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Introduction

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I don’t deserve this award, but I have arthritis and I don’t deserve that either.

Jack Benny

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Not everything that presents to the sports clinic is sports medicine! In daily practice, sports clinicians see many patients who have mechanical joint injuries, so it can be tempting to attribute a mechanical diagnosis to every patient who presents with a painful or swollen joint. It is, however, wise to maintain an index of suspicion for inflammatory joint disease masquerading as a mechanical condition.

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Consider the case of a 30-year-old runner who presents with recurrent knee swelling without history of injury. Swelling is very uncommon in patellofemoral pain (Chapter 33) and a meniscal injury is rare without trauma at that age. The clinician should be alert to the possibility that this swollen knee may be caused by an inflammatory condition.

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In this chapter, we discuss the clinical approach to diagnosing patients with the following four common presentations:

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  • the single swollen joint

  • low back pain and stiffness

  • multiple joint symptoms

  • joint pain and “pain all over.”

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We also discuss when to use rheumatological investigations and how to interpret them.

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The patient with a single swollen joint

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In the sportsperson with a single swollen joint without a history of trauma, a possible inflammatory cause should be considered. Table 55.1 summarizes the differential diagnosis of a single swollen joint.

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Table Graphic Jump Location
Table 55.1

Differential diagnosis in the sportsperson presenting with a single swollen joint without a clear history of trauma

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Clinical perspective

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The key to accurate diagnosis of a swollen joint is taking a careful history, performing a physical examination, and having an appropriate index of suspicion. Inflammatory joint problems are characterized by pain, swelling, warmth, redness, night pain, and prominent morning stiffness. In all sportspeople, and especially in children and adolescents, inflammatory, infective, or neoplastic conditions should be considered in the light of these symptoms.

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History
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Many of the inflammatory diseases are associated with extra-articular features that may provide additional clues as to the diagnosis:

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  • Psoriatic arthritis may be associated with rash, nail dystrophy, tendon insertion pain (enthesopathy), or low back pain.

  • A history of inflammatory bowel disease (ulcerative colitis, Crohn’s disease, or celiac disease) suggests enteropathic arthritis.

  • Urethral discharge or eye inflammation may suggest a reactive arthritis.

  • Rheumatoid arthritis is characteristically a small joint (hands, wrists, and feet), symmetrical polyarthritis but can ...

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