There are many different potential causes for joint pain and these include infection, accidents, crystals in the joint, inflammation and articular cartilage damage. The clinical history and joint examination are the strongest guides to establishing a differential diagnosis and once a provisional decision about the likely cause has been made then laboratory investigations can be useful to confirm or refute this. Without an initial guiding thought as to the possible diagnosis investigations can be more confusing than enlightening. The primary effort is in pinning down the likely pain source and then working out the disease process.
The source of joint pain can be from within the obvious joint, from structures which surround the joint or can be a referred pain from a structure elsewhere. Within the joint itself the pain can come from the surrounding capsule, the ligaments, the bone membrane, the synovial joint lining and the bone underneath the joint cartilage. The joint cartilage itself is not a source of pain as it does not possess any sensory nerve endings. It is very important to pin down the likely structure responsible for the pain as the diagnosis and so the therapy may be different depending on that evaluation.
Joint disease involves a number of damaging processes which can include enthesitis (inflammation of the junctions between tendons, ligaments and bone), infections, deposition of crystals, joint abnormalities and synovial inflammation. There may be structural abnormalities in a joint or changes secondary to mechanical stresses, such as meniscal tears. Some of the typical processes above may occur in the same joint at the same time. Inflammation of the joint lining (known as synovitis) in rheumatoid arthritis and many other conditions presents as the primary problem. An inflamed, puffy, warm joint results from growth of the membrane which can destroy cartilage.
The bony insertions of the tendons and ligaments are known as entheses, which include the annular fibres of the disc inserting into the vertebra, and these areas are especially implicated in certain conditions. Inflammation makes the entheses lay down bone in the soft tissues as bony outgrowths along the ligament, tendon or disc. The deposition of crystals can occur in the synovial lining, on the articular cartilage or on other internal joint structures so the joint can be locally or generally affected. A gouty joint can be diagnosed by its puffy, warm appearance and the severe pain involved on movement.
A joint infection can be the result of bacterial, viral or fungal infiltration and most infections are blood borne, with the patient often feeling unwell as the joint infection is part of a more systemic infection. The synovium is typically affected by the infection, which leads to areas of membrane death followed by proliferation of healing tissue and scar. Joint cartilage can be damaged and destroyed very quickly by some bacterial toxins. Osteoarthritis is the most common joint abnormality in the world and its occurrence and severity are governed by a variety of internal and external factors.
Local, more specific factors which can predispose to osteoarthritis are any previous damage to the joint, such as in sports injuries, developmental abnormalities of the joint, abnormalities of cartilage and collagen disorders such as hypermobility. Factors to do with the person include their genetic heritage, their occupation and their bodyweight, although osteoarthritis is most strongly correlated with advancing age. Articular cartilage damage in osteoarthritis is followed by an increase in density of the underlying bone and the formation of bony outgrowths at the joint margins. There may be a synovitis but inflammation is not always involved in this condition.
The first stage for the examining clinician is to determine the source of the pain more precisely. The joint may be painful or there may be pain from close anatomical structures such as ligaments, tendons or muscles or it may be pain referred from a distant source. The more central joints such as the hip and the shoulder are more difficult to diagnose. Pain referred to the hip area is often not related to the hip joint itself and hip pain could be secondary to trochanteric bursitis, hip osteoarthritis, stenotic lumbar changes or intervertebral disc disease. - 14130
The source of joint pain can be from within the obvious joint, from structures which surround the joint or can be a referred pain from a structure elsewhere. Within the joint itself the pain can come from the surrounding capsule, the ligaments, the bone membrane, the synovial joint lining and the bone underneath the joint cartilage. The joint cartilage itself is not a source of pain as it does not possess any sensory nerve endings. It is very important to pin down the likely structure responsible for the pain as the diagnosis and so the therapy may be different depending on that evaluation.
Joint disease involves a number of damaging processes which can include enthesitis (inflammation of the junctions between tendons, ligaments and bone), infections, deposition of crystals, joint abnormalities and synovial inflammation. There may be structural abnormalities in a joint or changes secondary to mechanical stresses, such as meniscal tears. Some of the typical processes above may occur in the same joint at the same time. Inflammation of the joint lining (known as synovitis) in rheumatoid arthritis and many other conditions presents as the primary problem. An inflamed, puffy, warm joint results from growth of the membrane which can destroy cartilage.
The bony insertions of the tendons and ligaments are known as entheses, which include the annular fibres of the disc inserting into the vertebra, and these areas are especially implicated in certain conditions. Inflammation makes the entheses lay down bone in the soft tissues as bony outgrowths along the ligament, tendon or disc. The deposition of crystals can occur in the synovial lining, on the articular cartilage or on other internal joint structures so the joint can be locally or generally affected. A gouty joint can be diagnosed by its puffy, warm appearance and the severe pain involved on movement.
A joint infection can be the result of bacterial, viral or fungal infiltration and most infections are blood borne, with the patient often feeling unwell as the joint infection is part of a more systemic infection. The synovium is typically affected by the infection, which leads to areas of membrane death followed by proliferation of healing tissue and scar. Joint cartilage can be damaged and destroyed very quickly by some bacterial toxins. Osteoarthritis is the most common joint abnormality in the world and its occurrence and severity are governed by a variety of internal and external factors.
Local, more specific factors which can predispose to osteoarthritis are any previous damage to the joint, such as in sports injuries, developmental abnormalities of the joint, abnormalities of cartilage and collagen disorders such as hypermobility. Factors to do with the person include their genetic heritage, their occupation and their bodyweight, although osteoarthritis is most strongly correlated with advancing age. Articular cartilage damage in osteoarthritis is followed by an increase in density of the underlying bone and the formation of bony outgrowths at the joint margins. There may be a synovitis but inflammation is not always involved in this condition.
The first stage for the examining clinician is to determine the source of the pain more precisely. The joint may be painful or there may be pain from close anatomical structures such as ligaments, tendons or muscles or it may be pain referred from a distant source. The more central joints such as the hip and the shoulder are more difficult to diagnose. Pain referred to the hip area is often not related to the hip joint itself and hip pain could be secondary to trochanteric bursitis, hip osteoarthritis, stenotic lumbar changes or intervertebral disc disease. - 14130
About the Author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Solihull, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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