An otherwise healthy 45 year old female presents to the primary care office with complaints of pain in the joints of her hands. She notes that her wedding ring won't fit on her finger any more. She tells you that when she is doing her job as a butcher her hand pain worsens. She has also noted times when her hands feel numb, especially in the morning. She thinks that her hands are starting to look like those of her grandmother's. She tells you that she was reading about her problems on the internet and wonders if she may have gout. She denies any other specific complaints, including fever, rash, diarrhea, and dysuria.

On physical examination, she has bony enlargement of her proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with mild tenderness and no warmth at the DIP joints. She is able to close her fist fully and her hand grip is normal.

What are the key features of her history and physical that will help you make the diagnosis?

The history is essential in determining the etiology of musculoskeletal complaints. Inflammatory joint pain is usually worse in the mornings or after periods of inactivity, with improvement with activity. It also commonly will present with warm and swollen joints, also known as synovitis or tenosynovitis when the tendons are involved. Non-inflammatory joint pain is worse with activity and rarely is there synovitis, although joint effusions may be present at times. The patient should also be questioned about associated symptoms which may be a clue to inflammatory conditions, including fever, fatigue, rash, gastrointestinal complaints, genitourinary complaints, and eye redness.

Approach to the Joint Exam

Observation - In terms of the physical exam, pattern recognition essential to the differential diagnosis. The distribution of involved joints can help guide you: number of joints (monoarticular, oligoarticular, or polyarticular); size of the joint involved (large or small) and symmetric or asymmetric involvement, can provide a clue to the diagnosis. The presence of redness, warmth and swelling is indicative of inflammatory versus non-inflammatory joint disease.

Examination - With the patient seated comfortably and dressed to allow examination of the joints, you should inspect the joints for redness, warmth, swelling or signs of deformity. Then examine the range of motion of the joints.

• Hands: dorsal and palmar surfaces, spreading the fingers, and making a fist.
• Wrists and elbows: flexion and extension.
• Shoulders: raising arms overhead, place hands behind the back and place hands behind the head.
• Hips: with the patient lying on his or her back, examine flexion, then internally and externally rotate the hip with the knee flexed
• Knees: flexion and extension; if indicated, examine for anterior and posterior cruciate ligament tears medial and lateral collateral ligament tears and medial meniscus injury.
• Ankles and feet: dorsiflexion and plantarflexion, plantar surface of foot.

With the patient standing, assess alignment of the spine, knees, heels, and feet as well as the arches. Examine the spine for deformity and range of motion (flexion, extension, and lateral rotation). Finally, observe the gait and note any assistive devices. In addition, you should assess muscle atrophy and the presence of extraarticular tender points).

In this case, the patient describes non-inflammatory sounding pain, in a typical osteoarthritis (OA) distribution-namely, PIP and DIP joints without metacarpophalangeal joint involvement Her clinical picture is most consistent with OA of the hand.