Referrer Information

• Presentation: Polyarticular / small joint, inflammation (morning stiffness, relieved with movement). There may be associated constitutional symptoms, family history, and smoking history. Other systems may be involved, e.g. skin / heart / lung.

• Evaluation: joint effusion / swelling, early morning stiffness, gel phenomenon.

• Consider Blood tests: FBE, ESR, CRP, anti-CCP, Rh Factor.

GP management options while awaiting specialist review:

• Consider NSAIDS, unless contraindicated.

• Prednisolone is an option if NSAIDs are inadequate or contraindicated.

• Anti-rheumatic drug therapy is generally recommended in all patients, but rheumatologist assessment is recommended before the institution of such therapy.

• Monitoring and mitigation of cardiovascular risk factors is essential.

Further information: Rheumatoid Arthritis (RACGP)

• Differentials: Gout, pseudogout (CPPD), septic arthritis, haemarthrosis, OA, trauma, inflammatory arthritis (e.g. psoriatic arthritis).

• Presentation: red / hot / irritable joint, possibly fever.

• Urgent aspiration of the joint with aseptic technique and evaluation of the fluid: m/c/s, crystals.

• Septic arthritis is a medical emergency – the patient should be referred to the hospital (via ambulance or emergency department) for further assessment and management.

Further Information: “My Knee Is Swollen“ (RACGP)

• Systemic lupus erythematosus – a multi-system inflammatory presentation often with arthritis, rash, anaemia, serositis, nephritis or CNS involvement.

• Scleroderma (systemic sclerosis) - Raynaud’s phenomena, dysphagia / GORD, skin tightening, telangiectasia.

• Myositis – muscle weakness, arthritis, rash, dyspnoea (due to interstitial lung disease).

• It is vital to ensure you check the patient’s blood pressure, respiratory status and renal function (eGFR / dipstick).

• Recommended tests include: ANA, dsDNA, ANCA, MSU (urinalysis, M&C), FBE, ESR, U&E, CK, CXR.

• A positive ANA in the absence of clinical features is unlikely to represent a significant immune disease.

• A negative ANA effectively excludes SLE as the diagnosis.

Further Information: Systemic lupus erythematosus: When to consider and management options (RACGP)

• Common presentation: Hip and shoulder girdle stiffness, headache, jaw / tongue pain, constitutional symptoms.

• Testing: elevated ESR / CRP, normal CK.

• PMR: therapeutic trial of medium dose Prednisone (15-20mg daily) for PMR can be considered. Immediate and complete resolution of symptoms is expected in PMR.

• Temporal arteritis can lead to irreversible blindness and must be assessed as an emergency. Consider referral to an emergency department (may require temporal artery biopsy) or contacting the rheumatologist directly to discuss the case.

• Biologic treatment (tocilizumab) is available for selected cases of GCA.

Further Information: “Polymyalgia rheumatica and giant cell arteritis: An ophthalmic emergency“ (RACGP)

• History: family history, age at menopause, fracture history, dietary Ca2+, steroid therapy, lifestyle factors – smoking, alcohol, exercise.

• Exam: vertebral deformity, height reduction.

• Investigations BMD (DEXA), Vitamin D, Thoracolumbar Xray for occult fractures (Wedging ≥20% loss of height), Ca, PO4, thyroid, U&Es, LFT. androgens in males.

• Consider pathological fracture: secondary to malignancy, multiple myeloma.

• Ensure Vitamin D / calcium are replete before starting antiresorptive therapy to reduce the risk of hypocalcaemia.

• Ensure dentition is adequate before starting antiresorptive therapy to reduce the risk of osteonecrosis of the jaw.

• When using denosumab, avoid delays of > 4 weeks of subsequent doses due to the risk of rebound osteoporosis.

Further information: Osteoporosis (RACGP)

• Consider differentials: non-specific back pain, malignancy, infection, fracture.

• Consider “Red Flags”: weight loss, PR bleeding, nocturnal pain, fever/rigors, cough / haemoptysis, haematuria, history of or suggestive of malignancy, neurological symptoms, gait disturbance – clinical evidence of these should prompt urgent assessment potentially via an emergency department.

• Xray / CT and MRI are not indicated for most cases of chronic non-specific back pain (i.e. in the absence of “red flags”).

• Management: consider paracetamol / NSAIDs for acute pain. Avoid opioids and steroids for chronic pain. Refer to a physiotherapist for an active exercise program.

Further information: Low back pain: Can we mitigate the inadvertent psycho-behavioural harms of spinal imaging? (RACGP)

• Issues: Rotator cuff pathology / Subacromial Bursitis, Greater trochanteric pain syndrome, epicondylitis, plantar fasciitis.

• History: acute injury or chronic pain occupational / exercise history.

• Examination: deformity, warmth, tenderness, range of motion.

• Imaging: consider X-ray or US. NB: degenerative changes in the rotator cuff / bursa in people >50 yo are common whether pain/dysfunction is present or not.

• Management: Analgesia (paracetamol). Consider NSAID if there is no contraindication. A cortisone injection may provide short term pain relief to facilitate the introduction of an exercise program. Comprehensive care involves referral to a physiotherapist.

Further information:

Shoulder Injuries

Hip Pain

Plantar Fascia Stretches

Lateral Epicondylitis

Presentation: Chronic mechanical joint pain with a lack of inflammatory symptoms.

Management:

• Exclude an inflammatory cause through history / examination. Investigations: usually not indicated – xrays can confirm the degree of joint change.

• Education (Arthritis Foundation).

• Physical therapy (eg physiotherapy, GLA:D program).

• Self management skills.

• Orthotic assessment.

• Simple analgesia (paracetamol).

• Avoid oral steroids and opioids for long term pain relief.

• There is evidence that intra-articular corticosteroid injections can accelerate osteoarthritis.

Further information: Guideline for the Management of Knee and Hip Osteoarthritis