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.

Related

Churchills Pocketbook of General Practice