Dr Gavin Clunie - Rheumatologist & Metabolic Bone Physician
 

HEALTH CONDITIONS

A LOT OF PEOPLE COME TO SEE ME BECAUSE THEY ARE REFERRED FOR TREATMENT FOR THE CONDITIONS DESCRIBED BELOW, OR BECAUSE THEY ARE SUFFERING FROM UNEXPLAINED MUSCLE, BONE, TENDON OR JOINT PAINS WHICH I CAN HELP ACCURATELY DIAGNOSE

 
 
 

Back Pain
& its causes

The majority of the population will suffer with back pain at one time in their lives! The range of conditions that cause back pain at different ages is different. Most causes of back pain are simple problems, not sinister or chronic. In some cases, specialist rheumatology review is recommended for chronic, severe, lifestyle limiting pain, and very effective treatment is available.

Arthritis
Joint inflamation

Inflammatory arthritis can be acute, or chronically progressive and damaging to joints. It's really important to notify your doctor if your joint pains continue and for your doctor to recognise whether it's an inflammatory arthritis, as there are various types (e.g. osteoarthritis, gout, psoriatic arthritis, rheumatoid arthritis). If missed and not treated early, joint inflammation/arthritis can cause permanent joint damage and disability.

Osteoporosis
Fragile skeleton

Osteoporosis is a condition that causes fragility of the skeleton leading to broken bones. To tell if someone has osteoporosis and what their fracture risk is, a specialist consultation, a Bone Density Scan called a DXA (or 'DEXA') scan, some blood tests, and in an older person, a falls risk assessment are required. Calcium deficiency, steroid use, genetic background, excessive alcohol intake, smoking and primary hyperparathyroidism are some of the contributors to causing osteoporosis.

Fibromyalgia
& widespread pain

The term Fibromyalgia describes widespread pain which is a function of amplification of brain pain processing. Some conditions can be mistaken for fibromyalgia, and often a delay in the diagnosis of chronic diseases which cause pain or multiple different diagnoses, can lead understandably to confusion, anxiety, frustration & onwards in a vicious cycle.

Autoimmune Connective Tissue Diseases

Apart from the brain, the body's immune system is probably the least understood body organ system by people. It is a complicated fluid organ system consisting of interacting cells & molecules which protects the body from micro-organisms like bacteria and viruses. Disease occurs when the system 'thinks' there is something invading the body to fight, but there isn't.

Polymyalgia Rheumatica & Giant Cell Arteritis

Polymyalgia Rheumatica (PMR) is a complex condition associated with older adults. Giant cell arteritis (GCA) is a condition where the larger arteries become inflamed, narrow and get blocked preventing blood getting to vital places in the body - like the eye and brain. Both conditions require a skilled rheumatologist to diagnose correctly to enable swift treatment.

Hypermobility & POTS

Musculoskeletal hypermobility can facilitate dancing and athletic excellence, or can be associated with pain, fatigue, cardiovascular autonomic dysfunction (POTS), bowel dysfunction and internal organ prolapse.  Diagnosis needs to be made very carefully considering both the features above and given the huge spectrum of normal tissue flexibility which exists between people, which does not constitute a ‘disease’.

General Musculoskeletal Conditions

Musculoskeletal problems are very common. A specialist rheumatologist has a broad view of the best tests that lead to correct diagnosis & the fastest links to others such as physiotherapists, surgeons & podiatrists so that the right treatment is undertaken quickly by the right person.

 
 
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Back Pain & its Causes

The majority of the population will suffer with back pain at one time in their lives! The range of conditions that cause back pain at different ages is different. Most causes of back pain are simple problems, not sinister, not chronic. Below are the commonest causes of back pain at different ages.


Muscle or ligament strain: common at all ages. Caused by trauma. Usually eases with rest. Often causes muscle spasm (stiff and rigid soft tissues around the injury), which can be very painful;


Intervertebral disc disease (IVDD). IVDD occurs mostly in the low back. Can be acute and severe in the young and middle aged (tear of the outer ‘annulus’ of the disc). Secondary muscle spasm very often occurs. Disc tears can lead to disc prolapse (“slipped disc”) which may then cause pressure on part of the sciatic nerve causing sharp/shooting/burning/severe leg pains to down below the knee or to the foot. In the elderly, IVDD is more likely to cause dull persistent aching pain in the back, sciatica is less likely, and co-existing facet joint osteoarthritis is common (see below);


Vertebral fracture. Rare under 50y old. More common the older the person, and more common in women than in men. Sudden, severe often mid back pain, with pain referred around the rib cage at the same level. There’s an urgent need for X-Ray/MRI and a need to consider vertebroplasty (see link below). The pain from a vertebral fracture can be severe requiring morphine to control the it very often. See link to information on Vertebroplasty below (NOS)


Axial Spondyloarthritis / Ankylosing Spondylitis. Can occur at any age (there is a juvenile form) but typically it occurs for the first time in a young adult. Pain is associated with stiffness in the back, it often disturbs sleep and is there in the morning on waking. The symptoms typically ease with movements (often go completely). Anti-inflammatory painkillers work best! Specialist Rheumatology review is highly recommended because the condition can become chronic, can be severe, can limit lifestyle considerably and there is very effective treatment. See links below also.


Facet joint arthritis. Rare in children, adolescents and young adults. Usually affects the lower back. The usual causes are osteoarthritis (condition of the elderly or middle aged) or psoriatic arthritis (see under Inflammatory Arthritis types). When long-standing, facet joint arthritis can lead to nerve root exit foramen or central lumbar canal narrowing. Essentially with this, the spinal nerves are crowded and compressed by the extra bone that forms around the arthritic joints, and this can cause leg symptoms – stiffening/heaviness worse on walking (though not always pain). The symptoms are often insidious not sudden in onset. When facet joint arthritis is severe, targeted injections can be done (usually in a ‘Pain Clinic’ environment by a specialist Pain Management Anaesthetist or Spinal Orthopedic Surgeon).


Links

About Back Pain generally https://www.versusarthritis.org/about-arthritis/conditions/back-pain


About Vertebroplasty – done to control pain from an acute vertebral fracture. https://nos.org.uk/about-osteoporosis/treating-osteoporosis/percutaneous-vertebroplasty

 
About axial Spondyloarthritis and Ankylosing Spondylitis https://nass.co.uk

See information on Spondyloarthritis on this website: http://www.drgavinclunie.co.uk/inflammatory-arthritis

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Early inflammatory arthritis

Inflammatory arthritis can be acute and self-limiting - like after a virus such as Parvovirus B19 - or chronic and potentially progressive and damaging to joints. It's really important to notify your doctor if your arthritis pains continue and for your doctor to recognise whether it's an inflammatory arthritis. If missed and not treated, then inflammatory arthritis can cause permanent damage to joints and permanent disability. The good news is that inflammatory arthritis can be successfully treated but you need to see a rheumatologist promptly to get a diagnosis and receive advice about treatments. Early inflammatory arthritis is so important to pick up it is the focus of a national UK audit. See the link below at rheumatology.org

 

The commonest inflammatory arthritis types which persist and are not just simple post-viral arthritis illnesses are: psoriatic arthritis, rheumatoid arthritis, small joint inflammatory osteoarthritis and arthritis linked to spondyloarthritis (where inflammation in the spine is also a feature);
In the hands, the presence of stiffness of joints, swelling around the knuckles and pain if the knuckles are squeezed suggests an inflammatory arthritis (the three 'Ss');


A review by a Rheumatologist, a set of immunology blood tests and a scan of affected joints (ultrasound or MRI) is key to making a diagnosis (X-Rays are often normal in early arthritis)

 

Links:
A national audit on the provision of health services to ensure early appropriate care for people suspected of having an early inflammatory arthritis:
https://www.rheumatology.org.uk/Knowledge/Excellence/Audits

 
 
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Rheumatoid Arthritis

Rheumatoid arthritis (RA) may be present in as many as 1 in 100 people. It is a chronic persistent inflammatory arthritis. Mainly the small joints are affected often in a symmetrical pattern. In its earliest stages it is important not to mistake RA for inflammatory small joint osteoarthritis (OA), calcium pyrophosphate arthritis or psoriatic arthritis. Key to diagnosis is the presence of autoantibodies (rheumatoid factor but more specifically, anti-CCP antibodies) and characteristic changes on scans of affected joints (Ultrasound or MRI).

Early diagnosis and treatment is important;
Treatments for RA are very effective. The most effective painkillers are non-steroidal anti-inflammatory drugs (NSAIDs). These drugs sometimes can cause side effects on the stomach lining and upper gut. Make sure you have discussed the pros and cons of the painkillers in your own case, with your doctor or a rheumatologist;
The main tablet treatments used long-term to treat RA (termed immunosuppressants or synthetic disease modifying anti-rheumatic drugs [DMARDs]) are methotrexate, leflunomide, hydroxychloroquine and sulfasalazine. These are often combined for greater effect;
Injection therapies are newer, more potent and some are relatively restricted in their use in The UK NHS. They are anti-TNF-alpha inhibitor biologic drugs (e.g. adalimumab, etanercept (e.g. benepali), golimumab, certolizumab, remicade, remsima etc), abatacept, rituximab, tocilizumab and JAK inhibitors (e.g. baracitinib);
There are standard advice sheets on each of the drugs used to treat RA licensed in The UK at: www.medicines.org.uk. The drug name can be searched on the homepage, then read the relevant PILs document listed there (the SmPC document is technical information written primarily for prescribers)

 

Links:
The web pages of the UK charity ‘Versus Arthritis’. Lots of excellent information on all aspects of RA: https://www.versusarthritis.org/about-arthritis/


Patient advocacy organisation in The UK. Resources and support for all people with RA. www.nras.org.uk

 
 

Psoriatic Arthritis

Psoriatic arthritis (PsA) is a diverse, sometimes subtle and frequently overlooked type of arthritis. Psoriasis occurs in up to 3% of the population many of whom do have either musculoskeletal problems linked to psoriasis or the associated arthritis. However, many people with PsA don't have psoriasis because psoriasis is just one manifestation of a single condition that can cause bone, joint, tendon, nail, skin and gut symptoms. It gets more complicated though! Not everyone has all these components when they get the condition and sometimes any number of these features can come and go over a period of years. For instance, someone can have psoriasis in their 20s, then it resolves not to occur again but they develop PsA in their 40s without developing psoriasis again.

 

And (even more confusing) some people with PsA don't have arthritis! 'Arthritis' means joint disease/inflammation. However, the painful and stiff symptoms in PsA are often due to problems - primarily inflammation-based lesions - occurring in a bone, tendon or an enthesis, not a joint. An enthesis is the part of a tendon or ligament which attaches to a bone. The Achilles' tendon at the back of your heel, fans out and attaches at a broad flat enthesis - and 'yes' Achilles' tendonitis (/enthesitis) can be part of PsA. Other entheses typically affected in PsA include at the base of the heel (plantar fascia), elbows (often misdiagnosed as 'tennis elbow'), around the front of the knees or side of the hips (greater trochanter) and in the back and neck.


Enthesitis-predominant PsA is also often misdiagnosed as 'Fibromyalgia' and often, where enthesitis only affects one place at a time, it is often diagnosed as something else and the opportunity to diagnose the parent condition PsA is missed.


The following treatments can help PsA: steroid injections, non-steroidal anti-inflammatory painkillers (NSAIDs), methotrexate, leflunomide, ciclosporin, TNF inhibitors (e.g. adalimumab), ustekinumab, apremilast, secukinumab (type the name of the drug in the search box at: www.medicines.org.uk and read the relevant PILs document)


Links:
Information on the condition and link to its treatments: 
www.versusarthritis.org/about-arthritis/

A principle source of advice, support and information on PsA:
www.papaa.org

 
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Spondyloarthritis

Spondyloarthritis (SpA) is a chronic autoinflammatory condition that affects spine structures, entheses and joints. SpA typically affects just the spine and posterior pelvis (sacroiliac joints) in many people - termed 'axial' (as opposed to ‘peripheral’) SpA. 

SpA causes inflammatory back pain, often at a young age (it can occur in children and adolescents) but it starts to cause symptoms typically in the 20s and 30s. Inflammatory back pain is notable for its effect - causing stiffness and pain often with immobility rather than movement. So people with SpA can get night-time back pain and stiffness which can be bad first thing in the morning then ease up as they move around.


The advanced form of SpA is termed Ankylosing Spondylitis (AS). AS occurs in about 0.5% of the population (1 in 200 people) and often runs in families. AS is very closely associated with the having the gene HLA B27 (which occurs in about 8-9% of the general UK, European or USA population). It's easy to test for this gene with a blood test.


If you are getting back pain with stiffness at night, first thing in the morning or after sitting still for long time (e.g. after long car journey) then you may have inflammatory back pain and you should see a rheumatologist. SpA is diagnosed through a rheumatologist's assessment, lab tests (e.g. checking inflammatory markers and HLA B27) and a scan of the back/pelvis (MRI).

An important feature of SpA (and indeed psoriatic arthritis) is that musculoskeletal symptoms/features can come and go over many years - particularly as both these conditions can cause pain and stiffness owing to inflammation at entheses (the insertion point of ligaments and tendons at bone edges). Any diagnostician/rheumatologist will need to be aware of the condition potentially appearing and disappaearing (mostly mildly) over a long duration of time - possibly back to childhood. Unfortunately ‘enthesitis’ is poorly understood by the vast majority of people (including doctors) and frequently the condition is missed and not diagnosed for many years (and other ‘wrong’ diagnoses given by many otheres!)

 

Links:


Patient advocacy charity in The UK formed pre-2009 before the modified ASAS criteria for SpA were published. Historically then geared more to people with AS compared with axial SpA: The National Ankylosing Spondylitis Society (NASS) 

https://nass.co.uk/

 
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Osteoarthritis

Osteoarthritis (OA) is caused by the breakdown of articular cartilage tissue in joints. OA tends to occur more often in older age, either following damage to the cartilage (e.g. previous injuries or mechanical overload – such as long-term obesity) or as a general condition – see below. There is a lot we don't know about the factors that lead to why OA occurs very readily in some people and not others. Probably the genetic background matters - with some people have a better design of joint cartilage then others. OA leads to a structural degeneration of joints, and is best diagnosed on X-Ray as long as other arthritis types (e.g. psoriatic arthritis) have been ruled out.

Severe OA in a large joint such as a knee or hip, where pain prevents sleep and walking, is best treated by arthroplasty - a joint replacement operation undertaken by an Orthopaedic Surgeon.

One form of OA occurs 'out of the blue' in the small joints of the hands - often in middle age and often at the time of the menopause in women. This form of OA is not a consequence of mechanical injury or overuse but can start instead with a 'storm' of inflammatory symptoms in the affected joints (stiffness and pain). It can appear similar to rheumatoid arthritis (RA) and care is needed not to misdiagnose it as such.

Some doctors think, in some people, generalised small joint inflammatory OA can start together with other symptoms such as tiredness, dry mouth, dry eyes (SOX syndrome [Sialadenitis, Osteoarthritis, Xerostomia]) or can accompany the autoimmune connective tissue disease Sjögren's Syndrome.

Generalised small joint OA can often be associated with calcium crystal induced inflammation on joints - often in more elderly people. The commonest crystal which accumulates in and around joints which causes this is calcium pyrophosphate (CPP). The episodic inflammatory symptoms of CPP disease (cPPD) in joints can ‘punctuate’ the course of generalised small joint OA in elderly people notably.

 

Links:

Patient information at The UK medical charity. Search here under 'Arthritis Information’
https://www.versusarthritis.org/about-arthritis/conditions/osteoarthritis/

For people with generalised osteoarthritis associated with CPPD see the following article:

 
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Gout

Gout is caused by inflammation against monosodium urate (MSU) crystals. MSU crystals can accumulate in the body (often in and around joints) when certain physicochemical conditions lead to uric acid becoming poorly soluble and precipitating in the soft tissues. Uric acid is a breakdown product of cells in the body.

A high level of uric acid in the blood is termed 'hyperuricemia'. The greater the hyperuricemia the greater the risk of gout. Hyperuricemia is more likely when:

  • there is an excess of foods or drinks containing purines in diet (e.g. alcohol, shellfish, liver);

  • the body load of purines/cells/uric acid is high (in obesity!);

  • with certain common medications (e.g. low dose aspirin and some diuretics);

  • uric acid cannot be excreted from the body (e.g. poor kidney function).

Also, the metabolic efficiency with which purines and uric acid are metabolised and excreted by the body is partly influenced by our genes, so the tendency to get gout can be partly inherited. 


Gout typically causes explosive pain and swelling and often reddening of skin (an 'attack'!). Pain is often intense. Typical sites of gout attack include great toes, ankles, the whole foot, knee and sometimes hands and wrist structures. It's important to discriminate carefully between gout of the great toe and dactylitis caused by Psoriatic Arthritis (toe looks 'sausage-like' with the latter and is usually not reddened).

Gout is typically different in men and women. In women it is rare before the menopause and when it occurs, gout behaves less like ‘attacks’ and more like general inflammatory arthritis. In men gout can occur in the 30s and 40s but its more common in 50s and older.


Acute gout is treated with rest, elevation of the affected part, ice and strong prescription-strength non-steroidal anti-inflammatory (NSAID) painkillers and sometimes colchicine. Sometimes a short course of steroid tablets are used. Where there is recurrent acute gout or chronic gout arthritis the treatment strategy must involve: weight loss, dietary changes where relevant and the use of drugs to lower the uric acid (e.g. allopurinol or febuxostat). Doctors treating gout should try to get the uric acid level down to <300µmol/l with these treatments (a 'treat-to-target' approach) because with the uric acid below this blood concentration ('the target'), then gout attacks will be rare.


Links:
http://www.ukgoutsociety.org


 2017 guidance on gout management is at BSR:
https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kex156


The Electronic Medicines Compendium. Information on allopurinol and febuxostat. Use the drug names in the search box then read the relevant PILs document for the drug, at:
www.medicines.org.uk

 

Calcium-containing crystal arthritis

As we age or with certain metabolic conditions calcium-containing deposits (crystals) can accumulate in our bodies. Often these cause no problems. Indeed, if we did an X-Ray on many people in their 80s we would see calcium in the soft-tissues. Some people are more prone to get calcium-containing deposits in their tissues. The different crystals that form from these deposits include basic calcium-phosphate crystals (BCPs), hydroxyapatite (HA) and calcium pyrophosphate (CPP). Under certain situations - often following another illness - these crystals can be 'unmasked' to the body's immune system which then mounts an 'attack' giving rise to either acute, or sometimes chronic inflammation and symptoms pain and swelling in or around joints, neck and spine. 

The most easily identified calcium-containing crystals are CPP crystals (CPP disease). These crystals can cause acute inflammation or pain/stiffness or chronic arthritis typically at the following sites: joints, a whole hand or foot, the spine and the top of the neck (odontoid bone). CPP disease is highly varied in its effects and because it can affect many different musculoskeletal structures in the body, not just joints, its sometimes referred to as calcium pyrophosphate deposition disease (CPPD).

One form of CPPD is termed 'pseudogout'. This is because it is very similar to acute gout in causing an acute attack of pain and swelling in a joint. Joints or a foot or hand can suddenly swell, be stiff and painful - just like gout. The diagnosis of pseudogout is made on polarised light microscopy examination of fluid taken from an inflamed joint (and this test discriminates from gout).


CPPD can often mimic (or better considered - is one cause of) polymyalgia rheumatica. Some underlying metabolic conditions increase the risk of having CPPD include: Kidney Diseases, Hyperparathyroidism, Hemochromatosis, hypomagnesemia, hypophosphatasia, but most people with CPPD don’t have these other conditions.

Treatment depends on where the inflammation is and how bad it is. Usually anti-inflammatory painkillers (NSAIDs) and a time-limited course of steroid tablets are used for the acute form of the disease - pseudogout. Chronic CPPD can respond to methotrexate and sometimes hydroxychloroquine in certain cases.
 

Links

Patient information on pseudogout at ‘Versus Arthritis’ UK medical charity website:
https://www.versusarthritis.org/about-arthritis/

 
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Osteoporosis

 

Osteoporosis is a condition that causes fragility of the skeleton leading to fractures with minimal trauma (breaking a bone). To tell if someone has osteoporosis and what their fracture risk is, then the following are generally needed: a specialist consultation, a Bone Density Scan called a DXA (or 'DEXA') scan, some blood tests, and in an older person, a falls risk assessment. There are lots of drug therapies that have been shown to reduce fracture risk and treat osteoporosis successfully. Generally, tablet treatments have shown to reduce the risk of fracture by about 30-40% (e.g. alendronic acid), and the injection treatments reduce the chance of fracture by about 60-70% (e.g. zoledronate). If you are over 50 years old or (for women) if you have gone through your menopause and you have had a broken bone, then its advisable you have an assessment for osteoporosis.
 

Osteoporosis and fracture prevention – specific assessments

There is a lot of published guidance on how to assess people for osteoporosis and fracture risk, for example from the National Osteoporosis Society (link: www.nos.org.uk/page.aspx?pid=234) and NICE in The UK (link: www.nice.org.uk/cg146). A quantitative fracture risk assessment can be made using the online FRAX tool (www.shef.ac.uk/FRAX) and also see these PDFs:

Links and Resources:

PDF - Paper on Fracture Liaison Services (UK)

PDF - Glucocorticoid (steroid) Induced Osteoporosis

The chance of breaking a bone for an elderly person is importantly dependent, not only on the fragility of the skeleton, but on the risk of falling. There are a number of important things to look for and address with regard to 'falls risk'. See: https://www.nice.org.uk/guidance/cg161

and

PDF - Falls: the assessment and prevention of falls in older people

Osteoporosis treatments: The commonest treatments used to treat or prevent osteoporosis are called Bisphosphonates (Alendronic acid, Risedronate, Ibandronic acid, Zolderonic acid). Their effect is optimised if the person taking them does not have vitamin-D deficiency or calcium lack.

PDF - Patient information sheet on Zoledronate (Aclasta)

PDF - Patient information sheet on Denosumab (Prolia)

PDF - Patient information sheet on Forsteo (PTH injections)

A DXA scan is a quick, safe and simple scan that estimated the density of your bones. It is a completely open scanner without requiring undressing! See button below:

 

Vitamin D Disorders

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Vitamin D is not a vitamin, it's a hormone! Vitamin-D is necessary for a number of bodily functions. It's made from the breakdown of skin cells, catalysed by UV light (the sun!) and undergoes a number of metabolic 'activation' steps in the body before it can exert its effect on cells. 

PDF - Vitamin D metabolism

When vitamin D is very deficient, people can get muscle pain and weakness and bone pains - a condition called osteomalacia (or rickets in children) but mild vitamin D deficiency is very common in The UK (little sun!) and usually causes no symptoms. There is currently great interest in medical science as to the importance of vitamin D in its role (including a preventive role) in inflammation, cancer and some other important areas of basic cellular function in mammalian biology.

  • Daily requirements for vitamin-D assuming person is replete initially is about 400iu;

  • For vitamin D deficiency usually a course of high strength Vitamin-D (cholcalciferol) is required and is obtained by prescription; 

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Primary Hyperparathyroidism (PHPT)

PHPT is a common disorder that typically affects adults over 50 years old. It is present in about 1 in 50 to 1 in 250 of the population depending on age (more common with increased age).
PHPT is a condition that can cause subtle but ongoing symptoms such as tiredness, achiness and changes in memory and mood. PHPT is a disorder of calcium and phosphate metabolism.

 

PDF - Calcium and PTH disorders

PHPT invariably causes high levels of calcium in blood and urine but it can be cured with an operation (parathyroidectomy). Rheumatologists sometimes uncover a diagnosis of PHPT in people who have calcification in their joints (chondrocalcinosis - which can be associated with CPP disease). PHPT is one of the many conditions that can cause osteoporosis as well.

 
 
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Fibromyalgia

 

Fibromyalgia is a term used to describe widespread pain which is a function of amplification of central (brain) pain processing. However, most thoughtful Rheumatologists will follow three important principles when they meet someone who has been previously diagnosed with 'fibromyalgia'. So sequentially:

  1. Does the person really have fibromyalgia? That is to say, is there a previously-undiagnosed identifiable condition causing the pains mimicking fibromyalgia? 

  2. Is there an underlying condition causing pain but is there fibromyalgia also (i.e. central brain mediated amplification of pains from the underlying condition)? 

  3. If there are fibromyalgia pains then what are the main influences (‘drivers’) of it (i.e. of pain amplification). Two of the commonest ‘drivers’ of fibromyalgia pain are poor sleep (non-restorative) and the intrusion of unresolved traumatic psychological issues.


Some conditions that can be mistaken for fibromyalgia by the unwary include: psoriasis-related musculoskeletal disease (enthesitis and bone lesions cause the pain), inflammatory bowel disease related musculoskeletal disease), sarcoidosis, SLE ('lupus') and other autoimmune connective tissue diseases, osteomalacia and primary hyperparathyroidism.
 
For anyone with widespread persistent pains, often a delay in the diagnosis of any of the above causes (which are all chronic diseases) and being in a position of having been given multiple different diagnoses, leads understandably to confusion, anxiety and frustration - all potential triggers for pain amplification, poor sleep and fatigue (i.e. fibromyalgia!). 

Links
Some patient information about fibromyalgia:
www.arthritisresearchuk.org/arthritis-information/conditions/fibromyalgia.aspx

 
 
 
 

Polymyalgia Rheumatica (PMR)

Polymyalgia Rheumatica (PMR) is a condition associated with adults of older age, and essentially is thought not to occur in anyone <55 years old. The features of PMR are:
•    achy pain of neck and shoulder muscles on waking in the morning which ease with movement (sometimes also muscles of the 'pelvic girdle' area);
•    the absence of any other identifiable inflammatory joint or other musculoskeletal condition;
•    evidence of inflammation in the blood (high ESR and CRP values);
•    the symptoms respond promptly to steroid tablets (15-20mg prednisolone daily).


Whether PMR is a single autoinflammatory condition or a symptom complex common to a number of different underlying disease processes, is unknown. For example, an acute episode of CPP disease of neck, spine and shoulders can give all of the features (bulleted) above; as can an episode of enthesitis-predominant psoriatic arthritis or spondyloarthritis. In a pure sense then, if PMR is always one of these three conditions then PMR does not exist!


General practitioners usually do not have the knowledge, skills and expertise to reliably exclude CPP disease, axial spondyloarthritis and enthesitis-predominant psoriatic arthritis. Ideally to unravel 'PMR' a person needs referral to a Rheumatologist who has the skills to diagnose these conditions (appropriate knowledge about the diseases, appropriate examination skills and access to all the relevant imaging investigations), though many general practitioners/family doctors take a pragmatic view of the condition and treat with steroids without too much investigation.


Giant cell arteritis (GCA) is a condition where the larger arteries become inflamed - this is termed a 'vasculitis' condition. It is very important to identify GCA and treat it promptly because the inflamed arteries can narrow and get blocked preventing blood getting to vital places in the body - like the eye and brain. The worst possible situation can be when GCA is not identified or treated and the affected person goes blind or has a stroke. GCA is associated with 'PMR'. A minority of people with 'PMR' get GCA but a greater proportion who get GCA have 'PMR' symptoms also.


The diagnosis of GCA is made by rheumatologists and ophthalmologists together. Tests include: detailed eye examination, lab tests, an ultrasound of the temporal artery (side of scalp), biopsy of the temporal artery and sometimes a positron emission tomography scan (PET). All UK NHS hospitals have a service for GCA (telephone advice / A&E visit / prompt triage for tests- assessments / treatment). The treatment is (quite high) dose steroids (prednisolone 40-60mg daily) - necessarily so because dose the consequences can be very serious if GCA is under-treated.


Links
Information for patients from American College of Rheumatology:
www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Polymyalgia-Rheumatica
Information on GCA:
https://www.versusarthritis.org/about-arthritis/conditions/giant-cell-arthritis

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Autoimmune Connective Tissue Diseases (AICTDs)

Apart from the brain, the body's immune system is probably the least understood ' body organ system' by people! The 'immune system' is difficult to conceptualise and learn about given it is a complicated 'fluid' organ system existing in the blood, lymphatics, bone marrow, spleen, thymus, gut lining and elsewhere and consists of interacting cells (e.g. lymphocytes) and molecules (e.g. cytokines, antibodies). Normally the main function of the immune system is to protect the body from micro-organisms like bacteria and viruses. The symptoms everyone gets as part of a cold or flu is a consequence of a successfully working immune system - it switches on to enable killing of the invading micro-organism when it needs to and switches off when the battle is won!


Autoimmune diseases occur when the immune system either switches on, or doesn't switch off, abnormally - simply put it 'thinks' there is something like a micro-organism invading the body to fight (but there isn't). So in a way the autoimmune system is 'failing' in certain respects. So as there can be: kidney disease / kidney failure, heart disease / heart failure etc., there can also be (auto)immune disease / (auto)immune failure.


Autoimmune disease can affect a single organ in the body (organ specific, e.g. thyroid or type 1 diabetes [pancreas]) or can be 'non-organ specific'. Autoimmune connective tissue diseases (AICTDs) are non-organ specific. People affected by AICTDs can get symptoms and problems from many different tissues in the body such as:
•    joints and tendons,
•    skin (often UV light/sun sensitive rashes),
•    mucosal linings in mouth, lungs and eyes (typically dryness symptoms),
•    muscles,
•    internal organs can become inflamed (lung, kidney),
•    blood vessels (livedoid skin, vasculitis, Raynaud's Syndrome)
 

Rheumatologists have a unique role in diagnosing AICTDs because they know and can assess for the wide range of symptoms and features that can occur in the AICTDs.
The main AICTDs are: Systemic Lupus Erythematosus (SLE; 'lupus'), Primary Sjögren's Syndrome, Systemic Sclerosis (scleroderma), Polymyositis, Dermatomyositis and Antiphospholipid Syndrome


AICTDs are treated with immunosuppressant medications such as steroids (prednisolone or methylprednisolone) hydroxychloroquine, azathioprine, mycophenolate, methotrexate, rituximab, belimumab and cyclophosphamide. For information on any of these medicines please see the PILS document on the relevant drug at https://www.medicines.org.uk/emc/


Links
Patient run advisory and support organisation in The UK to support sufferers with Sjögrens syndrome: 
www.bssa.uk.net

Patient run advisory and support organisation for people with SLE ('lupus'):
www.lupusuk.org.uk

Information on the inflammatory muscle diseases (myositis):
https://www.versusarthritis.org/about-arthritis/conditions/polymyositis-and-dermatomyositis/

Patient run organisation giving advice and support to people diagnosed with either systemic sclerosis or Raynaud's disease: 
www.sruk.co.uk

 
 
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Hypermobility

 

Musculoskeletal hypermobility can be an asset (i.e. not a disease or condition) for example in facilitating dancing aptitude or athletic excellence and its development) but it can be associated with problems including pains, fatigue, cardiovascular autonomic dysfunction (POTS), bowel dysfunction and internal organ prolapse (e.g. uterine, bowel, bladder). 

However, the diagnosis of hypermobility needs to be made very carefully where the above features are present. Very often there are other explanations for symptoms and the hypermobility is coincidental - thus not to blame for the symptoms.

Unfortunately, some doctors, physios and other practitioners may have the ability and skills to know about hypermobility but do not know about the alternative problems that can cause similar symptoms to those caused by severe hypermobility. Seeing a Rheumatologist then is important as they know about a wide range of potential problems. Remember all ‘specialists’ should remember to be clear about what they know but also what they don’t know.

The Beighton scale (see on the right of this page) was devised initially to assess hypermobility,and validated in caucasian adults. It is still used as part of clinical assessment. However, its not appropriate to apply the scale in children, and it should be remembered that both age and ethnicity affect the scoring. It is quite a blunt clinical tool. 

In hypermobility subtype Ehlers Danlos Syndrome (h-EDS) and Hypermobility Spectrum Disorder (HSD) joint stabilizing exercises with particular reference to core stability, posture and proprioception are beneficial, to avoid overuse injuries. A global approach to joint stability and function, as opposed to just treating regional symptoms,is usually effective. Finding an experienced physiotherapist to whom an affected person with h-EDS or HSD can return to when needed is important!

Pregnancy is often a concern. Unlike in EDS, h-EDS and HSD are not associated with any major vascular hazard during pregnancy and labour. However, people with h-EDS and HSD should talk to their obstetrician early in their pregnancies about risks.

Links

The diagnosis of hypermobility-type Ehlers-Danlos (h-EDS) and hypermobility Spectrum Disorder (HSD) has been recently redefined. See: https://www.ehlers-danlos.com/2017-eds-international-classification/ 

Patient led organization: http://hypermobility.org/


Information on postural tachycardia syndrome for patients: 
http://www.potsuk.org/

 

Beighton hypermobility rating

Person has the ability to:

1. Extend the fifth finger 90° or more

  • Right 1

  • Left 1

2. Pull the thumb back/down onto the same-side forearm  

  • Right 1

  • Left 1

3. Hyperextend the elbow 10°

  • Right 1

  • Left 1

4. Hyperextend the knee 10°

  • Right 1

  • Left 1

5. Place hands flat on the floor without bending the knees

  • 1

Possible maximum score

  • 9

 
 

General Musculoskeletal Conditions

 

Musculoskeletal problems are very common. The vast majority of musculoskeletal problems do not need an operation so for almost all people, a visit to a musculoskeletal doctor, physiotherapist or Rheumatologist first, is wisest. Rheumatologists have the widest knowledge of musculoskeletal conditions compared with other specialists, so are useful people to see to obtain a diagnosis. Rheumatologists will have a broad view of the right tests to do (imaging and lab tests) to make a diagnosis then, because they work in multidisciplinary teams, automatically link in, as necessary, with others (physiotherapists, surgeons, podiatrists and other therapists) so that the right treatment for a person’s problem is undertaken quickly by the right person.

Below are lists of common (‘body-regional’) musculoskeletal conditions that a Rheumatologist, such as Dr Clunie, typically sees in adult patients: 

Neck: osteoarthritis, intervertebral disc disease, crowned dens syndrome (CPP disease causing pain right at the top of the neck), spondyloarthritis, nerve root entrapment (‘radiculopathy’);


Shoulder and upper arm: arthritis of acromioclavicular joint, frozen shoulder, rotator cuff tendonitis/bursitis, enthesitis associated with spondyloarthritis, pseudogout of shoulder joint, referred pain from the neck, polymyalgia rheumatic;


Anterior chest wall: psoriatic arthritis (enthesitis of intercostal muscles), SAPHO Syndrome, costochondritis;


Back: see under ‘Back pain’ elsewhere on this website;


Elbow: arthritis; tennis elbow (?enthesitis), golfer’s elbow (?enthesitis), olecranon bursitis (?gout);


Wrist and forearm: arthritis (rheumatoid arthritis, psoriatic arthritis, CPP disease), tendonitis (e.g. DeQuervain’s tenosynovitis), ‘RSI’ (lay term for forearm pain, is not a disease and is usually due to one of a number of different conditions!), radicular pain (referred pain from trapped/irritated nerve in the neck);

Hand: finger/thumb joint arthritis, tendonitis, dactylitis, carpal tunnel syndrome (treated with splinting and cortisone injection often first before referral for an operation), ulnar nerve symptoms from nerve irritation at elbow or wrist;


Hip and pelvis: trochanteric pain syndrome (side of the hip, often due to gluteus medius tendon insertional enthesitis), symphysis pubis pain (central groin pains), arthritis of the hip joint (any type), sacroiliitis (posterior pelvis/buttock pains), ischial enthesitis, bone conditions (stress fracture, Paget’s disease);


Knee: arthritis (all types!), patella tendon problems (?enthesitis, fat-pad syndrome, patellofemoral joint osteoarthritis), enthesitis (many sites around the knee - common in spondyloarthritis and psoriatic arthritis), gout and pseudogout (often causes fluid to accumulate – rheumatologists can take fluid out, send it for analysis and inject cortisone if needed);


Ankle and foot: arthritis (all types!), tendonitis, enthesitis, ligament and plantar fascia problems (e.g. plantar fasciitis, which is commonly associated with spondyloarthritis – see information elsewhere on this website), tarsal tunnel syndrome, referred pain from a trapped nerve in the back (sciatica), interdigital neuroma pains (between the toes).