close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

This site is intended for Healthcare Professionals only
knee
bookmark icon off

Practice scenario: multiple joint pain

A 53-year-old woman presents to you with a three-month history of progressively worsening joint pain. It initially began in her hands and wrists, and has gradually involved her knees and ankles. She has been taking ibuprofen when the pain is particularly bad and reports that this does ease the symptoms. She has type 2 diabetes (on metformin 500mg three times daily) and hypothyroidism (thyroxine 100mcg daily). What do you advise?

Ross Ferguson, 07 Sep 2026clock11 Min

In Practice scenarios

By Professor Paul Rutter, University of Portsmouth

Problem representation

A 53-year-old woman with comorbidities presents with chronic pain affecting multiple joints that is progressively worsening.

Hypothesis generation

Joints may be painful (arthralgia) or inflamed (arthritis). Joint inflammation is usually accompanied by warmth, swelling (due to intra-articular fluid or effusion) and erythema.

A single joint or multiple joints can be affected. Medically, conditions involving four or fewer joints are termed oligoarticular, while those involving more than four joints are polyarticular.

Common causes of acute polyarticular arthritis include infection and systemic inflammatory disorders. Chronic causes include rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, and, in children, juvenile idiopathic arthritis.

Likely diagnoses

  • Ankylosing spondylitis
  • Multiple osteoarthritis
  • Psoriatic arthropathy
  • Rheumatoid arthritis
  • Viral polyarthritis

Possible diagnoses

  • Behçet’s syndrome
  • Connective tissue disorders
    • Systemic lupus erythematosus
    • Polyarteritis nodosa
  • Fibromyalgia
  • Juvenile idiopathic arthritis (not applicable in this case)
  • Lyme disease
  • Medicines
  • Polymyalgia rheumatica
  • Rheumatic fever
  • Sarcoidosis

Critical diagnoses

  • Amyloidosis
  • Malignancy (usually secondary).
Key points: rheumatoid arthritis
● RA incidence increases with age and is more common in women
● The small joints in the hands and feet are most affected
● Symmetry and prolonged morning stiffness are critical clues in inflammatory arthritis

Continued information gathering

If you consider the more likely conditions listed above as the potential cause of her symptoms, you know that the patient has had the symptoms for some time. On that basis, a viral cause seems unlikely.

In addition, you know that her hands, wrists, knees and ankles are affected. These are unlikely locations for pain if ankylosing spondylitis is the cause. This leaves multiple osteoarthritis, psoriatic arthropathy and rheumatoid arthritis to consider. All three conditions can affect the joints she mentions, so a diagnosis based on joint involvement alone is of low diagnostic value.

However, most patients with psoriatic arthropathy will have a rash. You ask if she has noticed any rashes before or since her joint pain started, but she says she has not. You can therefore discount this as the cause.

You ask further about the location of the pain, paying particular attention to whether the pain in her joints is symmetrical. She tells you that the same joints in both hands and ankles are sore or tender, and that they feel a little swollen, especially her fingers.

This description of inflammation and symmetry points to rheumatoid arthritis rather than osteoarthritis as the likely diagnosis.

Problem refinement

To further confirm your thinking, you ask about the degree of morning stiffness she experiences. She tells you that it can take quite a long time before her joints “wake up” and she is able to function more normally.

Again, this description fits with rheumatoid arthritis more than osteoarthritis. You ask about her general health; she tells you that she feels generally tired and a “little under the weather”. Once more, this fits with symptoms of rheumatoid arthritis.

You decide that rheumatoid arthritis is the most likely differential diagnosis.

Red flags

Your patient shows no signs of bone pain or weight loss associated with the critical diagnoses.

Management

Self-care options

You tell her that she could start taking an NSAID more regularly, but it may be necessary to have a PPI alongside this to mitigate any side-effects.

Prescribing options

Patients with suspected rheumatoid arthritis will need specialist assessment, but blood tests can be instigated to check for rheumatoid factor and inflammatory markers. DMARD therapy is an option, but a full blood count, alongside kidney and liver function tests, should be undertaken to establish baseline levels first. X-rays of the hands and wrists should also be arranged.

Safety netting

You tell the patient that her symptoms are consistent with rheumatoid arthritis and that, in the short-term, she could start taking analgesics to help with the pain. However, if she experiences any stomach discomfort, she will need another medicine to help prevent this.

You also tell her that she will need tests to confirm the diagnosis and that a more comprehensive assessment of her symptoms would have to be performed at the hospital.

Causes of joint pain

Likely diagnoses

Ankylosing spondylitis
This is a chronic spondyloarthropathy, which primarily involves the axial skeleton, especially the lower back. Morning stiffness is characteristic but relieved with activity. About one-third of patients also have peripheral arthritis involving the hips and shoulder girdle. Systemic features are common. Fever and weight loss may occur during periods of active disease. Fatigue is also prominent.

Multiple osteoarthritis
Patients report functional limitation, pain associated with activity/joint use and morning stiffness lasting <30 minutes. There may be swelling and tenderness, and restricted and/or painful range of motion. It is associated with increasing age, joint injury and obesity.

Psoriatic arthropathy
Symptoms may mimic rheumatoid arthritis – morning stiffness, swelling and warmth. It commonly affects the small joints of the hands and feet but shows less symmetry than RA. In addition, psoriasis is present in over 90% of patients – dactylitis, tendonitis and uveitis may also be observed.

Rheumatoid arthritis
Typified by symmetrical arthritis of the small joints in the hands and feet experienced as pain (usually worst at rest), warmth, swelling around the joint, and early morning stiffness that lasts over an hour. It is more common in women and those with a family history. Systemic symptoms are common and include fatigue, fever and malaise.

Viral polyarthritis (e.g. parvovirus B19, hepatitis B, rubella)
Characterised by abrupt onset of symmetrical arthritic pain in multiple (usually small) joints. Viral prodromal symptoms and/or rash will often precede the joint pain.

Possible diagnoses

Behçet’s syndrome
This is a complex multi-system disorder. It is associated with the triad of painful oral and genital ulceration and uveitis. Non-specific symptoms include tiredness, malaise and headache, muscle pains and transient fevers. Arthritis and arthralgias are common, which mostly affect the lower limbs, especially the knee but can impact the small joints. Back pain due to sacroiliitis may also occur.

Connective tissue diseases

• Systemic lupus erythematosus (SLE)
SLE is a multisystem, autoimmune disease that can present at any age. Signs and symptoms are often non-specific and include fatigue, malaise, fever, weight loss, skin rash and arthralgia. Arthralgia is common accompanied with early morning stiffness. The condition is prone to relapse and remission.

• Polyarteritis nodosa
This is a rare multisystem condition. It commonly presents with arthralgia/myalgia accompanied with extra-articular symptoms of skin lesions, abdominal pain, fever, weight loss, malaise and renal disease.

• Fibromyalgia
Fibromyalgia is a very common disorder, particularly in middle-aged women, characterised by diffuse chronic musculoskeletal pain, fatigue, low mood, non-restorative sleep and normal blood results. Patients often report dropping things due to pain and weakness. It is associated with irritable bladder, irritable bowel syndrome, headaches and temporomandibular joint pain.

• Juvenile idiopathic arthritis (JIA)
This is characterised with joint inflammation presenting in children under the age of 16 years that has persisted for at least six weeks. Approximately half of JIA present with oligoarticular involvement and typically presents with one or two swollen joints (knee and ankle are most affected) causing stiffness and reduced movement but often not much pain. The child usually feels well. A further 30% of patients have polyarticular presentation, which may also include symptoms of fever, liver and spleen enlargement.

Lyme disease
If a person develops a spreading red/purple flat rash with a defined border (bullseye appearance, although this does not always occur) and flu-like symptoms with a history of a tick bite, then Lyme disease should be considered. If left untreated, joint pain occurs (especially in the knees), as well as facial palsy, dizziness, palpitations and eye problems.

Medicines
Several medicines can cause bone pain as well as arthritis. The most implicated medicines are aromatase inhibitors, bisphosphonates and statins. Fluoroquinolone antibiotics can also cause back pain and, rarely, arthritis.

Polymyalgia rheumatica
This should be suspected in patients aged over 50 who present with bilateral shoulder and/or pelvic girdle pain that has lasted more than 2 weeks. Pain often radiates to the elbow or knees. Self-limiting peripheral arthritis can affect the knees and wrists. Approximately half of patients suffer from systemic symptoms such as fever, weight loss and depression.

Rheumatic fever
This is an uncommon condition and follows on from a streptococcal throat infection. The patient experiences sore knee, elbow or wrist joints (hot, red and sore to move). Extra-articular symptoms include fever, jerky movements, breathlessness, fast heart rate and rash.

Sarcoidosis
Symptoms are highly variable as it can affect many body systems, but in 90% of cases the lungs are affected causing dry cough and dyspnoea. Often, constitutional symptoms are present such as fever, night sweats, malaise, fatigue and weight loss. Other symptoms may include skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis. Sarcoidosis largely affects patients in their mid-20s to mid-40s

Critical diagnoses

Amyloidosis
Symptoms are largely determined by the organ or system affected but typically cause fatigue, weight loss, easy bruising, breathlessness, peripheral oedema, sensory change, carpal tunnel syndrome and postural hypotension.

Malignancy
This is suggested by persistent and progressive bone pain unrelated to activity, night pain and loss of function.
Now check your knowledge of joint pain by answering the following questions:
1. A 42-year-old woman presents with symmetrical pain and swelling of the small joints in the hands, morning stiffness lasting over one hour, and fatigue. Which ONE of the following is the most likely diagnosis?
a. Gout ☐
b. Osteoarthritis ☐
c. Psoriatic arthritis ☐
d. Rheumatoid arthritis ☐
e. Systemic lupus erythematosus ☐
2. A patient presents with joint pain, butterfly rash sparing the nasolabial folds, and photosensitivity. Which ONE of the following is the most likely diagnosis?
a. Osteoarthritis ☐
b. Psoriatic arthritis ☐
c. Rheumatic fever ☐
d. Rheumatoid arthritis ☐
e. Systemic lupus erythematosus ☐
3. A patient presents with acute onset of severe pain in multiple joints and a history of recent viral illness. Which ONE of the following is the most likely diagnosis?
a. Fibromyalgia ☐
b. Osteoarthritis ☐
c. Rheumatoid arthritis ☐
d. Septic arthritis ☐
e. Viral polyarthritis ☐
4. A 58-year-old man presents with joint pain worsened by activity, minimal morning stiffness, and bony enlargement of his finger joints. Which ONE of the following is the most likely diagnosis?
a. Behçet’s syndrome ☐
b. Osteoarthritis ☐
c. Psoriatic arthritis ☐
d. Rheumatoid arthritis ☐
e. Systemic lupus erythematosus ☐
5. A patient presents with chronic back pain, stiffness that improves with exercise, and reduced mobility. They also complain of peripheral joint pain. Which ONE of the following is the most likely diagnosis?
a. Ankylosing spondylitis ☐
b. Gout ☐
c. Osteoarthritis ☐
d. Rheumatoid arthritis ☐
e. Systemic lupus erythematosus ☐
Answers: 1.d 2.e 3.e 4.b 5.a


Share:

In Practice scenarios

Change privacy settings