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Inflammatory causes of MSK pain - referral guidelines


MSK Rheumatology Referral Guidelines

See chapters below:

Click on link for more information or see summary table below

Gout

 

Psoriatic Arthritis (PsA)

 

Giant Cell Arteritis (Temporal Arteritis)

 

Positive Antinuclear Antibodies (ANA)

 

Connective Tissue Diseases

 

Back Pain – Suspected Ankylosing Spondylitis & Spondyloarthritis

 

RHEUMATOLOGY  REFERRAL GUIDANCE (UHCW) 
CONDITION PRE-REFERRAL TESTS            PRE-REFERRAL Rx REFERRAL THRESHOLD
Fibromyalgia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Fibromyalgia Rapid Screening Tool is a brief and simple self-complete questionnaire that has been validated for screening FM in patients with diffuse chronic pain. A self-administered questionnaire developed by French researchers, the Fibromyalgia Rapid Screening Tool (FiRST) consists of six questions regarding the presence or absence of the following dimensions of fibromyalgia:

  • Widespread pain
  • Fatigue
  • Pain characteristics
  • Nonpainful abnormal sensations
  • Functional somatic symptoms
  • Sleep and cognitive problems
In line with recently published GIRFT  recommendations and BSR’s Adult rheumatology referral guidance (October 2021), we will not accept a referral if the diagnosis is already known; we know that very few patients evolve into a different diagnosis over time. If a re-referral is being considered it is very unusual that a second opinion is substantially different from the first.

Advise pacing, signposting to https://my.livewellwithpain.co.uk/

 

Main reason to refer: diagnostic uncertainty, e.g. where there is concern that an inflammatory rheumatological condition needs to be excluded – CLEARLY state clinical details and only use Early Arthritis Pathway if indicated.

Consider the use of Specialist Advice (A&G) for any diagnostic/management uncertainty.

Please note, an inflammatory condition is less likely if:

  • Pain occurs after use or the end of the day
  • Morning stiffness less than 30 minutes
  • No night time pain
  • No systemic symptoms
  • Chronic symptoms

 

Questions require only a “yes” or “no” answer, with each “yes” answer worth 1 point. A score of 5 or more has the highest sensitivity and specificity for fibromyalgia.

 

Consider:

  • Duloxetine (if significant low mood too)
  • Amitriptyline low dose (if very poor sleep pattern)
  • Gabapentin maximum 900mg a day (if concomitant anxiety). Stop if no improvement in 4/52
  • Do not prescribe opiates
Refer to local pathways, making the best use of MSK expertise in Primary and Community Care. This may include use of Clinical Pharmacists, First Contact Practitioners, Advanced Practitioners as well as MSK interface services and local orthopaedic, spinal and pain management services.
Consider checking TFTs, CRP/ESR, Calcium, Vitamin D (would have to be very low to be cause of symptoms) and Creatine Kinase. DO NOT request autoantibody screens unless symptoms of inflammatory rheumatological disease.   Do not refer patients with predominantly chronic fatigue (there is an overlap in around 50% of symptoms) as these referrals will be declined and suggested to be redirected to GEH Chronic Fatigue Service.
Gout

 

 

 

 

 

 

 

 

 

 

Check FBC, U+E, LFT, CRP, uric acid, fasting glucose, HbA1c, X ray of the affected joints, measure blood pressure

 

 

 

 

Review at 4-6 weeks Consider prophylactic medication if a person is having two or more attacks of gout in a year

 

 

 

Refer to Secondary Care:                                                Immediate: if Septic Arthritis is suspected (Please note it is possible for both gout and septic arthritis to co-exist)                                                                                    Routine: if complications relating to gout eg. Nephropathy, requires intra-articular therapy and primary care are not able to provide this, diagnostic uncertainty, the serum uric acid is unresponsive to uric acid lowering therapy, if gout persists despite controlled uric acid levels
Address lifestyle factors (diet, exercise, alcohol) and provide advice.  BSR guidelines for gout:   
Patient information leaflets: www.ukgoutsociety.org     
Assess and treat underlying cardiovascular risk factors: obesity, hypertension, lipids, diabetes mellitus    
Consider drug-induced gout: diuretics (inc. thiazide), B-blockers, ACE inhibitors and non-losartan angiotensin II receptor blockers, which increase serum urate.    
High doses of aspirin interfere with uric acid excretion and should be avoided during an attack     
Do any of the following apply?    
1) Definite diagnosis of gout following second or further attacks within one year     
2) Presence of tophi     
3) Presence of gouty erosive disease     
4) Evidence of gout interstitial renal disease    
If Yes, consider Long Term Treatment with Uric Acid Lowering Therapy    
 Inflammatory Myositis

 

 

 

  

Assess for muscle weakness, weight loss, appetite loss, skin rash, mechanics hands TSH CK ANA LFTs (expect ALT to be raised in PM) Refer with test results attached 

 

Most common cause of raised CK is statin use – if ANA is negative, consider stopping statins and repeating CK after 2-3 months before referral  
Dermatomyositis will always have skin changes some of which can be seen on:  
https://dermnetnz.org/topics/dermatomyositis-images/  
but CK may be normal – if CK is normal, refer to Dermatology initially  
Polymyositis will have raised CK (a CK of less than 400 is unlikely to be inflammatory in origin) with proximal weakness or tiredness and modest myalgia  
If concomitant neurological symptoms refer to Neurology   
 Polymyalgia  rheumatica Bilateral shoulder / pelvic girdle pain

Age >50yrs

Raised ESR / CRP

FBC ESR CRP TSH LFTs U&Es CK Chest X Ray Urine dip if possible Consider referral in the following circumstances:

  • Incomplete, poorly sustained or non-response to corticosteroids
  • Inability to reduce corticosteroids
  • Contraindications to corticosteroid therapy
  • The need for prolonged corticosteroid therapy (>2 years)
Refer to BSR guidance for further information: https://academic.oup.com/rheumatology/article/49/1/186/1789113  
 

 

SLE

 

 

 

 

 

 

 

Raynauds and Livedo are common in teenage girls and usually physiological.

 

 

Refer all suspected cases with test results attached

 

 

 

 

Ask for:

History of rashes (patient to keep phone pictures if they are being referred)

Photosensitivity

Mouth ulcers

Inflammatory joint pain (morning stiffness and / or morning swelling)

Hair loss

FH of autoimmune disease

ANA, CK, U&Es, LFTs, FBC, CRP and ESR

ENA will be automatically done by lab if ANA is positive

If anti double stranded DNA is positive, but Crithidea (done automatically by lab) is negative, then the anti DsDNA is likely to be a false positive

  If history of thrombosis or miscarriages/ pregnancy loss then add lupus anticoagulant and cardiolipin antibodies
Scleroderma

 

 

Virtually all will have Raynauds and either skin tightening or very marked puffiness in hands in the early stages ANA (usually anti centromere or anti-scl70 positive on ENA) U&Es LFTs LFTs CRP ESR CK Refer all suspected cases with test results attached

 

 

 

Many will already have very painful digital ulceration / pits at time of presentation  
Ask for history of swallowing difficulties and SOB  
Sjögren’s 

 

 

 

Persistent and excessively dry mouth (not explained by medication, ageing, chronic infection, head and neck irradiation, Lymphoma, Sarcoidosis or GVHD) Check ANA (usually anti Ro +/- La) U&Es LFTs Igs CRP ESR Refer patients with resistant symptoms, diagnostic uncertainty or suspected secondary or extraglandular manifestations to Rheumatology
Symptomatic treatments such as artificial tears and saliva are well tolerated and help to relieve the most obvious symptoms Refer refractory dryness to Ophthalmology                                 
Osteoarthritis

 

Only refer if joint pain previously amenable to a joint injection with longer term benefit (>6/52) or if there is diagnostic uncertainty with inflammatory arthritis  

 

Do NOT prescribe opioids or pregabalin

 

 

Refer for physiotherapy

 

 

 

 

Regular joint injections are not recommended as long-term therapy
Suggest topical agents and https://my.livewellwithpain.co.uk/
 
Psoriatic arthritis

 

Usually personal or family history of skin or nail psoriasis, pattern can be variable. Weight reduction advice if appropriate Refer all suspected cases using Early Inflammatory Arthritis form

 

 

 

Consider use of: PEST questionnaire (Psoriasis Epidemiology Screening Tool) FBC FBC U&Es LFTs CRP ESR AntiCCP
Joint pain for more than 4/52, Early morning stiffness for >30 minutes, synovitis of any joint. Also consider if inflammatory back pain, or enthesitis such as tennis/ golfer’s elbow, Achilles tendonitis or plantar fasciitis  
Inflammatory back pain / axial spondyloarthropathy

 

 

 

 

Early morning stiffness of spine >30 minutes in someone less than 45, or buttock pain worse in the morning FBC, U&Es, LFTs, CRP, ESR, HLAB27 (once only) and anti CCP if peripheral joint involvement Refer if inflammatory disease likely
Inquire for personal or FH of Ankylosing Spondylitis, iritis, inflammatory bowel disease or psoriasis If MRI spine requested (and inflammatory disease is less clear) request SI joints too as not visualised on a normal LS MRI Do NOT refer to community physiotherapy at this point as will benefit from specialist physio advice later
Ask about symptoms of peripheral joint inflammation, particularly hip (groin) or knee/ankle, or enthesitis such as tennis / golfer’s elbow, Achilles tendonitis or plantar fasciitis If no contraindications, try at least one full dose NSAID with PPI if appropriate  
Osteoporosis

 

 

 

 

 

Use FRAX score https://www.sheffield.ac.uk/FRAX/tool.aspx?country=1 to assess need for treatment Depending on age and comorbidity, consider causes of secondary osteoporosis and blood test including: Refer all patients with: non tolerance of oral bisphosphates requiring sub cutaneous or IV therapy or where treatment is not clear cut and Advice & Guidance not possible or not able to answer question after performing a FRAX score.

 

 

  Anti TTG Igs & Electrophoresis
Nb this score is not so helpful to decide on future treatment if already on medication Testosterone (in younger men)
Ensure calcium and vitamin D replete and supplement if necessary Advise weight bearing exercise
New early inflammatory arthritis symptoms

 

Symptoms and signs of Early Inflammatory Arthritis Request FBC, ESR, U&Es, LFTs, RF, ANA and ant-CCP Refer using EarIy Inflammatory Arthritis form
Joint pain for > 4/52 but < 12 months X-ray hands and feet +/- other joints if involved
Early morning stiffness for >30 minutes PLUS either two or more swollen joints or tender MCPs by squeeze test  
Possible GCA / temporal arteritis

 

 

 

 

Age >50 New onset of headache or jaw claudication (in the absence of current dental complaints)

NB- GCA uncommon in ethnicity other than Caucasian

Kindly follow the GCA pathway.

Bloods and temporal artery US will be arranged by acute hospital DO NOT commence steroids prior to discussion with Rheumatology / Ophthalmology as this reduces diagnostic capacity of ultrasound 9-5pm Mon – Fri
Refer to Rheumatology SpR on bleep 2531 or 1365Out of hours refer to A&E or MDUAny visual symptoms, refer to ophthalmology first
    If visual changes, please refer to OPHTHALMOLOGY assessment in eye casualty instead that day- they will refer on to us if concern of GCA

 

 

Rheumatology Services

The UHCW rheumatology service runs various clinics, mainly at UHCW but also at St Cross Hospital, Rugby.

There is a wide range of services, including an early arthritis clinic, an ankylosing spondylitis clinic, an urgent review clinic, and an osteoporosis service.

Here is a list of the consultants, with their interests and involvement at other hospitals:

  • Dr Tanya Potter (Pregnancy & Rheumatic Disease, Early Inflammatory Arthritis) UHCW ext 26706 Tel 02476 966706
  • Dr Kaushik Chaudhuri (Osteoporosis) UHCW ext 26708 Tel 02476 966706
  • Dr Price-Forbes (General Rheumatology and Connective Tissue Diseases) UHCW ext 26707 Te 02476 966707
  • Dr Gillian Peffers (Early Arthritis, General Rheumatology, Sjogrens)UHCW ext 26707 Tel 02476 966707
  • Dr Nicola Gullick (Psoriatic Arthritis and Research) UHCW Clinical Lead ext 26705 Tel 02476 966705
  • Dr Tim Blake (Acute Medicine, Spondyloarthropathy, Connective Tissue Diseases)UHCW ext 26705 Tel 02476 966705
  • Dr Ganesh Kasavkar (General rheumatology)UHCW ext 26705 Tel 02476 966705
    Dr Siwalik Banerjee (Connective tissue diseases/Vasculitis) UHCW/St Cross ext 26707 Tel 02476 966704/5
  • The Rheumatology Registrars carry bleeps (2531 or 1365) and are contactable 9am-5pm for advice.

For general enquiries use Consultant Connect or email:uhc-tr.rheumatologysecretaries@nhs.net

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