Joint pain: rheumatologist or orthopedist?
Joint pain may come from osteoarthritis and injury, or from an inflammatory, autoimmune disease. This article explains the difference between the work of a rheumatologist and an orthopedist and helps you know which to see first.
“My pain is in a joint. Which doctor should I see?” This is one of patients’ most common questions. It has no simple answer, because “joint pain” can have several quite different causes. This article explains the difference between the two specialties and suggests a way to decide. A general practitioner or family doctor is also usually the best place to start.
Who is a rheumatologist?
The ACR writes that a rheumatologist is an internal medicine or pediatric doctor with extra training in diagnosing and treating rheumatic diseases, meaning diseases of the joints, muscles and bones, and autoimmune diseases. These can also involve the eyes, skin, nervous system and internal organs. The ACR stresses that, unlike orthopedic surgeons, rheumatologists use non-surgical methods. Common conditions: osteoarthritis, gout, rheumatoid arthritis, chronic back pain, inflammation of tendons and joint bursae, and lupus. The ACR writes that there are more than 100 types of arthritis.
A rheumatologist’s treatment is mostly medicine, physical and occupational therapy, referral to other specialists, and sometimes an injection into a joint or tendon (ACR).
Who is an orthopedist?
An orthopedist is a surgeon; the ACR contrasts orthopedic surgeons with rheumatologists, who work without surgery. The Arthritis Foundation writes that some patients with osteoarthritis (wear-and-tear arthritis) are referred to an orthopedist. The NHS also says that in osteoarthritis, surgery is for a small number of patients, those for whom other treatments have not worked or whose joint damage is severe. Surgery may mean repairing, strengthening or replacing a joint.
How the two kinds of pain tend to look
This table is only a guide, not a diagnosis:
| More like osteoarthritis / mechanical injury | More like an inflammatory disease | |
|---|---|---|
| Morning stiffness | Absent or less than 30 minutes (NHS) | More than 30 minutes, sometimes more than an hour (NIAMS, ACR) |
| Relation to movement | Pain usually gets worse with use (NHS) | Stiffness gradually improves with movement (ACR) |
| Other signs | May have swelling and a grinding sound (NHS) | Fever, tiredness, rashes, mouth ulcers, eye inflammation (ACR) |
| Age at onset | Often over 45 (NHS) | Any age; RA usually 30 to 50 (ACR) |
For rheumatoid arthritis, the NHS also says the stiffness lasts longer than in osteoarthritis.
When to see a rheumatologist first
The ACR names signs that may call for a referral to a rheumatologist, if no other cause has been found:
- Repeated fever, tiredness, weakness, anemia, skin rashes or unexplained weight loss.
- Morning stiffness of more than 30 minutes, or repeated swelling of the joints of the fingers, wrist, ankle or foot.
- Suspicious rashes, hair loss, mouth or genital ulcers.
- Eye changes: blurred vision, double vision, redness and pain.
- Abnormal tests that have made the doctor suspect lupus, rheumatoid arthritis, vasculitis, scleroderma, gout, polymyalgia rheumatica or giant cell arteritis.
The ACR notes that because many diseases have similar signs, it is better to talk first with a general practitioner or family doctor. The Arthritis Foundation says a rheumatologist helps with difficult diagnoses and that an orthopedist is the referral for some cases of osteoarthritis.
When to see an orthopedist first
The Arthritis Foundation says an orthopedist comes in for some cases of osteoarthritis, and the NHS sees surgery for osteoarthritis as being for those for whom other treatments have not worked or whose joint damage is severe. So if osteoarthritis has been diagnosed and non-surgical treatment has not been enough, your doctor may suggest an orthopedist. If the pain began after a blow or a clear injury, a general practitioner will decide what assessment and referral are needed.
In practice
- If you are not sure: start with a general practitioner. They may ask for initial tests and, based on the results, send you to the right specialty. The NHS says that in osteoarthritis the doctor usually diagnoses by questions and examination and orders tests or X-rays mostly to rule out other causes.
- If you have swelling, fever, rashes or long stiffness: an appointment with a rheumatologist is reasonable.
- Both may be needed. A person may have rheumatoid arthritis controlled with medicine and later also need surgery because of joint damage. The NHS says that in rheumatoid arthritis, surgery becomes necessary when the joint has been damaged despite medicine.
- Bring your papers: tests, imaging reports and a list of medicines (see the “Your first visit and what to bring” guide).
A reminder
None of these tables replaces an examination. Only a doctor can decide which specialty your problem belongs to. If a joint suddenly becomes hot, red and swollen and you have a fever, do not wait for an appointment (see the guide “When should I call urgently?”).