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Andrew Harrison Rheumatologist Wellington Regional Rheumatology - PowerPoint PPT Presentation

First Presentation of Joint Pain Andrew Harrison Rheumatologist Wellington Regional Rheumatology Unit, HVDHB Bowen Centre, Crofton Downs, Wellington Assoc. Prof. in Medicine, University of Otago Wellington Clinical Leader,


  1. First Presentation of Joint Pain Andrew Harrison • Rheumatologist • Wellington Regional Rheumatology Unit, HVDHB • Bowen Centre, Crofton Downs, Wellington • Assoc. Prof. in Medicine, University of Otago Wellington • Clinical Leader, Research, CCDHB

  2. Disclosures • Advisory board member for AbbVie NZ and Pfizer NZ • Research grants from Roche and Abbvie • Sponsorship to attend conferences from AbbVie, Roche and Pfizer • Consultancy work for AbbVie to develop educational materials for GPs and rheumatologists

  3. Disclaimer • No qualifications or experience in primary care

  4. Learning Objectives • To provide a structured approach to the assessment of new- onset arthritis • To review the important data needed to inform diagnosis and prognosis • To understand the influence of different patterns of clinical and laboratory features on diagnosis and prognosis • To recognise the cases that require urgent referral and/or treatment to optimise long-term outcome

  5. Why Bother?

  6. Why Bother?

  7. Rationale for Early Immunomodulatory Treatment • In RA, early use of corticoteroids improves long-term outcome • DMARDs • reduce symptoms • reduce erosive progression • reduce need for NSAIDs and long-term corticosteroids • Early treatment associated with drug-free remission

  8. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory • Pain helped by activity worse with activity • Stiffness prolonged short-duration • Restricted movement helped by activity fixed • Swelling soft tissue hard tissue

  9. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS

  10. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider : • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA

  11. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal ? objective synovitis • swelling/tenderness • MTP squeeze Limb girdle Consider : Consider • RA • PMR • PsA • OA shoulders/hips • ReA • soft tissue syndromes • CTD • statin myopathy • viral • RA • OA • haemochromatosis • vasculitis: HSP / GPA

  12. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal ? objective synovitis • swelling/tenderness • MTP squeeze Limb girdle Knee/ankle Consider : Consider : Consider • RA • PMR • SpA – PsA / ReA • PsA • OA knee/ankle • OA shoulders/hips • ReA • soft tissue syndromes • sarcoidosis • CTD • statin myopathy • polyarticular gout • viral • RA • pseudogout • OA • RA • haemochromatosis • undifferentiated • vasculitis: HSP / GPA

  13. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal Axial ? objective synovitis ? Inflammatory back pain • swelling/tenderness ? SI / heel / costochondral • MTP squeeze Limb girdle Knee/ankle Consider : Consider : Consider : Consider • RA • ankylosing spondylitis • PMR • SpA – PsA / ReA • PsA • psoriatic SpA • OA knee/ankle • OA shoulders/hips • ReA • enteropathic SpA • soft tissue syndromes • sarcoidosis • CTD • Reactive SpA • statin myopathy • polyarticular gout • viral • degenerative spinal • RA • pseudogout • OA • RA disease • haemochromatosis • non-specific back pain • undifferentiated • vasculitis: HSP / GPA

  14. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal Axial ? objective synovitis ? Inflammatory back pain • swelling/tenderness ? SI / heel / costochondral • MTP squeeze Limb girdle Knee/ankle Consider : Consider : Consider : Consider • RA • ankylosing spondylitis • PMR • SpA – PsA / ReA • PsA • psoriatic SpA • OA knee/ankle • OA shoulders/hips • ReA • enteropathic SpA • soft tissue syndromes • sarcoidosis • CTD • Reactive SpA • statin myopathy • polyarticular gout • viral • degenerative spinal • RA • pseudogout • OA • RA disease • haemochromatosis • non-specific back pain • undifferentiated • vasculitis: HSP / GPA

  15. Effective Use of Investigations

  16. Effective Use of Investigations

  17. Effective Use of Investigations

  18. Effective Use of Investigations

  19. Effective Use of Investigations

  20. Effective Use of Investigations

  21. Effective Use of Investigations

  22. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal Axial ? objective synovitis ? Inflammatory back pain • swelling/tenderness ? SI / heel / costochondral • MTP squeeze Limb girdle Knee/ankle Consider : Consider : Consider : Consider • RA • ankylosing spondylitis • PMR • SpA – PsA / ReA • PsA • psoriatic SpA • OA knee/ankle • OA shoulders/hips • ReA • enteropathic SpA • soft tissue syndromes • sarcoidosis • CTD • Reactive SpA • statin myopathy • polyarticular gout • viral • degenerative spinal • RA • pseudogout • OA • RA disease • haemochromatosis • non-specific back pain • undifferentiated • vasculitis: HSP / GPA

  23. Effective Use of Investigations

  24. Effective Use of Investigations

  25. Effective Use of Investigations

  26. Effective Use of Investigations

  27. Effective Use of Investigations

  28. Effective Use of Investigations

  29. A Diagnostic Algorithm Joint symptoms ? inflammatory ? non-inflammatory ? mechanical • Pain helped by activity worse with activity ? degenerative • Stiffness prolonged short-duration ? neuropathic • Restricted movement helped by activity fixed Consider : • Swelling soft tissue hard tissue • OA • soft tissue syndromes • FMS Small joint / distal Large joint / proximal Axial ? objective synovitis ? Inflammatory back pain • swelling/tenderness ? SI / heel / costochondral • MTP squeeze Limb girdle Knee/ankle Consider : Consider : Consider : Consider • RA • ankylosing spondylitis • PMR • SpA – PsA / ReA • PsA • psoriatic SpA • OA knee/ankle • OA shoulders/hips • ReA • enteropathic SpA • soft tissue syndromes • sarcoidosis • CTD • Reactive SpA • statin myopathy • polyarticular gout • viral • degenerative spinal • RA • pseudogout • OA • RA disease • haemochromatosis • non-specific back pain • undifferentiated • vasculitis: HSP / GPA

  30. Effective Use of Investigations

  31. Effective Use of Investigations

  32. Effective Use of Investigations

  33. Effective Use of Investigations

  34. Effective Use of Investigations

  35. Effective Use of Investigations

  36. Effective Use of Investigations

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