Musculoskeletal medicine - Special interest

If left untreated psoriatic arthritis (PsA) can result in progressive, irreversible joint damage causing chronic pain and disability. It is a chronic, autoimmune inflammatory condition that can affect up to 30% of patients with psoriasis. PsA is a multisystem disease affecting other organs such as the eyes, gut and tendons. It is associated with multiple comorbidities such as diabetes mellitus, cardiovascular disease and metabolic syndrome. If PsA is suspected in primary care, routine blood tests should be requested to check for anaemia of chronic disease and raised inflammatory markers. Plain radiographs of hands and feet should be requested prior to referral, although classical changes do not occur early in the disease. If GPs suspect PsA, prompt referral is paramount. Patients should be referred if they have persistent joint symptoms, a positive screening questionnaire (PEST), joint swelling, dactylitis or enthesitis, and/or inflammatory back pain.

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of = 3 months between onset of symptoms and seeking medical advice.

The most common presentation of gout is a flare, characterised by acute onset of one, or occasionally more, hot, red, swollen joints which are very painful and tender. Less common is insidious onset of chronic usage related joint pain, especially in joints already affected by osteoarthritis. Subcutaneous tophi can also be the presentation, particulary in older people. In typical cases, clinical assessment alone is sufficient for diagnosis. Gout is also associated with comorbidities such as nephrolithiasis, chronic kidney disease, metabolic syndrome and heart disease, and increased mortality.

Chronic low back pain is a common problem. Lifetime adult prevalence rates vary from 50 to 80%, and around a quarter of adults say they have experienced back pain during the past month. One in 40 report disabling back or neck pain. Each year around 7% of patients consult their GP with back pain. In 65-70% of primary care patients with low back pain there is no known pathoanatomical cause. Their pain is described as nonspecific and is postulated to arise from muscle strain or ligamentous injury. A further 15-20% of patients have mechanical low back pain with an identifiable cause such as degenerative disc or joint disease. 

Psoriatic arthritis (PsA) is a chronic, autoimmune inflammatory condition that can affect up to 30% of patients with psoriasis. It is part of the seronegative spondyloarthropathy group of rheumatic diseases which also includes reactive arthritis and ankylosing spondylitis. It can be a multisystem disease affecting the eyes, the gut and the tendons and is associated with comorbidities such as ischaemic heart disease and metabolic syndrome. Early diagnosis is key as structural joint damage can occur within two years of disease onset.