Pain Management Of A Joint

                                                                                         

Joint pain can be caused by many different processes which include degeneration of the articular cartilage, infection, inflammation, trauma and deposition of crystals. Distinguishing one type of joint diagnosis from another is mostly made by taking a history and examining the joint, as this process is able to narrow down the options well. Once a provisional diagnosis is made then investigations are typically used to confirm the diagnosis and are less useful in trying to look for a cause without a narrow range of options. Clinicians try first to establish the source of the joint symptoms and then the potential underlying pathological process.

The source of joint pain can be from within the obvious joint, from structures which surround the joint or can be a referred pain from a structure elsewhere. Within the joint itself the pain can come from the surrounding capsule, the ligaments, the bone membrane, the synovial joint lining and the bone underneath the joint cartilage. The joint cartilage itself is not a source of pain as it does not possess any sensory nerve endings. It is very important to pin down the likely structure responsible for the pain as the diagnosis and so the therapy may be different depending on that evaluation.

The pathological processes which result in joint damage are several and cover infections, laying down of crystals in the joint, inflammation of the junctions between tendon and bone and ligament and bone (enthesitis), synovial inflammation and joint abnormalities. Joint changes can be structural or mechanical like injury to a meniscus. The above pathologies may occur in combination and not just one at a time. Inflammatory changes in the joint linings (synovitis) are the main pathology in many arthritic conditions including rheumatoid arthritis. The growth of the synovial membrane can cause cartilage destruction and a puffy, warm and inflamed joint.

Where tendons and ligaments insert for fixation into the bone is known as an enthesis and some arthritic conditions are particularly affected in this area. The local soft tissues of the entheses react to the inflammation by forming bony tissue within them which can grow into bony outgrowths along the structures concerned. A painful and inflamed joint can result from crystal deposition along the ligaments, on the synovial membrane or on the surface of the articular cartilage itself. Depending on the deposition pattern the joint can exhibit general or local symptoms and the warmth, exquisite pain and redness of a gouty joint are easily spotted.

A joint infection can be the result of bacterial, viral or fungal infiltration and most infections are blood borne, with the patient often feeling unwell as the joint infection is part of a more systemic infection. The synovium is typically affected by the infection, which leads to areas of membrane death followed by proliferation of healing tissue and scar. Joint cartilage can be damaged and destroyed very quickly by some bacterial toxins. Osteoarthritis is the most common joint abnormality in the world and its occurrence and severity are governed by a variety of internal and external factors.

Factors which make the onset of osteoarthritis more likely are a congenitally abnormal joint, a collagen joint condition such as hypermobility and the past history of the joint in terms of traumatic events such as meniscal tears or fractures. High bodyweight, the occupation followed and one's genetic inheritance all have a bearing on the likelihood of osteoarthritis, but age is one of the strongest correlating factors. As the joint cartilage surfaces deteriorate the bone underlying the cartilage can become denser and bony outgrowths appear at the margins of the joints. Osteoarthritis often does not exhibit inflammation but at times a synovitis may occur.

The first stage for the examining clinician is to determine the source of the pain more precisely. The joint may be painful or there may be pain from close anatomical structures such as ligaments, tendons or muscles or it may be pain referred from a distant source. The more central joints such as the hip and the shoulder are more difficult to diagnose. Pain referred to the hip area is often not related to the hip joint itself and hip pain could be secondary to trochanteric bursitis, hip osteoarthritis, stenotic lumbar changes or intervertebral disc disease.

About the author:
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Bolton visit his website.

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