This is a very common problem in primary care. Usually, there are few physical signs, although occasionally a genuine monoarthritis with all the classical signs of inflammation will present. Overall, the most likely aetiological factor is trauma, though other conditions may already affect a joint. In the elderly, an exacerbation of osteoarthritis is common; this condition may also cause multiple joint pain. The knee is probably the single most frequently affected joint.
Arm pain is a common presentation with a wide differential. Many generalised disorders, such as arthritis, neuropathy and polymyalgia, cause widespread symptoms, which may involve the arm – these are not considered here. Instead, this section concentrates on pain specific to the arm, or pain characteristically referred to the arm.
Calf pain is usually innocent, except when accompanied by swelling. It is often caused by cramp, which is especially common in the elderly. In this group it can cause significant distress, through the havoc wreaked on sleep. Some of the less likely diagnoses, such as peripheral vascular disease, have important implications, so careful assessment is necessary.
Pain in the foot is difficult for patients to ignore and so will often present with a relatively short history. Local causes predominate, but remember to think further afield: Referral through S1 (lateral border of the foot) and L5 (dorsum of the foot to the big toe) nerve roots may occur. Ankle pain is not considered here.
This may be the presenting problem but just as often it is a ‘while I’m here’ symptom. The differential diagnosis is quite wide but ‘arthritis’ is often uppermost in the patient’s mind. A brief history and focused examination should provide the correct diagnosis quite rapidly in most cases.
The presentation of a hand or wrist swelling may well be a welcome interlude in the average surgery, offering the opportunity for a quick spot-diagnosis, with a low chance of anything sinister or time-consuming. That said, the differential is wide and a definite diagnosis can be difficult.
Chronic leg ulcer is a major problem in the UK. It is reckoned that nearly 1% of the population may be affected by leg ulceration at some time during their lives. Recurrence is common. The vast majority have a vascular underlying cause.
This is an infrequent but alarming presentation, as it may herald significant pathology and may be difficult to manage properly in an uncooperative toddler. Assessment should be methodical and patient, and follow-up arranged unless the diagnosis is obvious at the outset.
The range of causes of multiple joint pain spans acute, chronic and chronic relapsing conditions. The difficulty for the GP is sifting through the wide differential and spotting early significant disease that requires prompt referral.
This symptom has a multitude of causes. A careful history is required to distinguish between muscle and joint pain, and between muscle pain and weakness. In some of the underlying pathologies, these symptoms may coexist. Cramp, causing very transient muscle pain, is covered elsewhere (see the 'Calf pain' section).
Hip area pain is a common presentation in the middle-aged and elderly, and the patient will often attribute it to osteoarthritis. This diagnosis may well be correct, although the differential is wide – besides, the patient’s view of what actually constitutes the ‘hip’ may be at odds with the anatomical truth. The differential for the child with hip pain is very different – see the 'Limp in a child' section.
Recurrent knee pain is a very common presentation with a wide differential. Classification of causes isn’t helped by changing and confusing nomenclature. As ever in general practice, a careful history and examination will provide useful clues – but management will often be dictated more by degree of disability and the patient’s wishes than by making a precise diagnosis.
This is one of the commonest presenting complaints in the elderly and, in this age group, may be linked to recurrent falls. As a result, it is frequently the reason for a home visit request. In younger age groups, it is much rarer, but much more likely to signify serious pathology.
Such has been the publicity about ‘economy class syndrome’ that this presentation – and the closely related symptom, ‘calf pain’ (refer to that section) – has become quite common. The worry the patient has about a possible DVT can prove quite ‘infectious’, with the GP anxious not to miss this significant problem. In most cases, a careful history, backed up by appropriate examination, should reveal the true cause.