Patients may report pain of “hinge”, regardless of whether the cause is located in the joint itself or in the surrounding (periarticular) structures, such as tendons and bursae; in both cases, the pain in or on an individual joint is referred to as monoartikulärer pain. Pain originating in a joint (arthralgia) can be caused by inflammation of the joints (arthritis). When inflammation occurs frequently in accumulation of intra-articular fluid (effusion) and clinical findings such as heat, swelling and redness rare. In an outpouring rapid assessment is essential in order to prevent infections. Acute monoarticular pain is sometimes caused by a disease that causes pain characteristically polyarticular (z. B. RA) and thus the first manifestation of rheumatoid arthritis (z. B. psoriatic arthritis, RA, pain in multiple joints) can represent. Pathophysiology The causes of pain in and around the joint may include: inflammation (for example, due to infection, arthritis or systemic autoimmune inflammation deposit induced) Non inflammatory disorders, usually mechanical The synovium and joint capsule are the main locations for (eg trauma, pathological internal findings.) intra-articular pain. The synovial membrane is the most common of inflammation (synovitis) affected area. Pain emanating from the menisci are much more the result of an injury. Etiology The most common causes of acute pain monoarticular are generally the following: Trauma infection deposition induced arthritis With an injury is a history of mostly trauma before, that’s diagnosis determining. An injury may involve intra-articular and / or peri-articular structures, and a direct violation (z. B. rotation during a fall) or overuse (for example, repetitive motion, long knees) include. An infection usually affects the joint (septic arthritis, acute infectious arthritis), but it can also periarticular structures, including bursae, the overlying skin and adjacent bone, be infected. Injuries (most common) infection Primary inflammatory diseases (eg gout and RA.) Are in older adults, the most common non-traumatic causes: among young adults, the most common causes are osteoarthritis (the most common) deposit induced arthritis (often gout or pseudogout) The most dangerous cause of joint pain regardless of age is acute infectious (septic) arthritis. Immediate drainage, i.v. Antibiotics and possibly surgical joint lavage may be necessary to minimize permanent joint damage and to prevent sepsis and death. Rare causes monoartikulärer pain osteonecrosis, pigmented villonodular synovitis, hemarthrosis (z. B. in haemophilia or clotting disorders), tumors (causes of pain and at a single joint) and diseases polyarticular usually pain, such as reactive arthritis and Enteropathic arthritis cause. The most common reason for periarticular pain is a violation including an overload. Common diseases are periarticular bursitis and tendonitis; Epicondylitis, fasciitis and tendonitis may also develop. A periarticular infection occurs less often. Sometimes pain related to a joint. For example, a splenic injury can cause pain in the left shoulder, and children with a hip disease may complain of knee pain. Causes of pain and at a single joint cause suspicious findings diagnostic access deposit-induced arthritis, generally caused by uric acid crystals (gout) or Kalziumpyrophosphatkristalle (pseudogout) and occasionally by Kalziumhydroxyapatitkristalle. Acute, self-limiting, recurring phases of monoarthritis, usually in the first metatarsophalangeal joint, ankle or knee (gout) or wrist or knee (pseudogout) Sometimes as tophi visible arthrocentesis acute (usually to the periarticular structures) with study on crystals hemarthrosis pain and effusion spontaneously or after trauma Typically, a known bleeding disorder arthrocentesis Infectious (septic) arthritis (eg., bacteria, fungi, viruses, mycobacteria, spirochetes) Acute or subacute onset of pain, swelling and hyperthermia, decreased mobility often common in immunosuppressed patien th, intravenous drug users, patients with diabetes or previous antibiotic use and in patients with risk factors for sexually transmitted diseases arthrocentesis with cell count, Gram stain and cultures disease Monartikuläre or oligoarticular arthritis in the late stages of Lyme disease Preceding manifestations of Lyme disease, such as erythema migrans, fever, malaise and / or muscle pain after a tick bite Serological tests for antibodies to Borrelia burgdorferi Chronic osteoarthritis indolent pain with or without swelling, usually in older adults bone overgrowth Gg f. Obesity, past joint overload (z. B. in professional athletes) and / or increase bone X osteomyelitis near a joint (rare) fever and hardly localizable pain without joint swelling or redness X-ray and bone scan, CT, MRI or bone biopsy with culture osteonecrosis (avascular osteonecrosis) Frequently past or current use of corticosteroids or sickle cell anemia radiographs usually MRI Peri-articular diseases ( ., For example, bursitis, epicondylitis, fasciitis, tendinitis, tenosynovitis) pain on active movement of the joint; mild pain on passive movement and joint loading point sensitivity and possibly swelling and / or redness on Bursa, tendon attachment site or other periarticular structure (. e.g., fascia); low local tenderness over the joint, no effusion Clinical examination if necessary Aspiration of bursa fluid for Gram stain, cell count and culture psoriatic arthritis (calls frequently polyarticular pain than monoarticular pain out) Usually strong joint effusion in the painful joint, often in a patient with psoriasis can with Dactylitis or enthesitis be associated Clinical evaluation trauma (eg. B. sprain, meniscus tear, fracture) start as a result of significant and hydrolysis with usually trauma x-ray if necessary MRI (z. B. with an unremarkable chest radiograph) or arthroscopy tumor Creeping, slowly progressive and ultimately constant pain, usually with joint swelling X-ray MRI clarification high Acute monoarticular joint pain requiring immediate clarification, because an infectious (septic) arthritis should as soon as possible be treated. Clinical examination should detect if the symptoms come from the joint or periarticular structures and whether there are indications of a joint inflammation. If signs of inflammation or unclear findings of systemic disease should be looked for symptoms and signs. History The history of the disease process should be based on the location of the pain, the rate of disease onset (abrupt z. B., gradually) and focus on whether the problem is new or recurrent and whether other joints have caused pain in the past. Likewise, temporal patterns, accompanying symptoms (eg. As swelling), exacerbation and ameliorating circumstances (eg. As activity) and a current or previous trauma should (z. B. persistent vs. intermittent) are noted in the joint. Patients should also have unprotected sexual contact, pointing to the risk of sexually transmitted disease, previous Lyme disease and possible tick bites in areas where Lyme disease is endemic, are interviewed. The review of organ systems can provide evidence of systemic disease. In reviewing the organ systems urethritis (gonoccocal or reactive arthritis), skin rash or redness should after extra-articular symptoms are sought by causal diseases, including fever (infection, possibly deposit induced arthritis), (reactive or psoriatic arthritis), past abdominal pain and diarrhea (inflammatory bowel disease ) and recent onset diarrhea or genital lesions (reactive arthritis). The history is very likely in chronic or recurrent pain of use. The history should known joint disease (especially gout and osteoarthritis), circumstances that can cause monoarticular joint pain or favor (z. B. bleeding disorder, bursitis, tendinitis), and disorders that may promote joint disease (eg., Sickle cell disease or chronic use of corticosteroids, which can lead to osteonecrosis identify). The drug history should particularly the use of anticoagulants, quinolone antibiotics (tendinitis) or diuretics (gout) into account. A family history should also be collected (some spondyloarthropathies, overview of seronegative spondyloarthropathies) .Körperliche examination A complete physical examination is essential. All major organ systems (eg., Skin and nails, eyes, genitals, mucous membranes, heart, lungs, abdomen, nose, throat, lymph nodes, neurological system) and the musculoskeletal system should be investigated. When checking the vital signs to watch out for fever. In the study of head, neck and skin plaques of psoriasis, tophi or ecchymosis is for signs of conjunctivitis, pay attention. On examination of the genitalia are discharge or other findings that indicate sexually transmitted diseases recorded. Since the involvement of other joints can provide indications of rheumatoid arthritis and systemic disease, all the joints in pain, deformities, redness and swelling should be investigated. the place of the pain can be determined by palpation. By palpation and joint effusion, warmth and bone overgrowth can be detected. The joint can be loaded even without flexion and extension. Mobility is rated active and passive, take into consideration the crepitus and whether can be solved out the pain through a joint movement (passive and active). In case of injury, the joint is to be charged with various maneuvers (if it is tolerated) to detect damage to cartilage or ligaments (z. B. the knee valgus and varus test, front and rear drawer test, Lachman test, McMurray -Test). The findings should be compared with those of the contralateral, unaffected joint to detect subtle changes. To clarify whether the pain articular (especially in knee participation) or periarticular, it is particularly useful to verify that the pain is directly over the joint space or in the vicinity or elsewhere. Large effusions in the knee can be seen usually readily. The examiner can determine minor bruising, by pressing the suprapatellar sac inferior and medial pressed on the lateral side of the patella with the knee. This maneuver causes visible (or palpable) swelling OClick the medial side. Large knee effusion in obese patients demonstrated most suitable by Ballottement the kneecap. In this technique, the examiner strokes with both hands from all four quadrants towards the center of the knee; then the patella with 2 or 3 fingers is pressed down into the sulcus trochlear and then released. A click or feel that the knee cap springs back, indicates an effusion. The periarticular structures should also be examined for Punktschmerzhaftigkeit how the tendon insertion (enthesitis) via a tendon (tendonitis) or bursa (bursitis). Some Bursitisformen (. Eg olecranon, präpatellar) can be swelling and sometimes an erythema on Bursa lokalisieren.Warnzeichen The following findings are of particular importance: erythema, heating, effusion and decreased mobility fever with acute joint pain Acute pain in a joint sexually active young adult skin lesions with signs of cellulite in the area of ??the affected joint underlying bleeding disorder or use of anticoagulants Systemic or extra-articular symptoms interpretation of the findings a recent instead found trauma can to injury as the cause point (z. B. fracture, meniscal tear or hemarthrosis ). However, a trauma does not rule out other causes, and patients often result in falsely emerging, non-traumatic pain to a back injury. To exclude more serious causes and diagnosis tests are usually required. An acute onset is an important feature. Massive joint pain that develops within hours, directs the suspicion of a crystal-induced or, more rarely, an infectious arthritis. Past periods of sudden onset monarthritis indicate a recurrence of a deposit-induced arthritis, especially if the diagnosis was previously confirmed. A gradual onset of joint pain is more typical of RA or non-infectious arthritis. Although uncommon in bacterial infectious arthritis can be a gradual onset of certain infectious arthritis (mycobacterial z. B., mushroom-related) occur. are whether the pain intraarticular, periarticular, or both (eg. as in gout that can affect intra- and extra-articular structures) and whether inflammation is present, are important findings, which are mainly due to physical findings. Rest pain or pain when starting to suggest a joint inflammation, while pain that gets worse with stress and subside at rest, a mechanical or non-inflammatory, degenerative etiology (eg. As osteoarthritis) suggest. Pain which is exacerbated by both passive and by active movement of the joint during the investigation and restricts the mobility, has usually indicates an inflammation. Warmth and redness are also signs of inflammation, but these findings are often not sensitive, so its absence does not exclude inflammation. Pain that is felt more strongly during active, not passive movement, indicate a tendinitis or bursitis, because the pain or swelling over a bursa or tendon attachment point may be. Pressure pain and swelling, strictly localized removed at a location of the joint or the joint space, have an extra-articular cause (for example, starting from tendon or bursae.) Out; local pain at the joint space or achiness are evidence of intra-articular origin. The loading of the joint without flexion or extension is not particularly painful, but very painful arthritis in patients with tendonitis or bursitis. The involvement of the metatarsophalangeal joint (gout) suggests a blast furnace, but can also be due to an infectious arthritis, reactive arthritis or psoriatic arthritis. Symptoms that indicate a dermatological, cardiac or pulmonary involvement can, suggest systemic disease and leading to more frequent polyarticular Gelenkschmerzen.Tests Gelenkaspiration (arthrocentesis) to study the synovial fluid should be done with joint effusion in patients. The examination of the synovial fluid include the number of white blood cells with differential distribution, Gram-staining and microscopic examination of cultures as well as the crystals in polarized light. The presence of crystals in the synovial confirms a form of crystal, but does not rule out a simultaneous infection. A noninflammatory synovial fluid (eg. As <1000 / ul leukocytes) can be rather involved an osteoarthritis or trauma. A hemorrhagic fluid matches a haemarthrosis. The leukocyte count in the synovial fluid may be both infectious and deposit induced arthritis very high (50,000 / ul leukocytes). In some patients with prior confirmed gouty arthritis treatment of recurrent event, no further investigation is likely to be required. However, if an educated guess, an infection or if the symptoms improve not surprising after appropriate treatment on gouty arthritis, a arthrocentesis should be. An X-ray examination often changes the diagnosis of acute monoarthritis, unless there is suspected fracture. X-ray can reveal signs of joint damage in patients with a history of recurrent arthritis. Other imaging techniques (. Eg CT, bone scan, but most commonly MRI) are rare in Aktutzustand necessary, but can be used for diagnosis of certain specific diseases (such as osteonecrosis, tumor [see table. Causes of pain and be indicated a single hinge], occult fracture, pigmented villonodular synovitis). Blood tests (eg. As ESR, rheumatoid factor, anti-citrullinated peptide (anti-CCP) antibodies) can be helpful in the diagnosis of clinically suspected systemic inflammation (eg. As RA). Uric acid serum levels should not be used for the diagnosis of gout, because they are neither sensitive nor specific and do not necessarily reflect the intra-articular uric acid. The total therapy treatment depends on the underlying disease. Iv Antibiotics are immediately in cases of suspected acute bacterial infectious arthritis generally or, as soon as possible. Joint inflammation is treated symptomatically with NSAIDs. If there is pain without inflammation Paracetamol is less toxic alternative, but not always sufficient. Additional measures for pain may be joint immobilization with a splint or sling and heat or cold therapy. Physical therapy is useful after the acute symptoms have subsided, to increase the mobility or to maintain and strengthen the surrounding muscles. Summary An arthrocentesis is mandatory to rule out infection in an acute monoartikulären joint pain associated with swelling. Infection is the most common cause of acute traumatic monarthritis in young adults, whereas osteoarthritis is the most common cause in older adults. Crystals in the synovial confirm a form of crystal, but do not rule out a simultaneous infection. Serum uric acid levels should not be used for the diagnosis of gout. Joint pain that remain unexplained even after arthrocentesis and X-ray examination should be examined with MRI to rule out rare causes (eg. As occult fracture, osteonecrosis, pigmented villonodular synovitis).

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