Preface
This textbook is designed to be a useful, up-to-date primer for
physicians and providers who take care of patients with musculo-
skeletal problems.
Introduction Musculoskeletal conditions represent a considerable disease bur-
den, and the majority of patients who present to medical services
are managed in the primary care setting [1]. It is important there-
fore that general practitioners (GPs) are able to correctly diagnose
and treat patients with joint pain.
It is well established that patients with infammatory arthritis
beneft from early treatment [2], so timely, effective triage and
referral are essential. There is also good evidence that prompt
treatment of acute soft tissue pain produces sustained beneft [3].
The aim of the initial assessment in primary care should be to
differentiate musculoskeletal from non-musculoskeletal pain and
to determine whether the joint pain arises from infammatory joint
disease or from a non-infammatory cause.
Globally, healthcare systems are struggling to meet demand
due to a combination of an ageing population and increasing dis-
ease burden [4]. At the same time, there are signifcant workforce
shortages, making it diffcult to maintain a high quality service.
Therefore, any assessment should aim to provide an accurate,
timely diagnosis and an effective management plan.
Epidemiology Musculoskeletal pain is common and accounts for 14% of GP
consultations in the UK [5] and over 38 million primary care vis-
its annually in the USA [6].
Doctor-diagnosed arthritis is associated with severe joint pain
in 15 million patients in the USA [7] and results in a limitation of
activity in 24 million patients [8].
In addition to the direct impact on the patient, the annual eco-
nomic cost of arthritis is also considerable and has been estimated
to be at least $303 billion annually in the USA [9].
The role of the family physician is important as they are the
most common point of frst contact, accounting for 37% of initial
consultations for joint pain in the USA [6].
Not only is musculoskeletal pain widespread, but the preva-
lence of symptomatic arthritis is also increasing [10] due to an
increase in risk factors such as obesity and an ageing population
[11]. This is refected in epidemiological studies of specifc rheu-
matological diseases, including gout [12], osteoarthritis (OA)
[13] and infammatory arthritis. If current trends continue, projec-
tions suggest that 78.4 million adults in the USA will have some
form of arthritis by 2040 [14].
Recent evidence in the medical literature [15] has suggested
that epidemiological studies based on doctor-diagnosed arthritis
have signifcantly underestimated the disease burden with a sensi-
tivity of only 52.5% in patients aged 45–64 years. It is likely
therefore that the true burden of arthritis is signifcantly greater
than that reported.
The Assessment of a Patient with Joint Pain
The average duration of consultation in primary care in the UK is
only 9 min [16] and 21 min in the USA [17]. It is important there-
fore to have a structured approach to the assessment that narrows
the differential diagnosis, aids appropriate investigation and pro-
vides effective treatment.
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