Assessment and prescribing

Approach to joint pain and inflammatory arthritis

Overview and approach

Start by deciding whether pain is articular, inflammatory, infectious or periarticular, and whether one or many joints are involved.

Inflammatory pain: morning stiffness over 1 hour, worse after rest and better with activity, warmth and swelling, sometimes night pain, systemic features (1)(2).
Mechanical pain: worse with activity, better with rest, stiffness under 30 minutes (1)(2).
Joint or soft tissue? Joint-line tenderness, effusion and pain on passive movement point to the joint. Focal tendon or bursa tenderness with pain only on active movement points to periarticular disease (1)(2).
Classify by number and pattern: mono-, oligo- or polyarthritis, symmetry, small versus large joints, axial involvement (1)(3).

Assessment and clinical features

Ask onset, stiffness, swelling, distribution, systemic symptoms, psoriasis, eye/bowel symptoms, exposures and functional impact.

History checklist: onset (acute or insidious), duration, pattern, number of joints, symmetry; fever, weight loss, rash, photosensitivity, dry eyes or mouth, Raynaud, red eye, bowel or urethral symptoms, recent infection; psoriasis and nails, family history, medicines, trauma, immunosuppression, prosthetic joint (1)(3).
Examination: look, feel and move every joint and compare sides. Document synovitis (swelling, warmth, effusion), range of movement, dactylitis, enthesitis, tophi, skin, nails, eyes and mouth (1)(3).

Differentials and investigations

Examine synovitis, range of movement, skin, nails and other systems. A hot joint may need urgent aspiration for cell count, crystals and culture.

Acute monoarthritis with effusion, fever, redness or warmth: aspirate for cell count, Gram stain and culture, and crystals (4). Septic arthritis is the diagnosis not to miss. Others: gout or CPPD, trauma or haemarthrosis, reactive or early inflammatory arthritis.
Asymmetric oligoarthritis with enthesitis, dactylitis, psoriasis, inflammatory back pain, IBD or preceding infection: think spondyloarthritis.
Symmetric small-joint polyarthritis with prolonged stiffness: think RA (apply the 2010 ACR/EULAR criteria); also viral arthritis and SLE.
DIP and bony enlargement with short stiffness: osteoarthritis. Widespread pain without synovitis: consider fibromyalgia.
First-line tests: FBC, ESR/CRP, urea/creatinine, LFT, urate, RF and anti-CCP if synovitis, X-ray of symptomatic joints, synovial fluid if an effusion is present. ANA/ENA only if connective tissue disease features. See Rheumatology investigations quick reference.

Management and follow-up

Treat pain safely and refer persistent synovitis early rather than repeatedly using steroids without a diagnosis.

NPS MedicineWise/ARA advice is that people with suspected RA should be referred to a rheumatologist as quickly as possible (5).
Treat the underlying cause once identified; see the condition pages.

Red flags and clinical pearls

Fever with acute monoarthritis, immunosuppression or a prosthetic joint needs urgent infection assessment. Crystals do not exclude coexisting infection.

Normal inflammatory markers do not exclude inflammatory disease.
Viva: "A 60-year-old has a hot swollen knee: what now?" Aspirate before antibiotics if possible, send blood cultures, urgent senior and orthopaedic input. See Rheumatology red flags and emergencies.

References

Last updated from Sen’s notes on 9 October 2026.