with juvenile arthritis affecting the joints in her legs, who continued to run cross-country despite active disease.  She would do well in races at “home,” when she could 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, the pain improves.   In osteoarthritis, the pain is due to joint damage due to 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 with non-inflammatory joint pain causes.

Finally, I evaluate patients with severe pain in multiple joints “all the time.”  These patients don’t have the warm, swollen joints 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 accidents and didn’t sustain strains, sprains, or fractures to multiple joints.  How can they have so much pain if their joints look so normal?  This is a topic that we are only beginning to understand.   It appears that some patients develop abnormalities in how 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 is 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 worsens 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 due to abnormalities in the nervous system.

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