oxford handook of rheumatology 3rd ed

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Rheumatology

THIRD EDITION

Alan J Hakim

Consultant Physician and Rheumatologist, Director of Strategy and Business Improvement, Whipps Cross University Hospital NHS Trust, London, UK

Gavin P.R Clunie

Consultant Rheumatologist, The Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK

1

Great Clarendon Street, Oxford OX2 6DP

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First published 2002

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Third edition printed 2011

All rights reserved No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means,

without the prior permission in writing of Oxford University Press,

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British Library Cataloguing in Publication Data

Data available

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Typeset by Glyph International, Bangalore, India

Printed in China on acid-free paper through

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ISBN 978–0–19–958718–6

10 9 8 7 6 5 4 3 2 1

Oxford University Press makes no representation, express or implied, that the drug dosages in

this book are correct Readers must therefore always check the product information and clinical

procedures with the most up-to-date published product information and data sheets provided by

the manufacturers and the most recent codes of conduct and safety regulations The authors and

publishers do not accept responsibility or legal liability for any errors in the text or for the misuse

or misapplication of material in this work Except where otherwise stated, drug dosages and

recommendations are for the non-pregnant adult who is not breastfeeding

The rheumatic diseases present in a variety of ways, many of the diseases

are life-threatening and certainly severe and disabling and they cover

almost the entire spectrum of clinical medicine Patients, when asked

what their major concern is in relation to rheumatic disease, inevitably

mention pain and this is the focus of therapeutic intervention on which

they would like us to concentrate Doctors more readily concentrate on

understanding pathology and trying to alter the process/pathogenesis

The Oxford Handbook of Rheumatology is a relatively small but very

practical textbook that covers all these aspects in appropriate detail It

starts with a full understanding of the anatomy of the problem, but very

much answers questions in relation to why pain is perceived and how to

treat it It is a pragmatic, note-related approach to rheumatic disease and

its treatment, ranging from the common to the very rare—with excellent

cross-referencing between the different chapters and the way they deal

with different aspects of the diseases

Most rheumatology problems do not require the full intervention of

specialist rheumatologists but are cared for in general practice by practice

nurses, general practitioners with specialist interests, and the

multi-disciplinary team Those patients who require more specialist care are

seen in hospital but still monitored by nurses and doctors many of whom

who cover both primary and secondary care Occasionally patients with

most severe disease will be managed in hospital

This small book, in addition to its practical, pragmatic approach, is

soundly evidence-based and its approach and structure make it very

readable and appropriate for trainees, specialists, nurses and general

physicians It is a book I would have been delighted to have when I started

my career in medicine and I found many areas of interest and many new

facts It is a valuable resource for all those involved in rheumatic disease

It certainly should be on their bookshelves

Professor David G I Scott Consultant Rheumatologist, Honorary Professor of Rheumatology Chief Medical Advisor to the National Rheumatoid

Arthritis Society Norfolk and Norwich University Hospital

Foreword

Rheumatic or musculoskeletal disorders can present in a number of

familiar ways but sometimes are atypical and occasionally bewildering

They may appear insidiously or acutely and their impact ranges from a

temporary nuisance, to a condition that is persistent and increasingly

disa-bling, and sometimes a severe, even life-threatening illness

Not only are they common, and increasingly so in an ageing population,

they are often compounded by other disorders associated with ageing

But they affect people of all ages and especially those of working age in

whom they are a major cause of sickness absence and curtailment of

normal working life Most do not call for specialist rheumatological care

provided the General Practitioner and General Practitioner with a Special

Interest are practiced in their diagnosis and treatment, and longterm care

Specialist referral is sought when the diagnosis is uncertain, the treatment

ineffective, or a patient is acutely ill, which in some instances will lead to

tertiarly referral

This small book is up-to-date, based soundly on evidence and good

clinical practice It provides a compact but remarkably comprehensive vade

mecum both for clinicians in training and trained clinicians who encounter

patients with rheumatologic conditions in any guise, and specialists too

Notably, this new edition includes an important chapter on emergencies

in rheumatology

It is a book that I should have been glad to have by me from the

ing of my own career in rheumatology, and I commend it to clinicians

today

Carol Black Professor Dame Carol Black, President, Royal College of Physicians, and Professor of Rheumatology,

Royal Free & University College Medical School,

London

Foreword from the previous edition

Rheumatic conditions are common both in general and hospital practice

Musculoskeletal symptoms are a primary feature of many multisystem

illnesses, not only in the autoimmune joint and connective tissue

dis-eases, but also metabolic, endocrine, neoplastic, and infectious conditions

Symptoms are also common in the context of injury, age-related change,

and psychological distress Many conditions in rheumatology are a major

source of morbidity and mortality

We have kept to the format of previous editions of this book, focusing

fi rst on history and physical signs in the differential diagnosis of rheumatic

disease The reader is then encouraged to consider diseases in more

detail There have been major advances in rheumatology, not least the

introduction of biologic therapy The third edition refl ects this in being

up-to-date with assessment, guidelines, and treatment options in 2010

We have also introduced a new section, Part 3

Part 1 offers a practical guide to arriving at an appropriate differential

diagnosis given the realistic presentation of rheumatic disease; for

example, how to assess someone complaining of a pain in the elbow,

knee pain, or of diffi culty moving the shoulder, etc The book suggests

appropriate lines of enquiry for patients who present with characteristic

patterns of abnormality such as widespread joint or muscle pain, or

joint pains in association with a rash The aim is to provide a guide for

obtaining diagnostic information but also for discriminating good from bad

information—where to lay emphasis in eliciting a history and examination

signs In most chapters in Part 1, text is laid out under the headings of

Taking a history, Examination, and Investigations, with the subheadings

indicating important considerations and areas of enquiry

Part 2 lists a number of rheumatic conditions encountered in

rheu-matology and general practice There is a focus on clinical features, specifi c

fi ndings of relevant investigations, and management There is reference

to childhood and adolescent rheumatic disease throughout The aim is

to provide a comprehensive, clinically orientated text Some reference is

made to disease epidemiology and pathophysiology However, for more

detail on the basic sciences the reader is referred to The Oxford Textbook

of Rheumatology

Part 3 is a rapid reference section on medication, injection techniques,

and a chapter on rheumatological emergencies

Preface

We would like to thank the editors of The Oxford Textbook of

Rheumatology , Dr Philip Seo for his update of the text and authorship

under the title of The Oxford American Handbook of Rheumatology , 2009,

and the staff at Oxford University Press for their support and patience

during the preparation of this latest edition

Acknowledgements

Part I The presentation of rheumatic disease

1 Evaluating musculoskeletal symptoms 3

2 Regional musculoskeletal conditions: making a working diagnosis 19

3 Patterns of disease presentation: making a working diagnosis 149

4 The spectrum of non-musculoskeletal disorders in rheumatic disease 193

Part II The clinical features and

5 Rheumatoid arthritis 233

6 Osteoarthritis 259

7 The crystal arthropathies 269

8 The spondyloarthropathies 281

9 Juvenile idiopathic arthritis 303

10 Systemic lupus erythematosus 321

11 The antiphospholipid (antibody) syndrome 343

12 Sjögren’s syndrome 353

13 Systemic sclerosis and related disorders 363

14 Idiopathic infl ammatory myopathies:

polymyositis and dermatomyositis 385

15 Primary vasculitides 405

Contents

16 Metabolic bone diseases and disorders of collagen 431

17 Infection and rheumatic disease 473

18 Miscellaneous conditions 489

19 Common upper limb musculoskeletal lesions 517

20 Back pain 525

Part III Medicine management and

21 Drugs used in rheumatology 545

22 Corticosteroid injection therapy 589

23 Complementary and alternative medicine in

24 Rheumatological emergencies 609 Index 627

Editorial advisers xx

Symbols and abbreviations xxi

Part I The presentation of rheumatic disease

Introduction 4

Localization of pain and pain patterns 6

Changes in pain on examination 8

The assessment of pain in young children 10

Stiffness, swelling, and constitutional symptoms 11

Gait, arms, legs, spine—the GALS screen 12

2 Regional musculoskeletal conditions: making a

Symptoms in the hand 54

Upper limb peripheral nerve lesions 66

Thoracic back and chest pain 72

Low back pain and disorders in adults 78

Spinal disorders in children and adolescents 92

Pelvic, groin, and thigh pain 100

Knee pain 112

Lower leg and foot disorders (adults) 128

Child and adolescent foot disorders 140

3 Patterns of disease presentation: making a working

Mono-articular pain in adults 150

Oligo-articular pain in adults 152

Oligo-articular and pauci-articular pain in children and adolescents 160

Detailed contents

Widespread pain in adults 168

Widespread pain in children and adolescents 184

4 The spectrum of non-musculoskeletal disorders in

Skin disorders and rheumatic disease 194

Skin vasculitis in adults 200

Skin vasculitis in children and adolescents 204

Disease criteria and epidemiology for use in clinical trials 234

Incidence, prevalence, and morbidity 235

The clinical features of rheumatoid arthritis 236

Organ disease in rheumatoid arthritis 238

The evaluation and treatment of rheumatoid arthritis 242

Polyarticular arthritis in children with a positive rheumatoid factor 256

Still’s disease 257

6 Osteoarthritis 259

Introduction 260

Clinical features of osteoarthritis 262

The investigation of osteoarthritis 264

The management of osteoarthritis 266

7 The crystal arthropathies 269

Gout and hyperuricaemia 270

Calcium pyrophosphate dihydrate disease 276

Basic calcium phosphate associated disease 279

Calcium oxalate arthritis 280

xvDETAILED CONTENTS

Rheumatoid factor negative polyarthritis in childhood 316

Chronic, infantile, neurological, cutaneous, and articular syndrome 319

10 Systemic lupus erythematosus 321

Introduction 322

The clinical features of systemic lupus erythematosus 324

Antiphospholipid (antibody) syndrome and systemic lupus erythematosus 329

Pregnancy and systemic lupus erythematosus 330

Diagnosis and investigation of systemic lupus erythematosus 332

Drug-induced lupus erythematosus 335

The treatment of systemic lupus erythematosus 336

Prognosis and survival in systemic lupus erythematosus 339

Childhood systemic lupus erythematosus 340

Neonatal systemic lupus erythematosus 341

11 The antiphospholipid (antibody) syndrome 343

Introduction 344

Epidemiology and pathology 345

Clinical features of antiphospholipid syndrome 346

Treatment of antiphospholipid syndrome 348

Catastrophic antiphospholipid syndrome 350

12 Sjögren’s syndrome 353

Epidemiology and pathology 354

Clinical manifestations of Sjögren’s syndrome 356

Investigation of Sjögren’s syndrome 360

Treatment of Sjögren’s syndrome 362

13 Systemic sclerosis and related disorders 363

Epidemiology and diagnostic critetria 364

Cutaneous features of scleroderma and their treatment 368

Systemic features of the disease, investigation, and treatment 372

Antifi brotic and immunosuppressive therapies for systemic sclerosis 378

Summary—the approach to systemic sclerosis 380

Scleroderma-like fi brosing disorders 382

14 Idiopathic infl ammatory myopathies: polymyositis and

dermatomyositis 385

Epidemiology and diagnosis 386

Clinical features of polymyositis and dermatomyositis 388

Investigation of polymyositis and dermatomyositis 392

Small-vessel vasculitis 426

Kawasaki disease 430

xviiDETAILED CONTENTS

16 Metabolic bone diseases and disorders of collagen 431

Osteoporosis 432

Osteomalacia and rickets 442

Parathyroid disease and related disorders 448

Paget’s disease of bone 456

Miscellaneous diseases of bone 460

Molecular abnormalities of collagen and fi brillin 464

17 Infection and rheumatic disease 473

Miscellaneous skin conditions associated with arthritis 498

Complex regional pain syndrome 504

Relapsing polychondritis 506

Miscellaneous disorders of synovium 508

Amyloidosis 510

Fibromyalgia and chronic widespread pain 514

19 Common upper limb musculoskeletal lesions 517

Shoulder (subacromial) impingement syndrome 518

Adhesive capsulitis 520

Lateral epicondylitis (tennis elbow) 522

20 Back pain 525

Categorizing of back pain 526

Conditions causing acute or sub-acute back pain in adults 528

Management of chronic back pain 534

Management of back pain in children and adolescents 538

Part III Medicine management and emergencies

21 Drugs used in rheumatology 545

The wrist and hand 595

The hip and peri-articular lesions 596

The knee and peri-articular lesions 597

The ankle and foot 598

23 Complementary and alternative medicine in

rheumatology 599

Introduction 600

Herbal remedies (phytotherapy) 602

Physical and ‘hands-on’ therapies 604

xixDETAILED CONTENTS Acute systemic lupus erythematosus 616

Systemic vasculitis 622

Scleroderma crises 624

Methotrexate-induced pneumonitis 625

Index 627

Professor David A Isenberg

Bloomsbury Rheumatology Unit,

University College London, UK

Professor Peter J Maddison

Department of Rheumatology,

Ysbyty Gwynedd, Bangor, North Wales, UK

Professor Patricia Woo

Centre of Paediatric and Adolescent Rheumatology,

Windeyer Institute, London, UK

Professor David Glass

Division of Rheumatology,

Childrens’ Hospital Medical Center,

Cincinnati, Ohio, USA

Editorial advisers

ACA Anticentromere antibody

ACE Angiotensin-converting enzyme

AChA Acrodermatitis chronicum atrophicans

AC(J) Acromioclavicular (joint)

ACL Anticardiolipin

ACR American College of Rheumatology

ADM Abductor digiti minimi

AKI Acute kidney injury

ALP Alkaline phosphatase

ALT Alanine transaminase

AMA Amyloid A

AML Amyloid L

ANA Anti-nuclear antibody

ANCA Antineutrophil cytoplasmic antibody

AP Anteroposterior

APB Abductor pollicis brevis

APL Abductor pollicis longus

ApL Antipospholipid

APS Antiphospholipid (antibody) syndrome

ARA American Rheumatism Association

ARB Angiotensin II receptor blockers

ARF Acute renal failure

AS Ankylosing spondylitis

AST Aspartate transaminase

ASOT Antistreptolysin O titre

ASU Avocado/soybean unsaponifi able

ATN Acetebular necrosis

ATN Acute tubular necrosis

BLyS B-lymphocyte stimulator

BMC Bone mineral content

BMD Bone mineral density

BMI Body Mass Index

BSR British Society of Rheumatology

BVAS Birmingham Vasculitis Activity Score

C Cervical (e.g C6 is the sixth cervical vertebra)

CA Coracoacromial

CAPS Cryopyrin-associated periodic fever syndromes

CBT Cognitive and behavioural therapy

CCP Cyclic citrullinted peptide

CCS Churg–Strauss syndrome

CHCC Chapel Hill Consensus Conference

CINCA Chronic, infantile, neurological, cutaneous, and articular

syndrome CIO Corticocosteroid-induced osteoporosis

CK Creatine kinase

CMC(J) Carpometacarpal (joint)

CMP Comprehensive metabolic panel

CMV Cytomegalovirus

CNS Central nervous system

COMP Cartilage oligomeric matrix protein

COX Cyclo-oxygenase

CPPD Calcium pyrophosphate deposition (arthritis)

CREST Calcinosis, Raynaud’s, Esophageal dysmotility,

Sclerodactyly, Telangiectasia (syndrome) CRP C reactive protein

CRPS Complex regional pain syndrome

DAS Disease Activity Score

dcSScl Diffuse cutaneous systemic sclerosis

DEXA Dual-energy X-ray absorptiometry

DIP( J) Distal interphalangeal (joint)

DISH Diffuse idiopathic skeletal hyperostosis

DLCO Diffusion capacity for carbon monoxide

xxiiiSYMBOLS AND ABBREVIATIONS

DM Dermatomyositis

DMARD Disease-modifying antirheumatic drug

DVT Deep vein thrombosis

EA Enteropathic arthritis

EANM European Association of Nuclear Medicine

EBV Epstein–Barr virus

ECG Electrocardiogram

ECM Erythema chronicum migrans

ECRB Extensor carpi radialis brevis

ECRL Extensor carpi radialis longus

ECU Extensor carpi ulnaris

ED Extensor digitorum

EDL Extensor digitorum longus

EDM Extensor digiti minimi

EDS Ehlers–Danlos syndrome

EED Erythema elevatum dictinum

EHL Extensor hallucis longus

ENA(S) Extractable nuclear antigen(s)

EPB Extensor pollicis brevis

EPL Extensor pollicis longus

ERA Enthesitis-related arthritis

ESR Erythrocyte sedimentation rate

ESSG European Spondylarthropathy Study Group

EULAR European League Against Rheumatism

FBC Full blood count

FCR Flexor carpi radialis

FCU Flexor carpi ulnaris

FDA Food and Drug Administration

FDL Flexor digitorum longus

FDP Flexor digitorum profundus

FDS Flexor digitorum superfi cialis

FFS Five Factor Score

FHB Flexor hallucis brevis

FHH Familial hypocalciuric hypercalcacaemia

FJ Facet joint

FM Fibromyalgia

FMF Familial Mediterranean fever

FPL Flexor pollicis longus

FR Flexor retinaculum

FVSG French Vasculitis Study Group

GARA Gut associated reactive arthritis

GBM Glomerular basement membrane

GBS Guillain Barré syndrome

GLA Gamma linoleic acid

GOA Generalized osteoarthritis

HA Hydroxyapatite

HCQ Hydroxychloroquine

HDCT Hereditary disorder of connective tissue

HIV Human immunodefi ciency virus

HLA Human leukocyte antigen

HPOA Hypertrophic pulmonary osteoarthropathy

HPT Hyperparathyroidism

HSCT Haematopoietic stem cell transplantation

HSP Henoch–Schönlein purpura

HTLV Human T-cell leukemia virus

IBM Inclusion-body myositis

IL Interleukin

ILAR International League of Associations for Rheumatology

im Intramuscular(ly)

IMM Idiopathic infl ammatory myopathy

INR International normalized ratio

IP Interphalangeal

ISN International Society for Nephrology

ITB Iliotibial band

ITP Immune thrombocytopenic purpura

iv Intravenous

IVDU Intravenous drug user

IVIG Intravenous immunoglobulin

JCA Juvenile chronic arthritis

JDM Juvenile dermomyositis

JHS Joint hypermobility syndrome

xxvSYMBOLS AND ABBREVIATIONS JIA Juvenile idiopathic arthritis

JIO Juvenile idiopathic osteoporosis

JPO Juvenile polymyositis

JPSA Juvenile psoriatic arthritis

JRA Juvenile rheumatoid arthritis

JSpA Juvenile spondyloarthropathy

KD Kawasaki disease

KUB Kidney ureter bladder

L Lumbar (e.g L5 is the fi fth lumbar vertebra)

LAC Lupus anticoagulent

LCL Lateral collateral ligament

lcSScl Limited cutaneous systemic sclerosis

LDH Lactate dehydrogenase

LFTs Liver function tests

LGL Large granular lymphocyte

LH Luteinizing hormone

LLLT Low level laser therapy

LOPA Late onset pauci-articular juvenile chronic arthritis

MAS Macrophage activation syndrome

MCP(J) Metacarpophalangeal (joint)

MCL Medial collateral ligament

MCTD Mixed connective tissue disease

MEN Mycophenolate mofetil

MFS Marfan’s syndrome

MG Myasthenia gravis

MMF Mycophenolate mofetil

MMPI Minnesota Multiphasic Personality Inventory

MND Motor neuron disease

MPA Microscopic polyangiitis

MPO Myeloperoxidase

MR Magnetic resonance

MRA Magnetic resonance angiography

MRI Magnetic resonance imaging

MSA Myositis-specifi c

MTP(J) Metatarsophalangeal (joint)

MTX Methotrexate

MVP Mitral valve prolapse

NCS Nerve conduction study

NICE National Institute for Health and Clinical Excellence (UK)

NMS Neuromuscular scoliosis

NO Nitrous oxide

NOMID Neonatal onset multisystem infl ammatory disease

NSAID Non-steroidal anti-infl ammatory drug

NSF Nephrogenic systemic fi brosis

OA Osteoarthritis

OI Osteogenesis imperfecta

PAH Pulmonary artery hypertension

PAN Polyarteritis nodosa

PBC Primary biliary cirrhosis

PCR Polymerase chain reaction

PE Pulmonary embolism

PET Positron emission CT

PHP Pseudohypoparathyroidism

PIN Posterior interosseous nerve

PIP(J) Proximal interphalangeal (joint)

PsA Psoriatic arthropathy

PSA Prostatic specifi c antigen

PTH Parathyroid hormone

PV Plasma viscosity

PVNS Pigmented villonodular synovitis

qds Four times daily

RA Rheumatoid arthritis

RCT Randomized control trial

REA Reactive arthritis

RF Rheumatoid factor

RNA Ribonucleic acid

RNP Ribonuclear protein

RP Raynaud’s phenomenon

RSD Refl ex sympathetic dystrophy (algo/osteodystrophy)

RSI Repetitive strain injury

RS 3 PE Remitting seronegative symmetrical synovitis with pitting

oedema RTA Renal tubular acidosis

xxviiSYMBOLS AND ABBREVIATIONS sACE Serum angiotensin converting enzyme

SAI Subacromial impingement

SAMA Serum amyloid A

SAP Serum amyloid protein

SAPHO Synovitis, acne, palmoplantar pustolosis, hyperostosis,

aseptic osteomyelitis (syndrome) SARA Sexually transmitted reactive arthritis

s/c Subcutaneous(ly)

SC(J) Sternoclavicular (joint)

SCS Spinal cord stimulation

SD Standard deviation

SERM Selective oestrogen receptor modulators

SI(J) Sacroiliac (joint)

SIP Sickness Impact Profi le

SLE Systemic lupus erythematosus

SNRI Serotonin-norepinephrine re-uptake inhibitors

SpA Spondyloarhthritis

SS Sjögren’s syndrome

SScl/Scl Systemic sclerosis/Scleroderma

SSRI Selective serotonin reuptake inhibitors

STIR Short tau inversion recovery

SSZ Sulfasalazine

T Thoracic (e.g T5 is the fi fth thoracic vertebra)

TA Takayusu’s arteritis

TB Tuberculosis

tds Three times daily

TENS Transcutaneous electrical nerve stimulation

TFTs Thyroid function tests

TGF Transferring growth factor

TIA Transient ischemic attack

TM(J) Temperomandibular (joint)

TNF( α ) Tumour necrosis factor (alpha)

tPA Tissue plasminogen activator

TPMT Thiopurine S-methyltransferase

TRAPs Tumour necrosis factor-associated periodic syndrome

TSH Thyroid stimulating hormone

U&E Urea and electrolytes (in UK test includes creatinine)

UC Ulcerative colitis

US Ultrasound

UV Ultraviolet

VDI Vasculitis Damage Index

vs Versus

VZIG Varicella zoster immunoglobulin

WBC White blood cell

WG Wegener’s granulomatosis

WHO World Health Organization

WRD Work-related disorder

The presentation

of rheumatic disease

Part I

Introduction 4

Localization of pain and pain patterns 6

Changes in pain on examination 8

The assessment of pain in young children 10

Stiffness, swelling, and constitutional symptoms 11

Gait, arms, legs, spine—the GALS screen 12

Evaluating musculoskeletal symptoms

Chapter 1

Introduction

Pain is the most common musculoskeletal symptom It is defi ned by its

subjective description, which may vary depending on its physical (or

bio-logical) cause, the patient’s understanding of it, its impact on function, and

the emotional and behavioural response it invokes Pain is also often

‘col-oured’ by cultural, linguistic, and religious differences Therefore, pain is not

merely an unpleasant sensation; it is, in effect, an ‘emotional change’ The

experience is different for every individual; patients who think of

them-selves as having a ‘high pain threshold’ may have the hardest time coping

In children and adolescents the evaluation of pain is sometimes

complicated further by the interacting infl uences of the experience of pain

within the family, school, and peer group Stiffness is also common It may

be a manifestation of infl ammation, reduced movement due to mechanical

pathology including swelling, or used by an individual to describe reduced

movement due to pain

The GALS screen is a valuable quick assessment tool for identifying sites

of reduced movement and function before entering in to a more detailed

physical examination

This page intentionally left blank

Localization of pain and pain patterns

• Adults usually localize pain accurately, although there are some

situations worth noting in rheumatic disease where pain can be poorly

localized (Table 1.1 )

• Adults may not clearly differentiate between peri-articular and articular

pain, referring to bursitis, tendonitis, and other forms of soft tissue

injury as ‘joint pain.’ Therefore, it is important to confi rm the precise

location of the pain on physical examination

• Pain may be well localized but caused by a distant lesion, e.g

interscapular pain caused by mechanical problems in the cervical

spine, or right shoulder pain caused by acute cholecystitis

• Pain caused by neurological abnormalities, ischaemic pain, and pain

referred from viscera is harder for the patient to visualize or express,

and the history may be given with varied interpretations

• Bone pain is generally constant despite movement or change in

posture—unlike muscular, synovial, ligament, or tendon pain—and

often disturbs sleep Fracture, tumour, and metabolic bone disease are

all possible causes Such constant, local, sleep-disturbing pain should

always be investigated

• Patterns of pain distribution are associated with certain musculoskeletal

conditions For example, polymyalgia rheumatica (PMR) typically affects

the shoulder girdle and hips, whereas rheumatoid arthritis (RA) affects

the joints symmetrically, with a predilection for the hands and feet

• Patterns of pain distribution may overlap, especially in the elderly,

who may have several conditions simultaneously, e.g hip and/or knee

osteoarthritis (OA), peripheral vascular disease, and degenerative

lumbar spine all may cause lower extremity discomfort

The quality of pain

Some individuals fi nd it hard to describe pain or use descriptors of

severity A description of the quality of pain can often help to discriminate

the cause Certain pain descriptors are associated with non-organic pain

syndromes (Table 1.2 ):

• Burning pain, hyperpathia (i.e., an exaggerated response to painful

stimuli), and allodynia (i.e., pain from stimuli that are normally not

painful) suggest a neurological cause

Table 1.1 Clinical pointers in conditions where pain is poorly localized

Peri-articular shoulder pain Referred to deltoid insertion

Carpal tunnel syndrome Nocturnal paraesthesias and/or pain, often diffuse

Trochanteric bursitis Nocturnal pain lying on affected side

Hip synovitis Groin/outer thigh pain radiating to the knee

7LOCALIZATION OF PAIN AND PAIN PATTERNS

• A change in the description of pain in a patient with a long-standing

condition is worth noting, since it may denote the presence of

a second condition, e.g a fracture or septic arthritis in a patient with

established RA

Repeated, embellished, or elaborate description (‘catastrophizing’) may

suggest non-organic pain, but be aware that such a presentation may be

cultural

Relieving and aggravating factors

In general mechanical disorders are worsened by activity and relieved by

rest This does not mean pain is not present at rest; in severe mechanical/

degenerative disorders pain disturbs sleep Patterns of pain distribution

are associated with certain activities In contrast, in infl ammatory

disor-ders pain may subside somewhat with activity

Whether mechanical or infl ammatory, pain is often worsened by

excessive stressing/movement of the joint

Individuals identify different relieving factors including hot/cold

compress, supports, massage, etc

Many individuals will have taken or be taking analgesics It is important to

understand which ones have been used, why they have been discontinued,

and how effective they were Was the frequency and dosage of analgesia

correct and has there been good compliance with taking a medication

before assuming ineffi cacy?

Table 1.2 Terms from the McGill pain scale that help distinguish

between organic and non-organic pain syndromes

Changes in pain on examination

Eliciting changes in pain by the use of different examination techniques

may be used to provide clues to the diagnosis:

• Palpation and comparison of active and passive range of motion can be

used to reproduce pain and localize pathology This requires practice

and a good knowledge of anatomy

• Many of the classic physical exam signs and manoeuvres have a high

degree of inter-observer variability Interpretation should take into

account the context in which the examination is done and the effects

of suggestibility

• Palpation and passive range of motion exercises are performed while

the patient is relaxed The concept of ‘passive’ movement is the

assumption that when the patient is completely relaxed, the muscles

and tendons around the joint are removed as potential sources of

pain; in theory, passive range of motion is limited only by pain at the

true joint This assumption has its own limitations, however, especially

since passive movements of the joint will still cause some movement

of the soft tissues In some cases, e.g shoulder rotator cuff disease,

the joint may be painful to move passively because of subluxation or

impingement due to a musculotendinous lesion

• The clinician should be aware of myofascial pain when palpating

musculotendinous structures, especially around the neck and shoulder

regions Myofascial pain is said to occur when there is activation of a

trigger point that elicits pain in a zone stereotypical for the individual

muscle It is often aching in nature

• Trigger points are associated with palpable tender bands It is not clear

whether trigger points are the same as the tender points characteristic

of fi bromyalgia

• Local anaesthetic infi ltration at the site of a painful structure is

sometimes used to help localize pathology, e.g injection under the

acromion may provide substantial relief from a ‘shoulder impingement

syndrome’ However, the technique is reliable only if localization of

the injected anaesthetic can be guaranteed Few, if any, rigorously

controlled trials have shown it to give specifi c results for any condition

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The assessment of pain in young

children

The assessment of pain in young children is often diffi cult:

• Young children often localize pain poorly Careful identifi cation of the

painful area is necessary through observation and palpation

• A child may not admit to pain but will withdraw the limb or appear

anxious when the painful area is examined

• Observing a child’s facial expression during an examination is very

important, as is the parent’s response

• Quantifi cation of pain often requires non-verbal clues, such as the

child’s behaviour Pain rating scales are often helpful (Fig 1.1 )

• Turning the examination into a form of play may put the child at ease

and assist with the examination For example, asking the child to

imitate your own movements may help you gauge range of motion

• The trappings of clinic may make young children nervous, and

removing a white coat or stethoscope from sight may also help place

the patient at ease

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32

10

Fig 1.1 Pain assessment in children—the faces rating scale

11STIFFNESS, SWELLING, AND CONSTITUTIONAL SYMPTOMS

Stiffness, swelling, and constitutional

symptoms

Diffi culty moving a joint may be a consequence of pain, swelling, stiffness,

or all three The added burden of a nerve or muscle pathology can make

the symptom of stiffness more diffi cult to interpret:

• Stiffness is often worse after a period of rest Short periods (less than

30 min) of stiffness that persist after mobilizing is not a meaningful

observation Stiffness lasting >30 min and often several hours after

mobilizing is a typical symptom of infl ammatory arthritis

• Stiffness can occur in normal joints Individuals typically click or crack

their joints to stretch the tissues and gain relief

• Stiffness may be a manifestation of tissue fi brosis; in tendons for

example fi brosis may cause nodules to form that in their most extreme

lead to locking or triggering ( b Chapter 2, p 19)

Swelling may arise from a number of different sites It is important to

deter-mine whether this is in the skin as a result of oedema, cellulitis, haematoma

or varicosities, for example, whether it is tendon infl ammation, synovial or

bone tissue, or an effusion from synovial fl uid or blood (haemathrosis)

Constitutional symptoms

Fatigue is a complex symptom experienced by many patients in association

with systemic illness, anaemia, endocrinopathy or metabolic pathology, or

as a consequence or disturbed sleep pattern

Other constitutional symptoms include fever, excessive sweating,

and weight-loss These symptoms may also be a manifestation of other

underlying diseases manifesting as arthritis ( b Chapter 4, p 149)