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Chapter 18: Rheumatology 235
https://t.me/med1917
& acute onset
• Stabbing lower back & leg pain
• Lower limb weakness
• Bladder/bowel disturbance
• Saddle anaesthesia
• Sexual dysfunction
• Lower limb motor function
• Lower limb sensory function
→ esp. perianal (S3, S4, S5)
• Reflexes
• DRE → sphincter tone
• Pre- & post-micturition bladder scan
(>200ml)
• MRI – may show disc prolapse
• Herniated lumbar disc
= most common
• Spinal stenosis
• Spinal tumour
• Spinal infection (abscess, TB)
• Severe injury to lower back
• Congenital malformation
Immediate referral to neurosurgery
→ urgent decompression e.g. via
discectomy
Lumbar myelopathy
Usually L4/5 or L5/S1 level
1. Age-related degeneration: osteophyte formation & ligament hypertrophy
2. Disc bulging/herniation: consider in younger patients
• Lumbar canal stenosis affects middle-aged/
elderly
• May be 1st presentation of prostate cancer
due to spinal mets
• Hx of back pain → dermatomal distribution
• Leg pain / weakness / heaviness that limits walking distance → distance
→ slowly relieved by rest
→ feels better bending forwards / going uphill
1. History & examination
2. Imaging: X-ray + CT/MRI
(lumbar laminectomy if severe)
spondylosis)
1. Conservative: rest, physio, NSAIDs, bracing
2. Surgery: if serious slip / worsening Sx
DDx: vascular claudication
Intermittent
claudication
distance
Pain relieved after
O/E: absent peripheral
pulses
Spinal stenosis
distance
Pain disappears after
O/E: pulses present but
neuro signs
Musculoskeletal disease
236 Chapter 18: Rheumatology
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Other causes of neck & back pain
• Worse with movement, relieved with rest
• Sudden onset & may be recurrent
± stiffness (<30min), muscular spasm, scoliosis
• Consider X-ray/MRI if:
▶ >50y or <20y
▶ Red flags of back pain or suspect malignancy
▶ Suspect inflammatory cause e.g. ankylosing spondylitis
→ Reassure & educate: continue normal activity
Key part of Mx
→ Exercise & physiotherapy: encourage activity, good posture → yoga/
Pilates/swim/walk
→ Analgesia: NSAIDs (with caution), weak opioids only if NSAID not tolerated /
ineffective
→ Treat underlying problems: sleep disturbance / depression
→ If chronic: Ix to find underlying cause & Tx appropriately
• X-ray/CT/MRI
• Bone scan
• FBC, ESR/CRP, biochemistry
Primary: meningioma, astrocytoma
Secondary: breast, lung, renal, prostate, bowel, thyroid
infection e.g. meningitis
• Pain & stiffness in neck, shoulders, arms & back
• Muscle wasting & weakness
• Loss of sensation & reflexes
• Painless burning sensation in fingers
• Headaches
Musculoskeletal disease
• Drain syrinx
• Correct underlying cause
2
NICE (2016, updated 2020) Low back pain and sciatica in over 16s [NG59]
Carpal tunnel syndrome (CTS)
Inflammation
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• pressure on median nerve as it passes through carpal tunnel at wrist
• Roof of carpal tunnel = transverse carpal ligament / flexor retinaculum
• May be due to tendon swelling
• Tingling/pain/numbness in
radial 4 digits (not pinkie)
→ may radiate into forearm
• Worse at night → wakes
them up (may be because
sleep with wrist flexed)
• Provoked by gripping
• Relieved by shaking hand /
dangling over side of bed /
raising hand
• May have reduced
coordination → clumsy / drop things
Flexor tendons
Fig. 18.10 Carpal tunnel anatomy.
Chapter 18: Rheumatology 237
CTS = very common
(esp. middle-aged women)
Risk factors for CTS:
• pregnancy
• DM
• thyroid disease
• wrist fracture
• wrist arthritis
• idiopathic
*inflammatory arthritis*
5% of RA cases present with CTS prior to
joint symptoms
Contents of carpal tunnel:
9 tendons: 4 FDS, 4 FDP, FPL
1 nerve: median nerve
• Hx & examination (check for thenar wasting, motor & sensory function)
• Nerve conduction studies (if still uncertain → slowed conduction)
• Activity modification (avoid triggers, better wrist position)
• Splint wrist at night
• NSAIDs ± steroid injection
• Optimise underlying conditions e.g. thyroid disease / DM
• Surgery: carpal tunnel release if persistent symptoms >6w = high success rate
▶ No surgery = likely wasting & numbness will worsen
▶ Surgery should improve tingling/pain but may take 1y
▶ Muscle weakness unlikely to improve but won’t worsen
Cubital tunnel syndrome
• Tingling/pain/numbness in 5th finger → may radiate into forearm
• ± Claw hand (only 4th & 5th fingers)
Morton’s neuroma
Special tests for carpal tunnel:
→ Tinel test (at wrist)
→ Phalen’s test
→ Durkan’s test
→ Resisted thumb abduction
Special tests for cubital tunnel:
→ Tinel test (at elbow)
→ Pitres–Testut test
→ Froment’s sign
Compression of the distal ulnar nerve at
‘Guyon’s canal’, where ulnar nerve passes through
a fibro-osseous tunnel at the medial wrist
e.g. wearing tight shoes
• Pain / burning between toes / ball
of foot
• Tingling / sensory loss between
toes
3
RCOS Commissioning Guide (2017) Treatment of carpal tunnel syndrome
• Offloading insoles
• Steroid injection
• Surgical incision of digital nerve
Musculoskeletal disease
238 Chapter 18: Rheumatology
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Pathophysiology
Lack of sleep causes sensitivity to pain (any cause of sleep can trigger the
Symptom severity score (SSS):
ranks severity of associated Sx out of 3
1. Fatigue
2. Unrefreshing sleep
3. Cognitive Sx
4. No. of somatic Sx
Widespread pain index (WPI):
19 areas in which patient has had pain over the
past week e.g. left hip
Diagnostic criteria: (all other Ix are normal)
1. Widespread pain involving all 4 quadrants
of the body
2. Scoring ≥7 on the WPI and ≥5 on SSS
or 3–6 on the WPI and ≥9 on SSS
(Previously ≥11/18 recognised tender/trigger
points)
3. Present for ≥3m
Clinical presentation
• Widespread pain (‘pain all over’)
• Fatigue
• Unrefreshing sleep – <6h sleep, early waking, vivid dreams
• IBS: abdo pain, nausea, constipation/diarrhoea
• Chronic migraine
• Chronic pelvic pain
• Chronic fatigue syndrome: top DDx → MSK pain is less prominent
• Depression, anxiety
• Dizziness, numbness, tingling
• Cold sensitivit y / Raynaud’s
• Dry eyes, sun sensitivity, rash
• Altered taste, sensitivity to smells
• Noise sensitivity
mainly women 40–60y
Investigations
→ Screen for comorbidities e.g. depression
→ Find / rule out underlying causes e.g. RA
try to minimise Ix
Differentials:
• Chronic fatigue syndrome
• SLE, MS, PMR
• RA, axial spondyloarthritis
• Hypothyroidism, T2DM, anaemia
Management
4
→ Reassure → no serious underlying pathology
→ Nature of the condition → relapsing & remitting, no easy cure
→ ‘Pacing’ → have ‘good’ & ‘bad’ days → do not over-exert on good days (makes
bad days worse!)
→ Sleep hygiene
→ Sleep: low dose TCAs
→ Pain: paracetamol, low dose TCAs, pregabalin, duloxetine, tramadol
Musculoskeletal disease
4
Macfarlane GR, et al. (2017) EULAR revised recommendations for management of fibromyalgia.
Ann Rheum Dis, 76:318
Gout
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monosodium urate monohydrate crystals (MSUM)
→ arises when there is prolonged hyperuricaemia
Primary gout: >90% due to inherited defect of uric acid excretion
Secondary gout: chronic hyperuricaemia due to renal impairment or drug
therapy
1. Initially: acute mono-arthritis in distal joint (50% in MTPJ of big toe)
• Sudden pain, with red, hot, swollen joint
• Often wakes patient in early morning
• ± fever/malaise
2. Untreated: recurrent attacks with reducing time between
• Progressive cartilage & bone erosion (deformities)
• Inflammatory polyarthritis in feet/hands/wrists
• Deposition of palpable masses of urate crystals = tophi
Chronic tophaceous gout : usually takes 10y
Deposits around finger, hands, forearm, elbows, Achilles tendon, helix of the ear
Chapter 18: Rheumatology 239
Differentials of gout:
∙ Septic arthritis
∙ RA
∙ Other crystal arthropathies
Sites affected by gout: smaller joints
toe → ankle → midfoot → knee → hands
→ wrist → elbow
Risk factors:
Primary gout Secondary gout
• Male
• Age
• FHx
• Metabolic
syndrome
( TGs, obesity, HTN,
DM)
• High alcohol
intake
(especially beer)
• High protein diet
(meat, seafood)
Reduced excretion:
• CKD
• Thiazide diuretics
• NSAIDs/aspirin
• Cytotoxic drugs
Increased
production:
• Myeloproliferative
disorders
Pseudogout
• Idiopathic/sporadic: most common
• Secondary: OA, trauma, dehydration, inherited metabolic disorder
(e.g. haemochromatosis, hypomagnesaemia)
1. Usually CPPD is asymptomatic: incidental finding of chondrocalcinosis on
radiograph
2. Acute attack (pseudogout): similar symptoms to gout (most cases in knee)
Calcic periarthritis
(muscles, cartilage etc.)
1. Acute attack: spontaneously or following trauma
• Extreme pain & tenderness, swelling & erythema
Most common site:
supraspinatus tendon
Sites affected by CPPD: larger joints
Knee → wrist →elbows→ pelvis/hips
→ shoulders
Gout: gouty
erosions + tophi
Fig. 18.11 Radiograph showing
gout in MTPJ of big toe.
Musculoskeletal disease
240 Chapter 18: Rheumatology
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Needle-shaped, strong negative
birefringence
yellow when parallel to ray
1. Joint aspiration for polarised light microscopy: confirms Dx
• MSUM crystals present in gout, CPPD in pseudogout
• Increased turbidity of synovial fluid (due to WCC)
• Often blood-stained/rust-coloured in pseudogout
2. Serum urate levels: hyperuricaemia is not diagnostic
• Levels may be low in attack as crystals have deposited in joints
3. Further assessment: determine cause
• FBC, ESR, CRP ( WCC & CRP in acute attack)
• Renal function (serum Cr, urine dip)
• BP
• Blood glucose
• Serum lipid profile
4. Consider X-ray: for erosions/tophi
1. Acute attack: do not start allopurinol for gout until acute attack has resolved
• Pain relief: fast-acting oral NSAID (or oral colchicine if NSAID
contraindicated)
Causes N&V + diarrhoea
• Stop attack: joint aspiration & intra-articular steroid injection
2. Long-term treatment (for gout only): aim to lower serum urate
Rhomboid, weak positive birefringence
blue when parallel to ray
Side-effects of allopurinol:
• Skin rash, N&V
• Headaches, drowsiness
• Altered taste
Avoid with azathioprine
Indications for long-term Tx:
• Recurrent attacks
• Evidence of bone/joint damage
• Tophi
• Associated renal disease
• Severely elevated serum urate
• 1st line: allopurinol OD (xanthine oxidase inhibitor → reduced urate
production)
• 2nd line: febuxostat (avoid in cardiovascular disease)
• Monitor serum urate monthly
3. Lifestyle factors:
• Reduce alcohol & eat healthily & ensure drinking plenty of fluids
• Weight management
• Optimise control of comorbidities (DM, HTN)
• Medication review (consider alternative diuretic / stop NSAIDs)
Musculoskeletal disease
5
NICE (2022) Gout: diagnosis and management [NG219]
Presentation
Peri-articular
Boutonnière
PIPJ flexed
DIPJ extended
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• Hot, swollen joint
• Joint pain
• Stiffness – worse in mornings (lasts >1h)
• Loss of function of joint
→ Systemic: malaise, fatigue, fever, weight loss
Extra-articular features
1. Lungs: fibrosis, pleural effusions
2. CVS: pericarditis, atherosclerosis
( risk MI/stroke)
3. Eyes: episcleritis, scleritis,
keratoconjunctivitis
4. Vasculitis: splinter
haemorrhages (rare), vasculitic
ulcers
5. Peripheral neuropathy
6. Atlanto-axial subluxation
7. Other: Sjögren’s syndrome, Felty’s syndrome*
Fig. 18.12 Hand deformities.
Swelling
*RA + enlarged spleen + neutropenia
Chapter 18: Rheumatology 241
Affects 1% of the population – F>M
Joint involvement: usually symmetrical
• Small joints of hands & feet (MCPJ,
PIPJ, MTPJ)*
*DIPJs spared
• Wrists & ankles
→ Can affect any other synovial joints as well
→ Spine usually spared
Atlanto-axial subluxation:
→ Synovitis of cervical spine causing ligament
damage & instability
= subluxation of atlanto-axial joint (C1 & C2)
Sx: neck stiffness/pain, neuro Sx (weak/numb/
tingling)
Dx: MRI
Investigations
• FBC: CRP, ESR, platelets
(inflammation) ( WCC suggests
infection) Hb = normocytic,
normochromic anaemia
• Rheumatoid factor (RF): not
specific
• ANA antibody
• Anti-CCP antibodies: specific
• X-ray joints: soft tissue swelling,
periarticular erosions
Kidney & liver function + CXR
• Joint aspirate: r/o infection & crystal arthropathies
• Serum uric acid: r/o crystal arthropathies
Differential diagnosis:
• Rheumatoid arthritis
• Septic arthritis
• Crystal arthropathies (pseudo/gout)
• CTDs (SLE, vasculitis)
• Spondyloarthropathies (‘PEAR’)
erosions
Fig. 18.13 Radiograph showing
features of RA hands.
Lost joint space
Subluxation
Psoriatic
Enteropathic
Ankylosing spondylitis
Reactive
Antibody sensitivity & specificity
RF Anti-CCP
Sensitivity 60–80% 60–65%
Specificity 60–70% >90%
Other causes of RF +ve
• EBV, parvovirus, TB
• Hepatitis B, syphilis
• Sarcoidosis
• SLE, Sjögren’s
• Dermatomyositis
Musculoskeletal disease
242 Chapter 18: Rheumatology
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Assessing severity: guide & monitor Tx
DAS28 score:
• Joints involved ( /28)
• CRP/ESR or no. swollen joints
• Global health
Biologics indicated if:
→ DAS28 >5.1 and
→ Trialled ≥2 DMARDs (one being MTX)
Ix before starting Tx:
• FBC, LFT, renal function
• CRP/ESR
• CXR for pulmonary fibrosis
• HIV/hepatitis screen if high risk
• TB screen – biologics can reactivate
Management
• Analgesics
6
*contraindicated in PUD, CVD, renal impairment
→ NSAIDs* (ibuprofen, aspirin, naproxen etc.)
→ Glucocorticoid injections (IM/IA): (prednisolone) = while waiting for
DMARDs to work / during flares
• DMARDs (disease-modifying antirheumatic drugs)
1st-line = PO/IM methotrexate once WEEKLY (+ folate)
→ Interfere with immune response to slow disease progression
→ Take 6–12w to become clinically effective
→ Regular blood monitoring: FBC, U&Es & LFTs (fortnightly for 6w,
then monthly)
→ Counsel on SEs / red flags: N&V, sore throat, mouth ulcers, infections
→ Can add additional DMARD if disease activity remains high
e.g. hydroxychloroquine, sulfasalazine
• Biologics: anti-TNF-α (e.g. IV infliximab, IL-6 inhibitors, SC etanercept)
NB: if untreated, long-term inflammation can cause OA
Things to consider when selecting DMARDs / biologic therapy:
• Pregnancy / family planning – sulfasalazine & hydroxychloroquine are safe to use
• Alcohol consumption – leflunomide and methotrexate contraindicated
• Pulmonary fibrosis – methotrexate, leflunomide and anti-TNF contraindicated
• History of cancer (site, type, years in remission) – biologics contraindicated
• Renal/hepatic health – important for all medications
• General health / comorbidities – important for all medications
Role of primary care:
• Annual review of Sx, comorbidities, Tx
• Blood monitoring
• Information & education
• Managing flares
Musculoskeletal disease
• Physiotherapy: education, exercise/hydrotherapy, pain relief (heat packs,
acupuncture)
• Occupational therapy: adaptive skills, equipment, splints, joint protection,
activity modification
• Patient education: adapt activities / conserve energy, sleep hygiene,
exercise, smoking cessation, weight loss
Patients have CVS risk &
important to counsel onthis
Consider referral for surgical review if:
• Persistent pain due to joint damage
• Worsening joint function
• Progressive deformity
6
NICE (2018, updated 2020) Rheumatoid arthritis in adults [NG100]
Shared clinical features
Syndesmophytes
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• Asymmetrical mono-/oligoarthritis of large joints (including spine & SIJ)
• Affects tendons (enthesitis): plantar fasciitis, Achilles tendinitis
• Extra-articular Sx: iritis, palmar/plantar rashes, dactylitis, mouth ulcers, IBD
Investigations to r/o other arthropathies:
1. FBC, CRP, ESR (not always raised)
2. RF & ANA/CCP antibodies (r/o RA)
3. Joint aspirate (r/o infection & gout)
Psoriatic arthritis
Chapter 18: Rheumatology 243
Types:
• Psoriatic
• Enteropathic (IBD)
• Ankylosing spondylitis
• Reactive
• Asymmetrical oligoarthritis of weight-bearing joints (sacroiliac) & DIPJs
(mimics OA)
Presents at 35–55y
• or symmetrical polyarthritis (mimics RA)
• or spondylitis (mimics ankylosing spondylitis)
• or arthritis mutilans (dactylitis & telescoping of digits)
• Clinical features (e.g. dactylitis)
• Lack of RF/ANA/CPP
DAS 66/68
assesses severity
• X-ray (bony spurs)
or if features of ankylosing spondylitis (SIJ/spinal involvement) treat as below
Ankylosis spondylitis
Presents at 20–30y, M>F
• Insidious lower back & buttock pain (better with exercise)
• Morning stiffness & restricted spinal motion
• ± extra-articular features
→ Later: loss of lumbar lordosis & thoracic kyphosis
• Examine for sacroiliac tenderness
• Assess spinal movements, chest expansion & lordosis
→ modified Schober’s (mark points on back & flex → increase of 5–7cm = normal)
Extra-articular features of PsA:
• Psoriatic rash (not always present)
• Nail changes (pitting, onycholysis)
Extra-articular features of AkS:
• Anterior uveitis (30%)
• IBD
• Apical pulmonary fibrosis
• Restrictive lung disease ( expansion)
• Cauda equina syndrome (rare)
(bridging)
MRI = gold standard (+ X-ray/CT)
• Inflammatory lesions in corners of vertebral bodies
• Syndesmophytes (bony bridges) between vertebrae
• Sclerosis of sacroiliac joints (up to 10y after symptom onset)
Bloods:
• May have mildly raised ESR but normal CRP (inflammation not infection)
1. Physio & OT: regular exercises, deep breathing, activity modification
2. Analgesia: strong NSAIDs
3. Anti-TNF-α: after tried 2 NSAIDs and BASDAI score still high
4. Surgery: only if severe/progressing despite optimal non-surgical treatment
and severely affecting quality of life*
7
NICE (2017) Spondyloarthritis in over 16s: diagnosis and management [NG65]
X-ray changes don’t
appear for 5–7y
‘bamboo spine’
*BASDAI & BASFI scores: assess mental health & functional ability
Fig. 18.14 Radiograph of spine in AkS.
Musculoskeletal disease
244 Chapter 18: Rheumatology
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Causative organisms:
• Salmonella, E. coli, campylobacter, shigella
• Chlamydia trachomatis, gonorrhoea
• Streptococcus
Extra-articular features:
• Reiter’s triad: conjunctivitis, urethritis,
arthritis ‘can’t see, can’t wee, can’t bend
the knee’
• Skin rashes / erythema nodosum
Reactive arthritis
→ Triggered by enteric or genitourinary (STIs) infection
• Acute asymmetrical oligoarthritis of lower limbs / back → backache
• Hot, swollen joints (DDx: septic arthritis & pseudo/gout)
• Fever & malaise
• ± extra-articular features
• CRP, ESR = largely elevated
• WCC = elevated if infection still present
• Stool & urine cultures + genitourinary swab = for cause
• IgM/IgA/IgG = raised/rising
• Joint aspiration – r/o septic arthritis & pseudo/gout
• Full dose NSAIDs (analgesia)
• Intra-articular steroid injections
• ABX if identified organism
Extra-articular features:
• IBD features
• Iritis & skin rashes / erythema nodosum
Enteropathic arthritis
→ in 10–15% of those with IBD
• Joint swelling, pain, stiffness
▶ Type I: oligoarticular & asymmetrical + active IBD
▶ Type II: polyarticular & symmetrical
• ± extra-articular features
1. Treat IBD
2. Treat arthritis
• Use NSAIDs with caution as can worsen IBD
• DMARDs: sulfasalazine is 1st line as helps IBD
• Anti-TNF-α
Musculoskeletal disease
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