Getting a diagnosis

What are the symptoms?

When your locomotor system goes wrong, you feel pain and stiffness and you may notice swelling of your joints. Symptoms can be very troublesome, even disabling, and can sometimes be out of all proportion to the seriousness of the condition.

Pain, in particular, is a complex symptom and can be made much worse by stress, anxiety or depression. It is important to recognise these influences and not just assume that your arthritis must be getting worse. Expectations can also play a part here. If you had watched an older relative gradually become disabled by painful arthritis, perhaps in the days before we had effective treatments, then, at the first sign of the inevitable aches and pains of middle age, you might become worried and upset that the same fate awaits you. Your anxiety and distress would make your pain much worse, and pain is by far the most disabling symptom – joints that are structurally sound may be almost useless if every movement causes severe pain.

Fortunately, we now understand a great deal about joint symptoms and arthritis, and we have lots of treatments and advice to help sufferers lead normal lives.

When you go to your doctor with pain, stiffness or swelling of a joint, your doctor will need quite a lot of information from you and may order various tests to establish the cause of the problem. Pain in or around a joint (known medically as ‘arthralgia’) doesn’t necessarily mean that you have arthritis. Other diseases can produce this kind of symptom. Flu, for example, can cause severe aching pain in the joints and muscles but the pain disappears as you recover.

Seeing the doctor
Taking your history
When you first talk to a doctor about your problems, he or she will check your symptoms and your past record of health. This is called ‘taking your history’.

Your doctor will also want to know whether any close relatives have arthritis. Your family history is relevant because some people inherit a genetic susceptibility to some forms of arthritis. You should also tell your doctor if you have had any past injury to the joint, because this may cause problems to develop later on.

Certain other conditions may be associated with the onset of arthritis, such as the skin disease psoriasis or the bowel condition ulcerative colitis. Sometimes, arthritis can follow an infection – when it is called ‘reactive arthritis’ – so it is important to mention any recent foreign travel in case you may have picked up an infection that could account for your symptoms.

Try to be as exact as you can when describing your symptoms – when they began, whether anything triggered them, whether they are constant or intermittent, whether anything makes them better or worse, what treatment you have tried so far and what effect it had, including side effects.

Physical examination
Your doctor may need to examine you thoroughly, even if you have only a single painful joint, because other joints may be similarly affected, even if they are not painful at the moment. Sometimes, a problem in one joint can cause strain in nearby joints.

Although these joints are normal, they become painful. For example, shoulder pain may be caused by a problem in the neck, back pain can arise from knee or hip problems, which are affecting the way you walk, and your knee may hurt even though the real problem is actually in your hip joint.

During the examination, your doctor will be looking for swelling, tenderness, stiffness of the joint and whether the joint is stable, which involves checking the muscles and ligaments that hold the joint in position. Your doctor may also take the opportunity to do other routine checks, such as measuring your blood pressure.

Tests and investigations
Very often, your doctor will be able to identify your problem without the need for any tests, especially if only one joint is painful or if the diagnosis is obvious and straightforward. Otherwise, the tests that you have will depend on individual circumstances, but may include some or all of the following.

Blood tests
Full blood count
A machine counts the number of red and white blood cells and platelets in a cubic millimetre of blood.

Taking a blood test
A blood test can provide your doctor with a great deal of information to assist with diagnosis.

The haemoglobin level in the red blood cells is also measured. This shows whether you are anaemic, as can happen in rheumatoid arthritis. Anaemia is a disorder in which haemoglobin (the oxygen-carrying component of red blood cells) is deficient or abnormal. A full blood count also measures the number of white cells in the blood, which can be increased in infection.

Erythrocyte sedimentation rate (ESR)
Blood consists of cells and fluid (plasma). The most numerous blood cells are red blood cells which transport oxygen round the body. The ESR measures the stickiness of the red blood cells. A raised ESR suggests that inflammation is present, although it gives no indication as to the cause. The ESR is raised in those types of arthritis where the joints are severely inflamed. In osteoarthritis, which is the most common form of arthritis, inflammation is absent or mild and so the ESR is normal.

Uric acid
This is the substance that forms crystals in the joints during attacks of gout. The level of uric acid in the blood is often raised in gout sufferers.

Rheumatoid factor
Rheumatoid factor is an antibody that appears in the blood in some people with rheumatoid arthritis. It can also be found in low levels in normal people, especially as they get older, and in some relatives of people with rheumatoid arthritis. Rheumatoid factor does not cause disease but it can be a useful marker.

X-rays
X-rays are not always needed to make a diagnosis of arthritis. Most people over the age of 50 have some degree of osteoarthritis and joint pain is not always related to changes seen on the X-ray.
Most forms of arthritis begin by affecting the soft tissues of the joint, such as the cartilage in osteoarthritis and the synovium in rheumatoid arthritis. Soft tissues are not easily seen on an X-ray. The X-ray is of most use in showing whether the arthritis has progressed to affect the bones and as a baseline against which future changes can be measured.

The X-ray of a joint with arthritis may show the following changes.

Reduced joint space
The space between the bones of the joint is normally filled with cartilage, which cannot be seen on an X-ray. In many forms of arthritis, but especially in osteoarthritis, the cartilage becomes thinner and the joint space becomes narrower.

Erosions
These are holes in the bones of the joint and they occur in advanced arthritis. Erosions can occur in rheumatoid arthritis and other forms of arthritis where the joints are severely inflamed. They are very unusual in osteoarthritis.

Bony overgrowth (osteophytes)
Sometimes, arthritis causes extra bone to grow at the edges of affected joints. This can be seen quite clearly on an X-ray. In the spine, the extra bone can cause pinching of a nerve, leading to pain along the route of the nerve.

Putting it all together
A careful history and examination, together with a few simple tests, are often all that your GP needs to make a diagnosis. Sometimes this is not possible and you will need to see a hospital specialist. However, even the specialist may not be able to make a diagnosis on the first consultation and the full picture becomes clear only with the passage of time. You will be given treatment to ease your pain and stiffness – and a period of observation, perhaps with a repeat of some of the tests, can help to establish a diagnosis.

The specialist whom you see may be a rheumatologist who specialises in inflammatory disease and the medical treatment of arthritis and rheumatism. Or he or she may be an orthopaedic surgeon if your problems are the result of injury or mechanical damage rather than inflammatory disease.

KEY POINTS
A careful history and examination help your doctor to make a diagnosis
Blood tests and X-rays may help but they are not always needed