Joint paints in primary care

With more than one in ten consultations in general practice relating to joint pain, knowing when to reassure, and how to support and manage affected patients are essential skills

Middle age is that time of life when mortality becomes no longer deniable. In youth, the normal routine is for an ache or pain to arise, probably following an injury or a recognisable cause, hang around for a few days or a week, and then correct itself so that you feel completely back to normal. When middle age hits, it becomes apparent that some aches and pains come on without an obvious reason and are probably not going to go away – you are stuck with them for years or the rest of your life, so that ‘recovery’ means never being quite the same again.

Arthritis Research UK estimates that 12% of all consultations in general practice are because of joint pain,¹ and that each year a fifth of the population consult a GP because of joint pain.² Consultations for joint pain are second in frequency only to those for respiratory disorders.³ Looking at long term disability in working age people, a third is attributable to musculoskeletal disorders, and a further nearly 20% due to a combination of musculoskeletal and mental illness (musculoskeletal and mental disorders not surprisingly often co-exist).²

This does not come cheap as far as society is concerned. The NHS cost of musculoskeletal disorders is £4.7 billion a year (including 34m prescriptions at a cost of £224m), and the wider social cost (lost work, informal care etc.) was estimated in 2007 to be up to £130 billion a year.²

Many older people regard joint aches and pains as an inevitable consequence of too many birthdays, and they are probably right. Despite being in pain, they would regard themselves as fit and healthy.⁴ This stoicism about their symptoms would no doubt be applauded by many who work in primary care, and especially by their political masters: wouldn’t the NHS run better if everyone just looked after themselves and stopped moaning? However, this may mean that sufferers are excluding themselves from treatments that might ease their symptoms and improve their independence: osteoarthritis is a common reason for elderly falls, the consequences of which do not need repeating.

The pain of osteoarthritis is often regarded by sufferers as due to ‘wear and tear’, which implies that the best management is to avoid further damage by reducing physical activity – the direct opposite of the real best management option.⁴

PERSISTENT JOINT PAIN

Persistent joint pain occurs more commonly with age, as do most of the chronic diseases that GPNs see in their clinics: the population which a GPN sees day by day is also the population which is likely to have joint pain. In addition the medications used to treat joint pain may interfere with other conditions or their treatments. For example, non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in anyone whose kidneys are not up to much (such as is often the case with diabetes), and used with caution in the elderly,⁵ i.e. that group of people most likely to be prescribed them. NSAIDs are to be avoided in anyone taking warfarin.

GPNs involved in patient triage will encounter situations where a patient has developed a new joint pain, or where an old pain has become unaccountably worse. Nearly all of the disease processes that cause chronic joint pain can be subject to remissions and relapses, including osteoarthritis. On occasion a GPN will get a patient on triage who has had an injury to a joint which was previously working normally: on these occasions a recommendation to attend the local A&E department is always worth considering. Those going to A&E with sports injuries may well get little sympathy (personal observation), but at least they are in the right place to get any imaging and specialist input that might be required.

Given their current demographic, GPNs may well have joint pains of their own, and so can empathise with their patients. Low back pain is particularly common among nurses both in the UK and internationally.⁶

THE CAUSES OF JOINT PAIN

By far the most common reason for persisting joint pain in patients seen in primary care is osteoarthritis.¹ If you diagnose everyone over 50 who has joint pain with osteoarthritis, you will be right most of the time. However there are about 100 different reasons why people get joint pain.² (See box). Another sizeable group of patients have an inflammatory joint disease such as rheumatoid arthritis or the arthritis associated with psoriasis: these conditions often affect a younger age group, can come on rapidly (but not suddenly), and often several joints are affected at once, so that (for example) psoriatic arthropathy typically (but not exclusively) affects the small joints of the wrists, hands, feet and ankles.⁷ As well as causing joint pain, inflammation often also causes obvious joint swelling.

To arrive at a diagnosis useful questions to ask include:

• Has there been an injury? Find out what has happened in as much detail as possible.
• Where is the pain? Which joint is affected? – This limits the diagnostic options a bit, for example Perthe’s disease only affects hips in children.
• What is the pain like? Pain you can put your finger on can usually be blamed on something in the joint itself. More diffuse pain is a feature of referred pain – pain caused by a trapped nerve elsewhere.
• When does the pain come on? Does anything make the pain worse? Pain that comes on with movement after resting is a feature of osteoarthritis: this is unfortunately another incentive not to move.
• Are there other symptoms? Stiffness is a feature of many causes of joint pain, particularly morning stiffness. A fever may suggest a joint infection – this is an orthopaedic emergency (if in any doubt, take the patient’s temperature, which is also useful for medico-legal reasons). Joint swelling may be present.
• What are the effects of the joint pain? These may be physical, psychological or social. What is your patient prevented from doing? (Consider work, hobbies, social events etc.) What is your patient’s mood? Being in pain makes people crabby, and mood problems can make joint pains feel worse.²
• Have you tried anything yet? This will indicate what is likely to work, and what isn’t.

BACK PAIN

Back pain is very common. Each year about a third of the UK adult population have back pain and 20% of all musculoskeletal consultations are due to back pain (with a majority related to low back pain).⁸ Low back pain is the leading cause of years-with-disability in the UK² (it never killed anyone, and since it is often contracted at a young age can cause many years of problems): 40% of those who need time off work because of low back pain will have further episodes.⁹ The cumulative population disability caused by low back pain is increasing with the passing years.

Back pain is a good example of many of the features of joint pain in general, from the point of view of clinicians as well as patients. Looking at the issues raised in some detail will shed light on joint pain at other sites.

1. Red flags

Occasionally (rarely) back pain is an indication of a serious spinal disorder, and this will almost certainly be in the mind of your patient. This is mentioned first since an assessment of Red Flags (symptoms and signs which may suggest serious illness) must be a part of any consultation for joint pain (or indeed any pain).

• Cauda equina syndrome occurs when the spinal cord is being compressed. It causes leg weakness, urine retention and faecal incontinence (so always ask about these). Cauda equina syndrome is a neurosurgical emergency: sufferers need an operation within 48 hours, and preferably within 8 hours of symptom onset.¹⁰
• Spinal fracture occurs suddenly following significant trauma, or after lesser trauma in patients with weak bones (for example, older women with osteoporosis). Pain is acute, and is eased by lying down.
• Bone cancer must be considered in anyone over 50. There is a gradual onset of pain that progresses remorselessly over weeks and months and is not relieved by posture (pain at night is a troublesome and worrying symptom). There may have been cancer in the past, or symptoms of cancer (weight loss, cough etc.). Primary bone cancer is rare, but secondary cancer is much more common. Cancers that metastasise to bone include lung, prostate, thyroid, kidney and breast.¹¹

2. What type of back pain?

Pain that is obviously localised to the back usually arises from structures in the back itself. Low back pain is commonly also felt in the upper leg (or sometimes both legs). Pains may run down as far as the knee, but a pain radiating as far as the foot may suggest nerve entrapment as is found in sciatica:12 indeed the leg pain may be more severe and troublesome than the back pain. Even though sciatica and a trapped nerve sounds like a more serious problem than just common-or-garden back ache, management is generally the same.¹³

3. What about an X-ray?

An X-ray is a diagnostic, not a therapeutic procedure. Unfortunately for back pain it has acquired a reputation as a panacea. The facts are stark:

• Ninety five per cent of people over 55 show evidence of degenerative changes in the spine on X-ray.¹⁴ There is little correlation between X-ray signs of degeneration and the degree of symptoms.¹⁵
• A lumbar spine X-ray uses 150 times as much energy as a chest X-ray.¹⁶ X-rays of the back are responsible for 15% of all medical X-ray exposure, and this can be extrapolated to infer that they cause 19 deaths per year in the UK.¹⁴
• An MRI scan is no better than an X-ray at revealing useful information.¹⁷

Current guidelines suggest that X-rays for low back pain are avoided unless there is suspicion of an underlying specific pathology such as osteoporotic collapse of a vertebra.¹⁸ In reality, most X-rays in general practice are arranged to further the progress of the consultation rather than to find the diagnosis.

4. Management

• Many patients will benefit from a discussion about what causes back pain and how long it lasts. This is also a good opportunity to find out about fears and concerns about back pain, and explore what sorts of treatment are likely to be effective. Getting fitter helps: the preference used to be for specific back-strengthening exercises, but now the type of exercise appears not to be important.¹⁹
• NSAIDs are considered the first line for medication. To this can be added an opioid such as codeine with or without paracetamol (paracetomol alone is not recommended).²⁰
• If poor progress is being made, a physical therapy is considered (for example, manipulation, massage, mobilisation). The NICE/CKS guidance recommends a physiotherapist, but these treatments are also available from osteopaths and chiropractors. These practitioners are now regulated by their own professional bodies (the General Osteopathic Council and the General Chiropractic Council, respectively) and you have to be registered before you can call yourself an osteopath or chiropractor. A Cochrane review found that an osteopath, a chiropractor and a physiotherapist can all provide equally effective physical back therapy, and the effect is about the same as taking tablets.²¹ Only physiotherapy is widely available through the NHS.
• When all else has failed, referral to an orthopaedic surgeon may be a good idea.

SELECTED OTHER JOINTS

Knee

Between 15 and 20 patients per 1000 will be seen each year in general practice because of knee pain.²² Of these, half of the over 55s will have X-ray evidence of osteoarthritis.²³ The knee is a complicated joint: compared to other joints there are the added complications of the patella, the meniscae (cartilages) and the cruciate ligaments within the joint itself. A knee injury can damage any of these structures.

As well as bending, the human knee also has a locking mechanism where the tibia and femur twist on each other (which is useful as it means you don’t have to use muscle power to keep the integrity of a straight leg – damage to this mechanism can result in the knee ‘giving way’). With all these complications it is surprising that knees are as resilient as they are.

Though the complexity of structure means that knees are prone to all sorts of injuries not seen in other joints (those of you not of a nervous disposition may want to look up the ‘Unhappy Triad of O’Donoghue’²⁴), nevertheless osteoarthritis is still the major cause of knee pain. Indeed past injury makes osteoarthritis more likely in later years (often many years later), and is worth asking about. Knees can be replaced with a prosthetic joint. The criteria for this will vary from place to place, but when there is pain at rest plus X-ray evidence of osteoarthritis, and when other strategies such as medication, physiotherapy and steroid injections have not worked, then replacing the knee is high on the agenda.²⁵

Knee pain may arise because of referred pain. When making an assessment it is sensible to also ask about the joint above and the joint below (hip and ankle). When pain is referred it can feel more vague, or else be accompanied by twinges like a small electric shock, or pins and needles.

Whatever is causing the knee pain it can usually be helped by strengthening the quadriceps muscles – this is the group of muscles on the front of the thigh that help to stabilise the knee joint, and which weaken quite quickly if the knee cannot be used properly. The exercises can be recommended in addition to medication, or while waiting for other treatment. There are various ways of strengthening quadriceps – see the reference for further information.²⁶

Hip

The hip is a ball and socket joint where the socket covers a lot of the ball. This limits mobility, and also means that bone causes of hip pain are more likely. Pain coming from the joint capsule and ligaments is less likely than pain due to osteoarthritis. In any given month, 10% of the UK population have pain in a hip,27 and a third of people aged over 40 already have X-ray evidence of osteoarthritis.²⁸

Heavy lifting at home or work, frequent climbing of stairs, past injury, and gender (commoner in women) make osteoarthritis more likely. And so does obesity, which the epidemiological data would suggest is going to be an increasing problem for the future.²⁹

Rest pain with X-ray evidence of osteoarthritis, and failure of other treatments are an indication for surgical hip replacement.³⁰ Some people are born with dysplasia of the femoral head, or have Perthe’s Disease in infancy – this really messes up the weight-bearing ability of a hip joint, and makes hip replacement necessary in the third or fourth decades of life.

Shoulder

The shoulder is also a ball and socket joint, but this time there is much less bone (look at a shoulder X-ray and you will see how pathetic the socket is – more like a tiny saucer). This lack of bone increases the mobility of the joint – consider what life would be like if your hip was as mobile as your shoulder – but also increases reliance on soft tissue to keep things in position.

Shoulders can be subject to osteoarthritis, but pain more commonly arises from the tendons, ligaments and joint capsule. In addition, neck problems can cause referred pain to the shoulder. And also remember that angina can cause shoulder pain.

Adhesive capsulitis (frozen shoulder) occurs most commonly after 40 years of age (peak age is 56), slightly often in women and more commonly on the non-dominant side. In less than a fifth of cases the other shoulder is affected within 5 years. It does not usually follow injury. Adhesive capsulitis typically goes through three phases:

1. The painful freezing phase lasts 10 to 36 weeks with a nagging constant shoulder pain worse at night. Sufferers have trouble lying on the affected side. Anti-inflammatory medication has little effect.

2. The adhesive phase lasts 4 to 12 months. The pain is a lot better, except at extremes of movement, but there is significant reduction of shoulder movements. If external rotation of the shoulder is very restricted or even non-existent, then there is a good chance that the diagnosis is adhesive capsulitis.

3. The resolution phase lasts from 12 to 42 months (so that the complete natural history of the condition can take well over 3 years) with spontaneous improvement of pain and mobility. Recurrence is uncommon.³¹

Injecting steroid into a shoulder probably carries fewer side effects than injecting a knee, because a shoulder is not a weight-bearing joint. For frozen shoulder, injections at the painful stage before the ‘frozen’ bit sets in will help.³² However, the value of steroid injections for other shoulder diagnoses is limited: it may secure short-term relief but rarely confers lasting benefit.³³ On the other hand, a quick fix is often what your patient wants, so a clinician can increase their popularity enormously by offering this service.

CONCLUSION

The demographics of joint pain mean that GPNs will often come into contact with those who suffer from it. There are many treatments available, but most are disappointing if the aim is to completely abolish the pain. Because of this, the patient with joint pain will frequently be in a ‘chronic pain’ scenario meaning that other strategies may be required, such as referral to a Pain Clinic.

Persisting pain is as much psychological as physical. A GPN can certainly assist in management by finding out the psychological and social impact of the pain, and also by exploring your patient’s hopes and expectations about treatment. People do not die of joint pains, and so management over years and decades is to be anticipated.

Joint pain is much less troublesome (pain severity and disability caused) if the individual is physically fit. Nearly all patients with joint pain would benefit from doing more exercise.

KEY FACTS²

Back pain Around 10 million people in England and Scotland report persistent back pain. Low back pain is the leading cause of years lived with disability (YLD). People who are obese are 4 times more likely to develop back pain than people with a healthy body weightOsteoarthritis affects 8.75 million people in the UK. Three-quarters report constant pain, and one-third take early retirement, give up work or reduce working hours because of their conditionOsteoporosis/fragility fracture In the UK, 3 million people have osteoporosis, and over 300,000 fragility fractures occur each year, costing the NHS £1.9 billion.Gout affects more than 1.5 million people in the UK. The incidence of gout increased by 30% between 1997 and 2012Axial spondyloarthritis (AxPA) 200,000 people in the UK suffer from AxPA (also known as ankylosing spondylitis). The annual cost to the economy is estimated to be £3.8 billion.Juvenile idiopathic arthritis affects approxinately 12,000 children in the UK. In one-third, active disease persists into adulthood.

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