Page 235 Guide to Pain Management in Low-Resource Settings

Rheumatic Pain 223

hip. Physical examination reveals cold skin with normal Pain in OA of the toes is mechanical. Deformi-
coloration. Scraping the patella against the femoral knee ty is seen after long progression. Moderate activity and
epiphysis will produce a sensation of shaving an irregu- a short of course NSAIDs with joint rest are the best
lar surface. Th e maneuver is usually painful. Th e range strategy. Surgery, when possible, can be a good alternate
of motion is normal at the beginning, deteriorating choice. Primary OA of the elbow is very rare. Among
gradually. Full extension and full fl exion become impos- the secondary forms, using a jackhammer produces a
sible, and gradually the limitation increases. Abnormal special type of OA. Patients have night pain, very simi-
movement (lateral motion in full extension) is a sign of lar to infl ammatory pain, improving or disappearing as
advanced cartilage destruction. X-rays, especially if tak- work resumes. In the ankle, shoulder, wrist, and meta-
en in a standing position, will demonstrate joint space carpophalangeal joints, OA is usually secondary.
narrowing, which is more pronounced in the internal
compartment. What is the signifi cance
Episodically, an infl ammatory attack of OA of “soft-tissue rheumatism”?
will occur, and the knee will become swollen. Th e pain
worsens and becomes continuous, while maintaining Soft-tissue rheumatism is the third most frequent cause
its mechanical character. Physical examination reveals of rheumatic pain. It is seen in 4.7% of the young and
synovial eff usion with limitation of joint movement. It adult population [1]. Pain is due to periarticular compo-
will disappear with rest, in a few days to a few weeks, nents (tendons, tendon sheaths, bursae, and ligaments).
and symptoms will settle to what they were previously. In the majority of cases, pain is mechanical and related
Laboratory tests are not necessary when the history is to the patient’s activity. Th e pain has a high tendency to
evocative. Th ey remain normal, as during the normal recur. Treatment outcome is unpredictable, from excel-
course of the disease. X-rays do not change during the lent with minimal intervention to resistant with the best
infl ammatory attack. known strategy. Th e best approach seems to be good
Treatment is indicated mainly for infl ammatory patient education with minimal intervention: NSAIDs
attacks, when walking must be limited to allow the joint (high dose) or steroids (15 to 20 mg prednisolone) for
to rest. Exercise to strengthen quadriceps is essential, few weeks, and if necessary local steroid injection (re-
especially when walking is limited. When possible, bicy- peated once weekly as needed, usually not exceeding
cling is a very good choice, by preventing long displace- three consecutive injections).
ments that are harmful to the knee joint, while exercis- Soft-tissue rheumatisms are numerous in types
ing the quadriceps. and location. Th e most frequent and important are lo-
cated at the shoulder (tendonitis, acute and subacute
What about osteoarthritis periarthritis, frozen shoulder, rotator cuff rupture), the
in other locations? elbow (golfer’s and tennis elbow), and the forearm (De
Quervain’s tenosynovitis), among others.
Osteoarthritis of the hip is much like knee OA, except
that the pain is localized to the groin and buttock. It What should one know
can project to the thigh or even the knee joint. Distal about osteoporosis?
interphalangeal joint (DIP) OA is named as Heberden’s
node. It is characterized by two nodes on the dorsal Osteoporosis is a natural course of bone physiology if
aspect of the joint. After a long progression, slight to one lives long enough. From birth to young adulthood
moderate deformity may appear. Th e pain is sporadic (around 30 years of age), bone mass increases. After
and is mainly seen when the nodes appear, and there- that, the body gradually starts losing its bone reserves.
after during progressive attacks. No treatment is ef- In women the rate of loss is very low until menopause,
fective. NSAIDs are eff ective only for the duration of and then it accelerates for 10 to 15 years before slow-
attacks. Proximal interphalangeal joint (PIP) OA is ing down again. In men, the descending curve is uni-
named Bouchard’s node. It is characterized by a single form. Th e decrease of bone mass density (BMD) makes
node on the dorsal aspect of the joint. It has the same the bone fragile. Th e quality of bone also degrades with
characteristic as Heberden’s node. EULAR guidelines age, even if bone mass remains stable, increasing the
for diagnosis are of interest [7]. fragility of bones. Both phenomena increase the risk