The pain’s location helps the physician establish an etiology and diagnosis. The pain in rheumatoid arthritis classically involves both small and large joints and is symmetric, while the pain in osteoarthritis usually involves weight-bearing or functional joints and may be asymmetric. The pain in tendonitis and bursitis is usually acute and localized. Entrapment syndromes and radiculopathies may cause referral of pain from primary to distant sites; for example, pain due to synovitis in the hip may be referred to the knee. Migratory arthralgias are common in acute rheumatic fever and, at times, are seen in systemic lupus erythematosus, early rheumatoid arthritis, gonococcal arthritis, and leukemia. Pleuritic chest pain, common in the connective tissue disorders, may mimic costochondritis, but the pain of the latter is “palpable.”
Preventive measures are extremely important in the management of arthritis, and therefore possible precipitating factors should be sought. For example, excessive weight-bearing exercises such as walking often aggravate, rather than help, osteoarthritis of the back, spine, and weight-bearing joints. Exposure to cold may bring on Raynaud’s phenomenon and severe pain in the extremities.
The range, severity, and timing of joint stiffness help differentiate the various arthritic disorders. Early-morning stiffness is a classic feature of rheumatoid arthritis and other inflammatory diseases of the synovium, whereas acute, severe stiffness after inactivity (“gelling”) is a prominent feature of osteoarthritis. Persistent pain and stiffness in the muscles throughout the day are seen in fibromyositis. The duration of morning stiffness can measure disease activity and guide adjustments in therapy.
Other important historical features include the patient’s complaints of joint swelling (often absent on physical examination), muscle and joint weakness, and an inability to perform functional activities of daily living (table 2). Depression, another potential finding, can cause, mimic, or result from general or localized weakness and fatigue. A number of rheumatic disorders are likely influenced by emotional or physical stress, and one school of thought even reports that stress may exacerbate some arthritic disorders, including rheumatoid arthritis. Certainly, fibromyositis is stress-related. When this condition is suspected, the patient’s sleep patterns should be evaluated. Generally, patients with fibromyositis are more exhausted on awakening than they were on going to sleep. Sleep studies have shown that these patients are unable to reach deep sleep. Many patients with fibromyositis are perfectionists who also have a number of other psychosomatic symptoms, such as migraine headaches and emotional liability.
Often patients have nonarthritic or nonrheumatic complaints that are important clues to diagnosis, for example, symptoms secondary to inflammation of the skin, vital organs, CNS, and gastrointestinal and genitourinary tracts. The patient’s family and social histories may also provide important diagnostic information. Finally, the patient’s ability to tolerate medications, particularly nonsteroidal antiinflammatory agents, should be noted in history taking, to avoid aggravating existing symptoms or precipitating new ones with poor choices of drug therapy.