Chronic Joint Pain/Stiffness Station

Presenting Complaint

Rachel reports pain, swelling, and stiffness in both knees for the past four months. She has also noticed pain in her wrists and fingers, particularly in the mornings.

Patient Quote:

“My knees ache all the time, but mornings are the worst. They feel so stiff, and it takes at least an hour before I can move properly.”

Symptoms (SOCRATES)

• Site: Bilateral knee pain (worse in the right knee), also affecting bilateral wrists and fingers.
• Onset: Gradual over the last four months.
• Character: Aching, throbbing pain in the knees, wrists, and fingers. Knees feel swollen and warm.
• Radiation: No radiation of pain beyond joints.
• Associated Symptoms:
  • Swelling in the knees and fingers.
  • Joint stiffness especially in the mornings.
  • Fatigue.
  • Occasionally feels ‘flu-like.’
• Timing: Stiffness worse in the mornings, lasting over an hour. Pain and swelling worse after prolonged inactivity. This has been going on for over 4 months.
• Exacerbating and Relieving Factors:
  • Worse in the morning, cold weather, and after rest.
  • Mild relief with movement and ibuprofen.
• Severity: Moderate (6/10), significantly impacts daily life.

Systemic Symptoms

• Fatigue: Yes, worsening over time.
• Fever: No.
• Weight Loss: No.
• Rashes or Nodules: No.
• Eye Symptoms: No.
• Chest Pain: No
• Shortness of Breath: No.
• Bowel or Urinary Symptoms: No.

Relevant Positive and Negative Findings

• Positive Findings:
  • Morning stiffness lasting >1 hour.
  • Bilateral knee and small joint involvement.
  • Fatigue and flu-like symptoms.
• Negative Findings:
  • No history of trauma or injury.
  • No fever, skin rashes, or weight loss.
  • No eye pain or redness.
  • No bowel symptoms.

Past Medical History

• Diagnosed with carpal tunnel syndrome 2 years ago.
• No history of psoriasis, inflammatory bowel disease, or other autoimmune conditions.
• No previous joint replacements or surgeries.

Drug History

• Ibuprofen (PRN for pain).
• Vitamin D supplements.

Allergies

• No known drug allergies.

Family History

• Mother: Had rheumatoid arthritis, diagnosed at 55.
• Father: Hypertension.
• Siblings: No major illnesses.

Social History

• Occupation: Office administrator.
• Impact on Life: Struggles with typing and household chores due to hand pain.
• Smoking: Never smoked.
• Alcohol: Drinks socially, 2-3 units per week.
• Recreational Drugs: None.
• Exercise: Used to jog but stopped due to knee pain.
• Diet: Balanced, but struggles with meal prep due to hand stiffness.

Ideas, Concerns, and Expectations

Ideas:

• “I think it might be arthritis, but I’m not sure what kind.”

Concerns:

• “My mum had rheumatoid arthritis, and I’m scared I might have the same thing.”

Expectations:

• “I want to know what’s causing my pain and stiffness and if there’s treatment to stop it from getting worse.”

Observations

Respiratory Rate: 16 breaths/min.

Oxygen Saturation: 98% on room air.

Blood Pressure: 128/82 mmHg.

Pulse: 76 bpm, regular.

Temperature: 36.9°C.

NEWS Score: 0

Physical Examination of the Knees

LOOK (Inspection)

• Inspect both knees front, side, and back with the patient lying supine and legs extended
• Observe for symmetry (RA typically affects joints symmetrically)
• Check for swelling, redness, or skin changes

Findings

• Bilateral joint swelling (due to effusion)
• Erythematous areas noted around the anterior surface
• No obvious nodules or vasculitic rash
• No obvious joint deformity

FEEL (Palpation)

Always ask about pain before touching, and palpate gently and symmetrically:

Temperature

• Use the back of your hand to compare warmth between knees → indicates inflammation

Effusion

• Patellar tap (large effusions)
• Sweep/bulge test (smaller effusions)
  
  

Joint Line Tenderness

• Medial and lateral joint lines
• Posterior aspect (may suggest popliteal cyst)

Findings

• Warmth noted bilaterally 
• Small joint effusions noted bilaterally
• Tender around joint lines bilaterally

MOVE (Active and Passive Movement)

Assess both active and passive movement:

Active Movement (Patient moves the joint)

• Ask patient to flex and extend each knee
• Observe for:
  • Pain, range limitation
  • Crepitus (common in joint damage)
  • Gait abnormalities if the patient is able to walk

Passive Movement (Examiner moves the joint)

• Gently flex and extend the knee, noting:
  • Pain
  • Crepitus
• Compare both sides

Findings

• Both active and passive range of motion limited secondary to pain and swelling present bilaterally
• Antalgic gait noted
• Soft tissue crepitus present bilaterally

Patient Questions & Example Answers

1. “What is rheumatoid arthritis?”

Answer: “Rheumatoid arthritis (RA) is a long-term autoimmune condition where your immune system mistakenly attacks your joints, causing inflammation, pain, swelling, and stiffness. Over time, it can lead to joint damage if not treated early.”

2. “Is rheumatoid arthritis curable?”

Answer: “RA isn’t curable, but it is manageable. With the right treatment, we can reduce symptoms, slow joint damage, and help you live a normal, active life.”

3. “Will I need medication forever?”

Answer: “You may need long-term treatment to control inflammation and prevent joint damage. Some people can reduce or stop medication if their RA goes into remission, but this depends on how well the disease is controlled.”

4. “Can RA affect my whole body?”

Answer: “Yes, RA can affect other parts of your body, not just the joints. It can cause fatigue, anaemia, lung inflammation, and in some cases, heart or eye problems. That’s why regular monitoring is important.”

5. “What are the treatment options?”

Answer: “The main treatments include:

• Lifestyle changes like exercise, physiotherapy, stopping smoking and joint protection.
• Specialised medications called DMARDs/immunosuppressive drugs (like methotrexate) slow disease progression.
• Pain relief (e.g., NSAIDs or paracetamol).
• Steroids for short-term inflammation control.
• Newer biologic therapies if standard treatments don’t work.”

Examiner Questions & Model Answers

1. “What are the key clinical, biochemical and serological features of RA?”

Clinical features:

• Synovitis (swelling) of the small joints of hands and feet (MCP, PIP, wrist, MTP) which spares DIP joints (seen in OA instead) and is in a symmetrical pattern (key characteristic)
• Morning stiffness of joints lasting typically > 1 hour
• Symptoms (pain, swelling, stiffness) lasting > 6 weeks without an obvious precipitant such as trauma/infection
• Joint deformity in advanced/untreated disease: includes Swan-neck deformity, Boutonniere deformity, ulnar deviation
• Extra-articular features: include pleuritis, interstitial lung disease, pericarditis, and inflammatory eye disease (e.g. scleritis/uveitis).

Biochemical and Serological features:

• Rheumatoid Factor (RF) – Positive in ~70%, but not specific.
• Anti-CCP antibodies – More specific (~98%) for RA.
• ESR/CRP – Raised in active disease.
• FBC – Anaemia of chronic disease may be present, neutropaenia in Felty syndrome (RA + splenomegaly + neutropaenia).

2. “What are the characteristic X-ray findings in RA?”

Early:

• Soft tissue swelling representing join effusion, oedema and tenosynovitis
• Juxta-articular osteopenia

Late:

• Joint space narrowing
• Erosions
• Subluxation/deformities (e.g., ulnar deviation)

Distribution mainly in MCPJs and PIPJs, ulnar styloid and triquetrum. Typically bilateral and symmetrical.

Case courtesy of Craig Hacking, Radiopaedia.org, rID: 69224

Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 7245

3. “What are the main treatment options for RA?”

• Lifestyle: Exercise, smoking cessation, physiotherapy.
• Topical/oral NSAIDs, paracetamol (for symptom relief).
• Short-term steroids (for flare-ups).
• DMARDs (e.g., methotrexate, sulfasalazine, hydroxychloroquine).
• Biologics (e.g., TNF inhibitors) if DMARDs fail/not tolerated.

4. “What are the potential complications of RA?”

• Joint deformities (e.g., swan neck, boutonnière).
• Extra-articular disease (e.g., lung fibrosis, pericarditis).
• Rheumatoid nodules.
• Osteoporosis (from steroids or inactivity).
• Increased cardiovascular risk (due to systemic inflammation).
• Functional limitations due to pain.
• Requirement for joint replacement surgery.
• Carpal tunnel syndrome.
• Adverse effects of medications ie: hepatotoxicity with Methotrexate, risk of infection/malignancy with TNF-alpha inhibitors. 

5. “How do you monitor response to RA treatment?”

• Composite scores e.g. DAS28 score (Disease Activity Score – includes joint count, ESR/CRP).
• Regular blood tests and clinical assessment (monitoring response to DMARDs).
• Patient-reported symptoms.
• Imaging (X-rays/MRI for progression).