11.4 Osteoarthritis, Low Back Pain, Polymyalgia Rheumatica, Fibromyalgia & Soft Tissue Disorders

Osteoarthritis, Low Back Pain, Polymyalgia Rheumatica, Fibromyalgia & Soft Tissue Disorders

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Osteoarthritis (OA, NICE NG226)

• Clinical diagnosis without imaging if the person is 45 or over, has activity-related joint pain, and has no morning stiffness or stiffness lasting 30 minutes or less.
• Signs: crepitus, bony swelling, reduced range of movement; in the hands, Heberden's nodes (DIP joints) and Bouchard's nodes (PIP joints), and base-of-thumb involvement.
• X-ray features (if done): Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts.

Management

1. Therapeutic exercise (strengthening and aerobic) and weight loss if overweight; information and self-management support.
2. Topical NSAIDs for knee OA (consider for other joints).
3. Oral NSAIDs at the lowest effective dose for the shortest time, with a PPI where needed.
4. Do not routinely offer paracetamol or weak opioids (except infrequent short-term use when other options are unsuitable), and do not offer strong opioids, glucosamine, hyaluronan injections or arthroscopic washout.
5. Intra-articular corticosteroid for short-term relief of a flare.
6. Joint replacement referral when symptoms substantially affect quality of life despite non-surgical treatment (no specific age, BMI or imaging thresholds).

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Low Back Pain & Sciatica (NICE NG59)

Red Flags

Non-Specific Low Back Pain

• Do not routinely image in non-specialist settings.
• Use a risk tool (such as STarT Back) to guide intensity of care.
• Encourage activity, self-management and group exercise programmes; manual therapy and psychological therapy only as part of a package with exercise.
• Oral NSAIDs (lowest dose, shortest time) if needed; weak opioids (with or without paracetamol) only for acute pain when NSAIDs are unsuitable.
• Do not offer paracetamol alone, SSRIs, SNRIs, tricyclics or gabapentinoids for low back pain.

Sciatica

Leg pain in a dermatomal distribution (often L5 or S1) from nerve root compression, usually a disc prolapse. Most cases settle over 6–12 weeks. NICE advises against gabapentinoids, other antiepileptics, oral corticosteroids and benzodiazepines for sciatica, and against opioids for chronic sciatica. Consider epidural injection for acute severe sciatica and spinal decompression when non-surgical treatment has failed and imaging matches the symptoms. Cauda equina features need emergency MRI (section 11.3).

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Polymyalgia Rheumatica (PMR)

• Features: age over 50, bilateral shoulder (and often hip) girdle pain and stiffness, morning stiffness over 45 minutes, fatigue and low-grade fever, with raised ESR or CRP. Muscle strength and CK are normal.
• Before steroids: exclude mimics (rheumatoid arthritis, myeloma, hypothyroidism, infection, malignancy, statin myopathy) with bloods including protein electrophoresis, TFTs, CK and bone profile.
• Treatment: prednisolone 12.5–25 mg daily, expecting a dramatic response within days (if not, reconsider the diagnosis), then a slow taper over 1–2 years with bone protection and monitoring for steroid side effects.
• Giant cell arteritis overlaps with PMR: ask about new headache, scalp tenderness, jaw claudication and visual symptoms at every review; GCA needs higher-dose steroids immediately (section 7.2).

Fibromyalgia & Chronic Primary Pain (NICE NG193)

Chronic widespread pain for more than 3 months with fatigue, unrefreshing sleep and cognitive difficulty, without inflammation. Investigations are normal. Management: explanation, exercise programmes, psychological therapy (CBT, acceptance and commitment therapy) and acupuncture; an antidepressant (for example amitriptyline or duloxetine) may be considered. NICE advises not starting opioids, gabapentinoids, NSAIDs, paracetamol or benzodiazepines for chronic primary pain.

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Common Soft Tissue Disorders

Imaging Rules for Ankle and Knee Injuries

• Ottawa ankle rules: X-ray the ankle only if there is pain in the malleolar zone and bone tenderness at the posterior edge or tip of either malleolus, or the patient cannot bear weight for 4 steps both immediately and in the department. X-ray the foot for midfoot pain with tenderness at the base of the fifth metatarsal or the navicular, or inability to bear weight.
• Ottawa knee rules: X-ray for age 55 or over, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight for 4 steps.

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Bursitis & Joint Dislocation

• Bursitis: inflamed bursa causing localised swelling and tenderness, for example olecranon (leaning on elbows), prepatellar ("housemaid's knee") and greater trochanteric (lateral hip pain). Treat with rest, ice and NSAIDs. A hot, red, tender bursa with fever may be septic (often Staphylococcus aureus): aspirate for microscopy and culture and treat with flucloxacillin, avoiding steroid injection.
• Shoulder dislocation: most are anterior (arm held abducted and externally rotated, loss of shoulder contour). Check axillary nerve function (sensation over the "regimental badge" area of the lateral upper arm) and distal neurovascular status, take X-rays before and after reduction, and reduce under analgesia and sedation. Posterior dislocations follow seizures or electric shocks.
• Hip dislocation: usually posterior after high-energy trauma (dashboard injury) or in people with hip replacements; the leg is shortened, adducted and internally rotated. It needs urgent reduction to reduce the risk of avascular necrosis and sciatic nerve injury.