Joint pain in a young adult
Most joint pain is chronic and can wait. Two kinds cannot: a single hot, swollen joint with fever (septic arthritis destroys cartilage within days), and fever with arthritis in a young person in a setting where rheumatic heart disease is common (acute rheumatic fever can damage the heart valves for life). The pattern of joints and a careful listen to the heart separate them.
- Setting: Health centre in a district where rheumatic heart disease is common; malaria transmission is seasonal
- For clinical officers, nurses and doctors at first-level facilities
- Reviewed October 2026
The presentation
Kofi, 19, a secondary school student, has had painful, swollen joints for 6 days with fever. It started in his right knee, then the left knee, then both ankles; now his left wrist is the worst. The knees are already better. He limps in, holding his wrist.
| Vital sign | Value |
|---|---|
| Temperature | 38.8 °C |
| Pulse | 112 per minute, regular |
| Breathing rate | 20 per minute |
| Blood pressure | 118/70 mmHg |
| Conscious level (AVPU) | Alert |
Tests at hand: Malaria rapid diagnostic test (RDT) · Haemoglobin (Hb) · HIV rapid test · Urine dipstick
- Acute rheumatic fever Must not missStill possible
- Septic arthritis Must not missStill possible
- Gonococcal arthritis Must not missStill possible
- Sickle cell crisisStill possible
- Viral arthritis (for example chikungunya)Still possible
- Malaria with joint painsStill possible
- HIV-associated or reactive arthritisStill possible
- InjuryLess likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Is Kofi an emergency? What do you check first?
Model answer
Quick check: airway, breathing, circulation, consciousness. He is alert and walking, BP normal. His pulse of 112 is high for a fever of 38.8 °C in a young man, which you should note: a fast pulse can be a sign of carditis.
Ask straight away about breathlessness, chest pain and swelling of the legs (heart failure), and look for signs of sepsis. He has none. He is not an emergency, but he needs a full assessment today.
Two patterns to recogniseFever with a hot, swollen joint is septic arthritis until shown otherwise. Fever with a fast pulse and arthritis in a young person in an RHD-endemic area is acute rheumatic fever until shown otherwise.Differential now- Acute rheumatic fever Must not missStill possible
- Septic arthritis Must not missStill possible
- Gonococcal arthritis Must not missStill possible
- Sickle cell crisisStill possible
- Viral arthritis (for example chikungunya)Still possible
- Malaria with joint painsStill possible
- HIV-associated or reactive arthritisStill possible
- InjurySet aside for now (moved down)
- Step 2 of 7 · Ask
What do you ask? Which answers point to which diagnosis?
Model answer
- Pattern: one joint or several; moving from joint to joint (migratory); which joints were first.
- Sore throat or skin sores in the last few weeks (group A streptococcus), and any previous rheumatic fever.
- Chest pain, breathlessness, palpitations (carditis); jerky, uncontrolled movements (chorea).
- Sexual history: new partner, urethral discharge, pain passing urine, rash of small pustules (gonococcal arthritis).
- Sickle cell disease or previous painful crises.
- Injury; diarrhoea or red eyes before the joint pain (reactive arthritis).
- Others in the area with fever, rash and severe joint pain (a viral outbreak such as chikungunya); HIV status.
He had a bad sore throat about 3 weeks ago and did not see anyone. No previous similar illness; an older cousin had 'heart trouble from rheumatism'. No chest pain or breathlessness. No jerky movements. He has a girlfriend; no discharge, no pain passing urine, no rash. No sickle cell disease. No injury, no diarrhoea, no red eyes. No outbreak in the area. HIV status unknown.
Differential now- Acute rheumatic fever Must not missLeading (moved up)
- Malaria with joint painsStill possible
- HIV-associated or reactive arthritisStill possible
- Septic arthritis Must not missLess likely (moved down)
- Gonococcal arthritis Must not missLess likely (moved down)
- Sickle cell crisisLess likely (moved down)
- Viral arthritis (for example chikungunya)Less likely (moved down)
- InjurySet aside for now
- Step 3 of 7 · Look
What do you examine in the joints and beyond, and why?
Model answer
- Each joint: heat, redness, swelling, tenderness and range of movement. One hot joint that will not move suggests septic arthritis.
- Skin around the joints: a wound, ulcer or abscess (a source for septic arthritis); small pustules on the limbs (gonococcal).
- Heart: rate, rhythm and murmurs. A new murmur at the apex suggests carditis.
- Signs of heart failure: raised neck veins, crackles, enlarged liver, leg swelling.
- Skin: erythema marginatum (pink rings on the trunk) and painless nodules over the bony points (rheumatic fever).
- Lymph nodes, mouth (thrush), genitals; spleen (malaria).
Left wrist hot, swollen and very tender; both ankles warm and puffy; knees tender but no longer swollen. No wounds. A soft blowing murmur at the apex during systole. No raised neck veins, chest clear, liver not enlarged. No rash, no nodules, no pustules. No lymph nodes.
Differential now- Acute rheumatic fever Must not missLeading
- Malaria with joint painsStill possible
- HIV-associated or reactive arthritisStill possible
- Septic arthritis Must not missLess likely
- Sickle cell crisisLess likely
- Viral arthritis (for example chikungunya)Less likely
- Gonococcal arthritis Must not missSet aside for now (moved down)
- InjurySet aside for now
- Step 4 of 7 · Test
Which of your bedside tests help, and what can only the hospital do?
Model answer
- Malaria RDT: he has fever in a malaria area. Malaria can cause aching joints, but not hot swollen joints; a positive test would not explain this picture on its own.
- Haemoglobin: a low Hb with joint pain may suggest sickle cell disease; it is also a baseline.
- HIV rapid test, with consent: HIV can cause arthritis and changes the causes to consider.
- Urine dipstick: not needed unless there are urinary symptoms.
Results: RDT negative. Hb 12.6 g/dL. HIV test negative.
The tests that confirm rheumatic fever and septic arthritis are at the hospital: inflammatory markers (ESR, CRP), evidence of recent streptococcal infection, an ECG for a prolonged PR interval, echocardiography for carditis, and aspiration of a hot joint for microscopy and culture.
Differential now- Acute rheumatic fever Must not missLeading
- Septic arthritis Must not missLess likely
- Viral arthritis (for example chikungunya)Less likely
- Gonococcal arthritis Must not missSet aside for now
- Sickle cell crisisSet aside for now (moved down)
- Malaria with joint painsSet aside for now (moved down)
- HIV-associated or reactive arthritisSet aside for now (moved down)
- InjurySet aside for now
- Step 5 of 7 · Do
Apply the revised Jones criteria. Is this rheumatic fever, and how sure can you be at the health centre?
Model answer
A first episode of rheumatic fever needs evidence of a preceding group A streptococcal infection plus 2 major, or 1 major and 2 minor, manifestations. In moderate- and high-risk populations:
Adapted from the revised Jones criteria (2015) as presented in the WHO guideline on rheumatic fever and rheumatic heart disease (2024). Kofi's findings Criterion Migratory arthritis of several large joints Major: arthritis (polyarthritis) New apical murmur, fast pulse Major: carditis, if confirmed (echocardiography also detects subclinical carditis) Temperature 38.8 °C Minor: fever of 38.5 °C or more Sore throat 3 weeks ago Supports preceding infection; laboratory evidence is needed He has probable acute rheumatic fever with possible carditis. Septic arthritis is much less likely: several joints are involved and they move; the knees settled on their own. If one joint stayed hot and swollen while the others settled, it would need aspiration to exclude infection.
Differential now- Acute rheumatic fever Must not missLeading
- Septic arthritis Must not missLess likely
- Viral arthritis (for example chikungunya)Less likely
- Gonococcal arthritis Must not missSet aside for now
- Sickle cell crisisSet aside for now
- Malaria with joint painsSet aside for now
- HIV-associated or reactive arthritisSet aside for now
- InjurySet aside for now
- Step 6 of 7 · Do
What do you do now? Why refer the same day?
Model answer
- Refer the same day to a hospital with echocardiography and specialist support: suspected rheumatic fever with a new murmur needs confirmation of carditis and a treatment plan.
- Paracetamol for pain and fever, per national formulary, while he travels.
- Write a referral note: joint sequence and dates, sore throat, the murmur, vital signs, tests done.
- If breathlessness, chest pain, fainting or leg swelling develop, the referral becomes immediate.
At the hospital, once the diagnosis is confirmed, he will usually need penicillin to clear the streptococcus and then secondary prophylaxis: benzathine benzylpenicillin every 4 weeks, for years, to prevent recurrences that damage the valves further. The health centre is often where those injections are given.
- Step 7 of 7 · Ask
What do you tell Kofi and his family?
Model answer
- Rheumatic fever follows a throat infection; the joints recover fully, but the heart can be damaged, and each new attack adds damage.
- If the diagnosis is confirmed, the monthly penicillin injection protects his heart: missing doses is the main reason people go on to develop rheumatic heart disease.
- Sore throats in brothers and sisters in a high-risk area should be seen and treated.
- Come back at once if he becomes breathless, has chest pain, faints or his legs swell.
Your joints will get better. But this illness can also affect the heart, and we heard a sound that needs checking with a heart scan at the hospital today. If the doctors confirm it, a regular injection will protect your heart, and we can give it here.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Septic arthritis | Acute onset, usually one large joint (often the knee), hot, swollen, tender, painful to move; fever; a skin source, diabetes, sickle cell disease or injecting drug use. | Refer the same day for joint aspiration, cultures, IV antibiotics and drainage; untreated, cartilage is destroyed rapidly. |
| Acute rheumatic fever with carditis | Young person in an RHD-endemic area; sore throat or skin infection usually 10 to 21 days before; migratory polyarthritis, fever, new murmur, fast pulse, chorea, rash or nodules. | Refer the same day for echocardiography and confirmation; now if heart failure. |
| Gonococcal arthritis | Sexually active; migratory joint pains, tenosynovitis of hands or wrists, small pustules on the skin; genital symptoms may be absent. | Refer for IV antibiotics; treat partners per STI protocol. |
| Heart failure from carditis or known RHD | Breathlessness, orthopnoea, raised neck veins, crackles, enlarged liver, leg swelling. | Sit up, oxygen if low; refer now (see heart failure protocol). |
Decision at first-level care
Kofi has probable acute rheumatic fever: migratory polyarthritis and fever three weeks after an untreated sore throat, with a new apical murmur suggesting carditis. Septic and gonococcal arthritis are much less likely. He is referred the same day for echocardiography and confirmation; if confirmed he will need secondary prophylaxis with benzathine benzylpenicillin every 4 weeks.
Source: WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease (2024); IMAI district clinician manual, volume 2 (2011); WHO AWaRe antibiotic book (2022).
- Joint pain over 40 that is worse with use and eases with rest, no heat or fever (osteoarthritis): analgesia, exercise, review.
- Aching joints with a positive malaria test and no swollen joint: treat malaria, review.
- Mild joint pain with a viral illness during a known outbreak, no hot joint and no murmur: symptomatic care, review in 2 to 3 days.
- Recent minor injury, able to bear weight, no fever: rest and analgesia, review if not improving.
- A single hot, swollen joint with fever, or one that will not move: the same day.
- Fever with arthritis in a young person in an RHD-endemic area, or a new murmur: the same day.
- Any sign of heart failure, chest pain or fainting: now.
- Joint pain with chorea, or a known RHD patient with a new problem.
Key learning points
- Ask about the pattern: one hot joint (septic) or several joints moving from one to the next (rheumatic fever, gonococcal, viral).
- In a young person with fever and arthritis where RHD is common, always listen for a murmur.
- The revised Jones criteria: preceding streptococcal infection plus 2 major or 1 major and 2 minor manifestations; in high-risk areas monoarthritis or polyarthralgia can count as major.
- Septic arthritis destroys cartilage quickly: a hot swollen joint with fever is a same-day referral for aspiration.
- Secondary prophylaxis with monthly benzathine benzylpenicillin is how first-level care protects the heart after rheumatic fever.
Sources
- World Health Organization. WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease. 2024. Revised Jones criteria (Table 1) for low- and moderate/high-risk populations; rheumatic fever usually 10 to 21 days after a group A streptococcal throat (or possibly skin) infection; first episode usually at 5 to 14 years, RHD diagnostic peak in young adults; benzathine benzylpenicillin every 4 weeks; echocardiography; secondary prophylaxis (as summarised in the RHD protocol).
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 2. 2011. Section 10.13, painful joints: history, examination, DDx tables for single and multiple painful joints (septic, gonococcal, gout, rheumatoid, osteoarthritis, TB, chikungunya, HIV-associated arthritis).
- World Health Organization. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. 2022. Chapter 36, septic arthritis: acute onset, usually a single joint (often the knee), systemic signs; cartilage destruction if untreated; samples before antibiotics; drainage; gonococcal arthritis with skin lesions.