APPROACHES TO MUSCULOSKELETAL SYMPTOMS

Polyarticular pain

• Acute symptoms: consider viral illness or acute presentation of inflammatory arthritis.

• Ask about diurnal variation of pain /stiffness and presence of joint swelling.

• Constant pain persisting by day and night without stiffness after inactivity or joint swelling consider: somatic presentation of psychosocial problems. Look for changes in mood, lack of energy and poor sleep patterns.

• Investigations help confirm clinical impression and sometimes help reassure patients.

• Chronic widespread pain is common. The term ‘fibromyalgia’ may be useful in some cases and helps reduce over-investigation. Do not advise restricted physical activity in such cases.

Monoarthritis

• Exclude infection.

• Is it a bursitis, an arthritis, mechanical problem (e.g. knee meniscus), or referred pain?

• Common causes are reactive or other sero-negative arthritis i.e. associated with psoriasis, ankylosing spondylitis etc. or flare of OA, RA and gout.

• Diagnosis based on clinical picture plus some fairly simple investigations.[Back]

Upper limb and neck pain

• 10% of the population have this at any one time.

• Clinical examination is sufficient in most cases.

• X-rays: 90% of over 65s have cervical spondylosis (i.e. OA changes) but not all have pain i.e. very poor correlation between pain and x-ray findings. Certain postures and movements cause symptoms from cervical spondylosis. Avoid the terms "degenerative" or "crumbling". They do not help patients.

• Non-specific arm pain is common. The term “repetitive strain implies (RSI)“ implies violation of a victim and culpability e.g. of an employer - This raises potential for litigation¹.Where there are few physical signs and pain does not conform to an identifiable anatomical or pathological pattern avoid the term RSI. Address occupational dissatisfaction and boredom.

• Tenosynovitis is a specific diagnosis in which the synovium around a tendon is inflamed. It may occur post-traumatically but do not use this label indiscriminately label indiscriminately.[Back]

Lower limb and back pain

• Beware hip disease or other referred pain.

• Recognize vascular claudication or similar symptoms due to spinal stenosis.

• Some clinical features are associated with more serious disease: [Back]

Shoulder pain

• May be articular (e.g. glenohumeral joint disease in RA, acromio-clavicular joint disease in OA) or peri-articular (e.g. rotator cuff tear).

• Peri-articular disorders include those with or without a capsulitis. If the capsule is unaffected passive shoulder movements are full but pain or weakness (e.g. in rotator cuff tears) may limit active movements.

• With capsulitis passive movement is generally restricted in more than one direction of movement.

• Beware referred pain from the neck,chest, and diaphragm. [Back]

RECOMMENDED GP TEST

Suspected inflammatory arthritis

FBC, ESR or CRP, rheumatoid factor, and anti-nuclear factor (ANF). [Back]

Monoarticular pain

As above, if considering inflammatory causes: urate for gout, and X-rays for suspected OA. [Back]

Myalgia and polymyalgia

Polymyalgia rheumatica is a diagnosis of exclusion and a full physical examination is mandatory. It is most often confused with sero-negative rheumatoid arthritis. FBC, ESR, rheumatoid factor and ANF. Conditions that mimic polymyalgia include thyroid deficiency (check TFTs), myositis (check CPK), occult neoplasm (check CXR and exclude myeloma). [Back]

Arthralgia and polyarthralgia

Most patients do not have a progressive rheumatic disorder. Reassurance based on a physical examination and limited blood tests suffice in most cases. Patients should not be advised to reduce physical activity on the basis of pain symptoms alone.[Back]

Low Back Pain and Neck Pain

Do not request x-rays routinely. They rarely contribute to management. Changes of asteoarthritis ("degenerative") on spinal x-rays are almost universal after age 40 and correlate poorly with symptoms. In suspected ankylosing spondylitis i.e. intermittent back pain for many months with stiffness (>30 minutes) and sleep disturbance, x-rays of sacro-iliac joints may be diagnostic.[Back]

Connective tissue diseases and immunological tests

Rheumatoid factor and ANF suffice as an initial screen. Weak positive ANF (e.g.1:40 or even 1:100) does not mean that the patient has SLE. Such results are found commonly in other conditions or in normal people. Referrals should not be made solely on the basis of a weak positive ANF (please discuss if necessary).[Back]