Introduction to Arthritis in Prehospital Patients

Arthritis in Prehospital Patients is an illness that is defined by the inflammation of one or extra joints and it could be acute (temporary) or chronic (long term). It is commonly linked to pain, stiffness, swelling in joints and the loss of mobility in the joints or in serious cases it may lead to the deformity of the joints. Management of arthritis in pre-hospital patient is necessary for proper care and safe transport, especially in complication of septic arthritis or during arthritis –related flare-ups.

There are over 100 kinds of arthritis such as osteoarthritis, rheumatoid arthritis and gout and each of them require different treatment. The physical exam and the history of the person are relevant to a diagnosis, but additional study with further imaging and other examinations is mandatory to confirm the disease. In prehospital care, the quick diagnosis and treatment of pain due to arthritis play a significant role in case the patient does not experience the discomfort anymore and the symptoms do not worsen in the situation of emergency.

Epidemiology of Arthritis

According to NICE Clinical Knowledge report (2023) more than 8.75 million individuals in the UK aged over 45 years had received treatment related to osteoarthritis (OA), with 18% of them suffering knee osteoarthritis and 8% of them having hip osteoarthritis Additionally, Rheumatoid arthritis (RA) is a disease that occupies approximately 1% of the UK population and women have a higher incidence. The highest occurrence in the age of onset is 30-50 years with another peak at the age 70s.

Imaging evidence of arthritis is observed in more than one-third of the American population, and the prevalence progressively rises with the age.

Gout is the most prevalent inflammatory arthritis in the U.S., afflicting 8 million (about 3.9 percent) of the population (and an estimated 9 percent of patient over the age of 60). It is on the rise and currently stands at more than 45 per 100 000 per year. Pseudo gout occurs in 4-7 % of adults and is usually manifested as arthritis of the knee.

Rheumatoid arthritis (RA) is present in approximately 1% of Caucasians, and with an even greater incidence in women (3.6% lifetime frequency compared to 1.7 in men). It begins to develop at an early age during adulthood and the prevalence rises up to 5 percent among women aged above 65.

Osteoarthritis (OA)- is the most popular one which is found in 19 to 30 per cent of adults above 45 years of age and is mainly prevalent in the knee, hip and the hand. The risk of developing it may increase by up to 47 percent in the course of life and to 60 percent among victims of obesity (BMI>30).

Septic arthritis is reportedly rare among the general population (0.01%), but more so among patients with RA (0.7%) and in the aforementioned pathological conditions, it occurs most often as a result of haematogenous dissemination after another infection, most often a urinary tract infection or cellulitis.

Pathophysiology Of Arthritis

Osteoarthritis is a degenerative joint disease that is characterised by cartilage losses caused by mechanic stress and enzyme depletion. Inflammatory mediators include, MMPs and proteases, which activate collagen-degrading enzymes. The cartilage also becomes calcified and eroded with time losing its regenerative potential.

It is an autoimmune disease where the synovial membrane is damaged by the immune cells. TNF- an and IL- 1 cytokines result in synovial hyperplasia, persistent inflammation, synovial, and consequent destruction of cartilage and bone.

In Gout, Monosodium urate crystals are deposited in the joints which affects lower temperatures areas in the body. The acute inflammation associated with the release of IL-1 by the crystals leads to a lot of pain in the joints.

It implies a concentration of calcium pyrophosphate dehydrate crystals in joints and cartilage. They trigger inflammation and injury and inflammation as well as are often associated with metabolic issues.

The outcome of an infection of the bacteria in the joint space. Bacteria induce production of cytokines and activating proteins, which cause high-paced disintegration of cartilage and inflammation of the synovium.

Causes Of Arthritis

Signs & Symptoms of Arthritis

The signs and symptoms of arthritis in prehospital patients vary depending on the specific type and severity of the condition. However, many forms of arthritis share common features. These may include:

Morning stiffness, particularly after periods of rest, which can limit joint mobility and ease of movement.

Joint pain, typically aggravated by movement or activity.

Swelling and warmth around affected joints, often indicating active inflammation.

Reduced range of motion, making it difficult to perform everyday tasks.

Visible joint deformity in advanced or chronic stages, especially in conditions like rheumatoid arthritis.

Systemic signs of inflammation, such as fever, malaise, and severe fatigue, are often seen in inflammatory types like rheumatoid arthritis.

Severe, incapacitating joint pain and high fever are especially characteristic of septic arthritis and gout, often affecting one joint but potentially spreading to adjacent areas.

History & Assessment Of Arthritis In Prehospital

History taking and assessment is needed for arthritis in prehospital patients.

A focused and structured patient history is essential for arthritis in prehospital patients to identify the type of arthritis, assess for red flags, and inform urgent management decisions. Key elements include:

Symptom onset and progression
Ask when the symptoms began, how they have progressed, and whether they fluctuate (e.g. flare-ups). Clarify the duration, severity, and impact on daily activities.

Nature of the pain
Determine if the pain is acute or chronic, constant or intermittent, and whether it worsens with movement or rest.

Previous diagnoses or episodes
Ask if the patient has a known history of arthritis (e.g. osteoarthritis, rheumatoid arthritis, gout) or has had recent flare-ups or infections.

Medical history
Enquire about comorbidities such as diabetes, chronic kidney disease, cardiovascular disease, previous joint replacements, or use of immunosuppressive medications (which may increase the risk of septic arthritis).

Recent infections or injuries
Explore recent systemic or local infections (e.g. urinary tract, skin), injuries, or procedures (e.g. intra-articular injections) that may trigger or mimic joint inflammation.

Once history has been obtained, conduct a structured assessment focusing on both local and systemic signs:

Initial observation
Visually inspect for joint swelling, redness (erythema), deformity, or restricted movement. Observe for pain-related behaviours such as guarding or limping.

Vital signs
Record heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. Look for signs of systemic infection or sepsis (e.g. fever >37.5°C, tachycardia, hypotension).

Joint examination
Palpate the affected joint for warmth, tenderness, swelling, and fluctuation. Assess range of movement and check the patient’s ability to bear weight or mobilise.

Pain assessment
Use a validated pain scale (e.g. 0–10) to document and guide analgesia. Reassess after treatment.

Red flag identification of arthritis in prehospital patients.

Be alert to signs of septic arthritis:

• Hot, swollen, painful joint
• Systemic symptoms (fever, rigors, confusion)
• Rapid deterioration or inability to move the joint

These require urgent transport and hospital notification.

Referral and handover

If infection or sepsis is suspected, pre-alert the receiving hospital. For non-emergency cases, advise GP or rheumatology follow-up as appropriate. Ensure a structured handover (e.g. using ATMIST or SBAR).

Management of Arthritis in Prehospital Patients

Give analgesics medicine such as paracetamol or NSAID in absence of contraindications. In extreme cases, or in severe pain opioids can be administered on a medical prescription Use splints, slings or packs to help support the affected joint to limit the movement and discomfort. Use cooling packs on acute swelling and inflammation or heating packs on chronic stiffness when the situation is right.

Make the patient comfortable to avoid stress on the joints.  Monitor patient’s vital signs and check on an occurrence of injury, severe pain or an infection (e.g. septic arthritis). Make arrangements to take to hospital, in case necessary. Offer encouragement and elaborate every care procedure to rule out anxiety.

The identification and early treatment of arthritis in the prehospital environment are essential to ease pain and avoid possible infection (complications), as well as define severe conditions such as septic arthritis. Early evaluation, proper pain management, and early transfer to a hospital can help save a patient in a significant way.

Differential Diagnosis

When examining a patient with a joint pain and swelling there are some conditions that are likely to present the patient with similar symptoms and must be taken into consideration.

Septic arthritis is a joint infection which usually includes a hot, red, swollen joint as well as fever and intense pain. The patients cannot maintain movement of the affected joint and the condition needs emergency care in the hospital.

Gout is very painful and the pain is abrupt and occurs within a joint e.g. big toe, knee. It most of the time occurs without fever and is associated with the lifestyle like food habits or kidney problems. A patient can possess a background of past gout.

Rheumatoid arthritis exacerbations start with several joints, usually symmetrical. It is a long-term autoimmune disease, which frequently leads to the swelling during the mornings without fever and regular stretching.

Osteoarthritis – It attacks include persistent joint pain and stiffness; this condition tends to deteriorate during the activity. Fever and systemic symptoms are not a part of osteoarthritis like infections.

Lastly, traumatic joint injury needs to be conceived when another history of trauma or injury exists. This may lead to swelling, pain and restricted motion of the joints commonly associated with mechanical injuries.

Key Points

Bibliography

Kidd, B. L., Langford, R. M., & Wodehouse, T. (2007). Arthritis and pain: Current approaches in the treatment of arthritic pain. Arthritis Research & Therapy, 9(3), 214. https://doi.org/10.1186/ar2147

NICE Clinical Knowledge Summaries (CKS). (2023). Osteoarthritis – prevalence. Retrieved June 29, 2025, from https://cks.nice.org.uk/topics/osteoarthritis/background-information/prevalence/#:~:text=An%20Arthritis%20Research%20UK%20report,of%20the%20hand%20and%20wrist

NICE Clinical Knowledge Summaries (CKS). (2025, April). Rheumatoid arthritis: Prevalence and incidence. National Institute for Health and Care Excellence. Retrieved June 29, 2025, from https://cks.nice.org.uk/topics/rheumatoid-arthritis/background-information/prevalence-and-incidence

Senhaji, S., Li, J., Ardeshirzadeh, S., & Thomas, M. A. (2023, June 20). Arthritis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518992