15: RHEUMATOLOGY AND ORTHOPAEDICS

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CHAPTER 15 RHEUMATOLOGY AND ORTHOPAEDICS

JOINT PAIN

Many patients present with multiple aches and pains and some of these may be described as joint pains.

Diagnosis

History.

• The duration of symptoms: a short-term illness requires a diagnosis. In long-term problems, first find out what the patient wants: symptom relief or reassurance.

• Associated features such as viral illness, depression or fatigue.

• Generalised or localised symptoms.

• Diurnal symptoms.

• Joint stiffness.

Investigations.

If the diagnosis remains unclear having taken a careful history and examined the relevant parts, bloods can be requested for FBC, ESR and CRP, rheumatoid factor and serum uric acid. See the patient after 2 weeks. Insignificant causes will produce normal results (except, perhaps, for a slightly raised ESR in viral illnesses).

Persistent abnormality prompts management as in the relevant sections listed in the box on p. 238, or referral for further diagnostic tests.

GOUT

Gout presents most commonly in middle-aged men. It may affect any joint, but is usually seen in the big toe, ankle or knee.

NECK PAIN

Neck pain is commonly a mild, self-limiting nuisance due possibly to muscle tension.

Diagnosis

History

• Ask about the duration of the symptoms. A short history of neck pain, usually on one side of the neck more than the other and with a twisting of the neck, suggests acute torticollis. This sort of acute pain, but without the twisting, is common in whiplash injuries.

• Ask about chronic pain and stiffness in the neck. These symptoms may be due to degeneration in the cervical intervertebral discs, suggestive of cervical spondylosis. Early morning stiffness may be a feature of osteoarthritis of the cervical spine. Severe acute cervical spine pain, usually accompanied by occipital headache, suggests meningism, especially in someone not accustomed to neck pain.

• Exclude radiculopathy and myelopathy by asking the patient about symptoms of pain or weakness in the arms or legs.

Examination.

• Tenderness in the neck muscles. If the head is held to one side and the patient cannot straighten the head, think of acute torticollis.

• A reduced range of movement of the cervical spine, which suggests cervical spondylosis or arthritis.

• Weakness and wasting in the arms or legs, which suggest a radiculopathy or myelopathy, are not uncommon in cervical spondylosis. Examine for this if there are suggestive symptoms.

Investigations.

If the diagnosis is in doubt or if the patient is particularly requesting it, an X-ray of the cervical spine may be useful. Cervical spondylosis and arthritis usually show up after 6 months of disease.

Management

• Physiotherapy helps to improve the range of pain-free movement in both acute and chronic cases of neck pain.

• A collar often helps by temporarily resting the neck.

• Prescribe NSAIDs or simple analgesics for pain.

• Diazepam tablets 2–5 mg tds help relieve the muscle spasm of acute torticollis.

• Refer all cases with neurological complications.

OSTEOARTHRITIS

Osteoarthritis is the most common joint disease seen in general practice, its incidence increasing with age. It is a progressive, debilitating disease, mainly affecting the weight-bearing joints and hands.

Diagnosis

History.

Ask about pain and early morning stiffness, usually in a knee, hip or ankle. Symptoms will have been present for some months and may have been exacerbated by recent injury or overuse.

Examination

• Look for a reduced range of movement or pain on movement of the affected joint or joints.

• Crepitus may be felt by laying a hand on the joint while moving it.

• The soft-tissue swelling of osteoarthritis produces a ‘fattened’ joint and fluid effusions are often absent.

• The patient may have a limp, use a stick or have difficulty getting on to the examination couch.

Investigations

• X-rays are unhelpful in the early stages of the disease, although 6 months of osteoarthritis will usually show characteristic X-ray changes.

• Blood tests exclude other causes of arthritis (see rheumatoid arthritis, p. 244).

Management

Advice

• Aim for ideal weight.

• Encourage mobility/activity.

• Social Services will advise the patient about allowances and benefits and a disabled parking permit.

• Educational leaflets and support groups are a useful source of information for patients.

• Be on the lookout for depression and carer stress.

Treatment

• For the relief of pain, start with simple paracetamol and increase if necessary to co-codamol or co-dydramol.

• Stiffness can be relieved by NSAIDs. A big evening dose is useful in early morning stiffness, e.g. ibuprofen S/R 800 mg, two tablets nocte.

• Beware of the risk of gastric irritation from NSAIDs in the elderly. Prescribe a proton-pump inhibitor such as omeprazole 10 mg daily.

• Consider glucosamine 1500 mg a day as an adjunct for pain relief (only available OTC).

• Physiotherapy is useful for maintaining joint mobility.

• Consider intra-articular injection of corticosteroid if only one or two joints are affected (e.g. for knee joint, methylprednisolone 40 mg).

• Walking aids such as sticks and frames can be obtained by referral to the local occupational therapy or physiotherapy department or from the day hospital.

• Occupational therapy can also help with activities of daily living and modification of the home.

Referral.

Consider referral for joint replacements. The timing of referral depends on the effect of the disease on the patient’s life in terms of immobility and pain. Generally, the patient who is being woken at night despite full doses of anti-inflammatories and non-addictive analgesics should be considered for surgery.

POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS

Polymyalgia rheumatica is a common condition in Caucasians, mainly affecting women over 55. It coexists with giant cell arteritis in about 30% of cases (see p. 232).

Diagnosis

History

Polymyalgia rheumatica.

Ask about pain and stiffness around the shoulders or, occasionally, the hips, which is worse in the mornings.

Giant cell arteritis.

Ask about temporal headache, visual loss or diplopia.

Both may present occasionally with fever, fatigue or weight loss.

Examination

Polymyalgia rheumatica.

Look for mild tenderness on palpation of the shoulder muscles. Patients with PMR have difficulty in raising their hands above their heads. Examination of the shoulder joints and neck should be normal.

Giant cell arteritis.

Look for a tender temporal artery on palpation.

Giant cell arteritis is an ophthalmological emergency due to the risk of sudden blindness. If the diagnosis is suspected on the grounds of visual loss and/or temporal headache and tenderness in patients over the age of 55, the patient should be seen urgently by an ophthalmologist.

Investigations

• ESR: a result >50 is strongly supportive of the diagnosis of PMR. If a borderline raised ESR is obtained, repeat after 48 hours. Do not await the ESR result if there is a strong suspicion of giant cell arteritis.

• If the ESR is very high, exclude myeloma with serum electrophoresis (para-protein band) and urine electrophoresis (Bence–Jones protein).

• TFTs: to exclude hypothyroidism.

Management

• For polymyalgia rheumatica: give prednisolone 10–20 mg daily.

• For giant cell arteritis: urgent referral if suspected, but the starting dose of steroids is 60–80 mg daily.

• For both: stay on the initial dose of prednisolone until the symptoms have come under control, then begin to reduce the daily dose of prednisolone by increments as long as there is no recurrence of symptoms or a significant rise in the ESR.

• Any recurrence of symptoms should prompt an increase in dose for 1 month.

• Most patients are maintained on less than 5 mg daily for the duration of the illness.

It is not unusual for these patients to require steroids for 2 years or longer, in order to maintain remission of symptoms.

• Beware the risk of osteoporosis in long-term steroid use. Use the minimum dose possible. Give osteoporosis prophylaxis (see p. 244) at the start of steroid treatment.

OSTEOPOROSIS

Osteoporosis is most common in postmenopausal women. It is characterised by a decreased bone density due to demineralisation and is responsible for 45 000 hip fractures a year in the UK.

Management

• Treat the complications of osteoporosis, i.e. fractures.

• The deep bone pain of vertebral collapse usually responds to analgesia and bed rest in 2–4 weeks.

• For the prophylaxis and treatment of osteoporosis, including all patients with a history of low-impact hip fracture, bisphosphonates, e.g. alendronic acid or risedronate, are the drugs of first choice. For the prescribing regimen, see the BNF.

Prevention

• Stopping smoking reduces the risk of postmenopausal hip fracture by 25%.

• Regular weight-bearing exercise reduces the risk of postmenopausal hip fracture by up to 50%.

• Five years’ use of oestrogen replacement therapy reduces the risk of postmenopausal hip fracture by 50–75% but the risk of osteoporosis is no longer considered to be a sole indication for initiating HRT (see hormone replacement therapy, p. 52).

• If a patient is on steroids, reassess the need.

• Maintain sufficient dietary calcium and vitamin D intake. Supplements are indicated in all elderly mobile patients in residential care and those at risk of falling or with a history of falls.

RHEUMATOID ARTHRITIS

The average GP list of 2000 will have 3–4 rheumatoid arthritis patients. It is three times more common in women. Patients are usually over 40, but may be younger.

Diagnosis

History.

• Joint pain: symmetrical pain and morning stiffness are very common, especially in the small joints of the hands and feet. The distal interphalangeal joints are usually spared. Swelling of joints often occurs.

• Other symptoms, which include:

– general malaise

– weight loss

– carpal tunnel syndrome

– tenosynovitis.

Examination.

• Joints which are tender, hot, swollen and painful to move. The proximal interphalangeal, metacarpophalangeal and wrist joints are usually inflamed in the acute phase.

• Carpal tunnel syndrome (see p. 249), which is often associated with rheumatoid arthritis. Tender metatarsophalangeal joints may also be found.

Investigations.

All suspected cases of rheumatoid arthritis should have ESR or CRP. If these are raised for the patient’s age, organise the following:

• Rheumatoid factor: positive in 80% of rheumatoid arthritis patients, but 5% are false-positive results.

• Antinuclear antibody: should be negative to exclude SLE.

• Serum uric acid: should be normal to exclude gout.

• X-ray of the hands and feet: the characteristic appearances of rheumatoid arthritis appear after 6 months of disease.

It is a mistake not to refer new cases of rheumatoid arthritis at an early stage, since disease-modifying drugs reduce erosive disease and resultant loss of function.

Management

Care of the chronic case

The level of help required by the patient depends on the activity of the disease. Not all patients with rheumatoid arthritis have active disease.

• Liaison with the rheumatologist is helpful for prescribing, advice and follow-up.

• Physiotherapy can improve joint mobility and muscle wasting.

• Occupational therapy can address problems with activities of daily living by modification of the home and the provision of walking aids.

• Provide leaflets and support group details.

• Ask the patient to contact Social Services for allowances and benefits, e.g. the disabled parking badge.

• Watch for depression and carer stress (see p. 292).

• Consider pain clinic referral.

• Some patients find fish oils and evening primrose oil helpful.

• Advise patients against being overweight.

Try to avoid an unnecessarily gloomy outlook. Many cases follow a mild, remitting course with no long-term disability.

SHOULDER PAIN

Shoulder pain can be a symptom of problems in the neck, such as cervical spondylosis, but is usually caused by either adhesive capsulitis (frozen shoulder) or the rotator cuff syndrome (e.g. supraspinatus tendonitis). Consider cardiac ischaemia or diaphragmatic irritation as a possible cause, e.g. gallstones.

Management

• Physiotherapy can be useful for some painful arc syndromes, but is of little value in the treatment of frozen shoulder.

• NSAIDs, if not contraindicated, are useful in reducing pain and inflammation.

• The injection of long-acting corticosteroids into the subacromial space is useful in the treatment of supraspinatus tendonitis, e.g. methylprednisolone 40 mg with 2% plain lidocaine 2 ml. Warn the patient the pain will get worse over the ensuing 24 hours. If improvement is partial, a second injection is useful.

Beware the fractured neck of humerus. This is usually more painful initially. Bruising develops over the first 48 hours. Some movement of the glenohumeral joint is often possible.

TENNIS ELBOW

Tennis elbow is the name usually given to lateral epicondylitis, inflammation of the insertion of the forearm extensor muscles at the elbow.

Diagnosis

History.

Ask about pain on the outer side of the elbow, especially when gripping. The pain often radiates down the forearm.

Examination.

Tenderness can be elicited at the point of insertion of the forearm extensor muscles into the lateral epicondyle.

Management

• Tennis elbow can settle spontaneously, but this usually takes several months.

• Avoid trigger movements as far as possible.

• A short course of NSAIDs can help.

• A sports support for tennis elbow may be purchased.

• An injection of e.g. hydrocortisone and local anaesthetic is usually helpful but the recurrence rate is relatively high. Using a blue needle inject hydrocortisone 100 mg with 1% lidocaine 1 ml deep into the tender point of the elbow. Warn the patient that the symptoms will worsen over the ensuing 24 hours.

• Ultrasound from the physiotherapist can be an effective alternative.

TENOSYNOVITIS

Tenosynovitis is inflammation of the tendons of the dorsum of the hand or foot. It commonly presents in general practice following repetitive overuse. Occasionally it can occur spontaneously.

Diagnosis

History.

Ask about pain and tenderness over the tendons, usually of the hand, where they cross the wrist within a synovial sheath. The pain is worsened by movement of the tendon within the sheath.

Examination.

• Swelling. This is a common feature of De Quervain’s tenosynovitis (thumb extensors).

• Tenderness and exacerbation of the pain on palpating the affected tendon.

Management

• Rest for 2–3 weeks with immobilisation is often all that is needed. A temporary change of use of the hand may help.

• A short course of NSAIDs can help.

• An injection of hydrocortisone with local anaesthetic may be useful, if the GP is confident in the technique. Refer to a rheumatologist otherwise.

• Referral for surgical decompression is occasionally required, particularly if the above measures are unhelpful and the patient is handicapped by the symptoms.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is the most common cause of paraesthesiae in general practice. The syndrome of pain and tingling in the hand should always raise this possibility.

Management

• Rest the affected hand. This advice can be supplemented by the provision of a Futura-type wrist splint, or just a plain sling.

• NSAIDs can be useful in mild cases.

• Injection of methylprednisolone 40 mg with local anaesthetic under the flexor retinaculum of the wrist, around the median nerve (situated between the radial artery and palmaris longus tendon) can be useful if the GP is confident in this technique. Refer to orthopaedics or rheumatology outpatients otherwise.

• Refer to orthopaedic outpatients for carpal tunnel release if there is no improvement or if there is wasting of the small muscles of the hand.

PARONYCHIA

A paronychia, or whitlow, is a suppurative collection around a fingernail. The pus can easily be seen adjacent to a nail as a white, tense, tender swelling.

LOW BACK PAIN

Low back pain is the commonest cause of days lost from work in the UK. Decide first whether the patient is presenting with a new, acute episode of back pain, or a chronic problem.

ACUTE PRESENTATION

The acute onset of lumbar back pain usually follows lifting, and often radiates to the buttock or leg.

Diagnosis

History.

Ask about: bladder paralysis symptoms, muscle weakness in the lower limbs, paraesthesiae. The following features are significant:

• Age <20 and >55.

• Nocturnal pain.

• Thoracic pain.

• Patient on oral steroids.

• Weight loss.

• Past history of carcinoma.

Examination.

Look for: neurological signs in the lower limbs. Look particularly for weakness of dorsiflexion of the ankle and extensor hallucis (L4–L5 prolapse), weakness of the peroneal muscles, toe flexors, calf and tibialis posterior (L5–S1). Check for power/sensory loss, reflexes (knee and ankle) and straight leg raising.

Investigations.

In the elderly with acute back pain, consider ESR, and PSA in men. X-rays are unhelpful except to exclude ankylosing spondylitis in young people and vertebral collapse or malignancy in the elderly. Limited MRI should be considered if nerve root symptoms persist for >4 weeks.

Indications for immediate orthopaedic referral are:

• bladder paralysis

• extensive muscle weakness

• objective neurological signs.

Management

In the absence of neurological signs:

• Mild low back pain (e.g. sacroiliac joint discomfort) often requires reassurance only.

• Advise mobilisation. Encourage activity within the limits of pain. Frequent short episodes of activity are best.

• Prescribe analgesics, e.g. co-codamol, 1–2 tablets 4–6-hourly (max = 8 tabs/24 hours). A laxative helps if opiates are prescribed, e.g. lactulose 10 ml bd. Diazepam 5 mg tds is useful, as a muscle relaxant and an anxiolytic, in the short term.

• Follow up if symptoms do not settle in 2–3 weeks. Repeat the neurological examination if suspicious symptoms develop.

• For the prevention of further attacks, advise on correct posture, lifting and exercises, and enquire about work-related back strain. Consider referral to a physiotherapist, chiropractor or osteopath.

KNEE PAIN

After low back pain, knee pain is the second most common orthopaedic problem in general practice.

Diagnosis

History.

It is useful to divide knee problems into those associated with some trauma to the knee and those of spontaneous onset.

With trauma.

If there is no limitation of movement, and the patient can weight-bear, the likely diagnosis is a simple sprain.

Symptoms that suggest damage to the internal structures of the knee include swelling, locking, giving way, inability to weight-bear and an inability to extend the knee fully. Often these symptoms follow a recurring and remitting course.

Examination.

Watch as the patient climbs onto the examination couch. This will tell you a lot about the functioning of the knee.

Look for redness, heat and swelling. These suggest the presence of acute inflammation or infection, usually gout, prepatellar bursitis or, occasionally, septic arthritis.

The examination is often normal in e.g. chondromalacia patellae and minor sprains.

If there is a history of trauma, test the ligaments and cartilages. Holding the lower leg at mid-calf level and with the knee slightly flexed, attempt to bend the knee sideways in each direction in turn. A few degrees of movement is normal, as can be demonstrated on the patient’s good knee. Excessive movement suggests a collateral ligament tear. Ask the patient to roll onto their front. With the knee flexed to 90°, push down on the foot and rotate the foot in each direction in turn while extending the knee. Acute pain suggests a torn meniscus (Apley’s test).

Management

Chondromalacia patellae

• Conservative management with explanation, analgesics, rest and quadriceps exercises usually suffice.

• Referral for consideration for surgery is rarely needed.

Prepatellar bursitis

• If the inflammation is confined to the patellar area, rest, analgesia and Tubigrip will suffice.

• If there is considerable swelling in front of the knee, aspiration under local anaesthetic will ease the pain by reducing the pressure within the bursa.

• If there is evidence of inflammation extending beyond the area of the patella, antibiotics should be prescribed, e.g. flucloxacillin 250 mg qds.

• If aspiration of the bursa produces pus and there is evidence of cellulitis, consider admitting the patient for surgical drainage and splinting of the knee.

Septic arthritis.

Admit immediately if this is suspected.

Gout.

Acute knee injuries with swelling require X-rays to exclude a fracture, and aspiration to exclude a haemarthrosis or lipohaemarthrosis. Refer to casualty.

In the absence of swelling and if the patient can weight-bear, the acute knee injury can be treated by rest, analgesia, Tubigrip, ice-pack and quadriceps exercises.

Chronic knee pain

• Chronic traumatic knee pain in a sportsperson can often be helped by a change of footwear.

• Referral to a sports medicine, rheumatology or orthopaedic clinic depending on local specialist interest.

• If the history or examination suggests the presence of either ligament or cartilage damage, consider referral for arthroscopy, especially if quadriceps exercises have not helped.

Osteoarthritis.

SPRAINED ANKLE

This is a common soft-tissue injury in general practice, usually due to inversion of the ankle, damaging the lateral talofibular ligament. Nearly all soft-tissue sprains settle with rest, followed in severe cases by physiotherapy, but the fractured ankle should be excluded early.

PAINFUL HEEL (PLANTAR FASCIITIS)

Plantar fasciitis causes chronic pain under the heel, especially when taking the first steps in the morning, with no history of trauma. There is usually a tender point just in front of the bony part of the heel. The condition usually resolves spontaneously after several months.

INGROWING TOENAIL

An ingrowing toenail is a spike of toenail growing into the nail-fold, causing pain and often infection.

Management

Conservative management.

Show the patient how to elevate the nail edge. Recommend that this is done after a long soak in a warm bath. A nail file or other blunt instrument can be used. A pledget of cotton wool can be pushed under the elevated nail. This should be done daily for a week or so.

If the nail-fold looks infected, prescribe an antibiotic, e.g. oral flucloxacillin, for 5 days.

Surgical management

• Nail edge excision can be performed in general practice if the GP is confident in the technique. Otherwise, refer to a surgical podiatrist or orthopaedic outpatients.

• Consider Zadik’s procedure (bilateral wedge excision) for recurrent cases.

Prevention

Encourage square nail-cutting, i.e. advise the patient to avoid trying to cut the nail with a curve at the edges. This allows the edges to grow free of the end of the toe without digging in.

Related

Churchills Pocketbook of General Practice