Non-inflammatory conditions

Fibromyalgia

Fibromyalgia is often confused with polymyalgia but in fibromyalgia there is no sign of inflammation. People with fibromyalgia are often worried that they have arthritis or some other serious disease but this is almost never the case. Blood tests and X-rays are normal.

Most people with fibromyalgia are women in their middle years – and in some cases the symptoms seem to be triggered by bereavement or stress and they are often associated with poor sleep (see below). It can be difficult to decide whether the chronic pain of the condition led to the symptoms of tiredness, fatigue and poor sleep, or whether insufficient sleep or poor quality sleep is actually the root cause of the problem.

Symptoms of fibromyalgia

• Widespread pain and tenderness, particularly across the shoulders, back, elbows and knees

• Although the joints and soft tissues are tender, they are not swollen

• The muscles and joints may feel stiff in the mornings but this disappears quickly once you get up

• Low spirits or depression

• Poor sleep

• Lack of energy.

Treatment

Your doctor may prescribe medication to lift depression and help you to sleep more soundly if necessary. Remaining as active and mobile as possible will help. If you rest a lot, you may feel worse as you will become unfit and more tired and your muscles will become weaker and more susceptible to injury. Regular exercise can also help to clear your mind and improve the quality of your sleep. You can help yourself with some other simple lifestyle changes (see box below) in addition to any treatment provided by your GP.

Self-help tips for fibromyalgia

• Don’t drink coffee or other caffeine-containing drinks in the evening because they may disturb your sleep

• Consider relaxation classes

• Try to deal with any major sources of stress in your daily life

• Keep as active as possible, and consider taking up some gentle, regular exercise such as swimming or brisk walking

Hypermobility

This is not actually a disease but it may be a cause of very painful joints in young people. People come in all shapes and sizes and there is a similar variation in joint flexibility. Some people normally have rather stiff joints whereas, at the other extreme, some have very supple, mobile joints and are often called ‘double-jointed’. If you are one of these people, you may be able to bend over with your knees straight and put your hands flat on the floor in front of you when most of us struggle just to touch our toes. Your elbows and knees may bend backwards and your fingers may turn up when you hold them outstretched. If you can do this, you may have ‘hypermobility syndrome’.

Hypermobility represents the supple end of the normal spectrum of joint mobility. A small number of people with extremely mobile joints suffer recurrent dislocations and their joints are easily damaged but most people with hypermobility have it in a mild form. Very supple joints are easily strained by everyday activities and people with painful, hypermobile joints may worry that they have arthritis although this is unlikely to be the case. A few simple measures will help to keep the pain under control.

Self-help tips for hypermobile joints

• Take care not to strain your joints

• Take regular exercise to build up your muscles – well-toned muscles will help to support your joints and protect them from strain

• Avoid exercises or activities that overstretch the joints, such as ballet and gymnastics

• Most important of all, resist the temptation to perform ‘party tricks’ to show off your mobile joints

Neck and back problems

Back pain

Low back pain, or lumbago, is very common: 80 per cent of the population experience it at some time in their lives. Most back pain is ‘non-specific’ or ‘mechanical’ – in other words, it results from some minor physical problem in the complex structure of the back, such as a strained muscle, ligament or tendon, which will heal on its own in time. Serious causes of back pain are very rare indeed. Surprisingly, the severity of the pain is not a good guide to the seriousness of the cause and in fact the most severe pains are usually non-specific and should heal in their own time.

Correcting poor posture, taking care with lifting and carrying, and performing regular exercise can all help. Much useful information about the spine can be found in the book Understanding Back Pain in the Family Doctor series.

Sciatica

Sometimes pain is felt in one of the legs as well as in the back. Sciatica, which is caused by pressure on a nerve by a disc in the spine, is one cause and the leg pain may be accompanied by tingling, pins and needles or numbness. Although this is often referred to as a ‘slipped disc’, discs do not actually slip in and out. A more correct name is ‘prolapsed disc’ or ‘ruptured disc’. Discs are filled with a jelly which acts as a cushion between the bones of the spinal column. When a disc ruptures, or tears, some of this jelly squirts out and can irritate a nearby nerve, causing severe pain down the leg.

Treatment

With pain-killers, a few days’ rest, and then gentle exercise and physiotherapy, the tear heals, the disc material is absorbed and the pressure on the nerve is relieved. It is important to keep as mobile as the pain permits, although initially a day or two of bed rest may be necessary if the pain is severe. Most people get completely better in a few weeks, but in a small number of people, symptoms do not get better with pain-killers and physiotherapy and they may need surgery to remove the disc material.

Neck pain

Pain in the neck is probably as common as pain in the back and often has similar causes, although a ruptured disc is much less common in the neck than in the lower back. Poor posture is a common culprit. Many people hunch their shoulders and allow their head to poke forwards. The head is very heavy (as heavy as a bucket of water) and, to stop the head from flopping onto the chest, the muscles at the back of the neck have to work hard to hold the head up.

Eventually, this chronic contraction, or tension, causes aching pain and stiffness in the trapezius muscles across the shoulders, and up the neck to the back of the head. It can even cause severe headaches (tension headaches) felt across the forehead and behind the eyes.

Treatment

Treatment involves understanding the problem, correcting the posture and performing regular simple exercises to loosen the muscles and keep the neck supple.

Arthritis of the spine

Degenerative arthritis, or spondylosis, of the spine is extremely common. If an X-ray were taken of the spine of everyone over the age of 50, almost all of them would show degenerative changes. But not all of these people have back pain and, of those who do, the pain often comes and goes. So there is no clear relationship between X-ray changes and symptoms. Regardless of whether there are degenerative changes on the X-ray, most episodes of back pain will get better with pain­killers and a few days’ rest, followed by gentle exercise and then getting back to normal activities. It is important to keep as mobile as the pain permits, although initially a day or two of bed rest may be necessary if the pain is severe. But if the back pain lasts longer than a week and you find it difficult to get back to work, then you should consult your doctor.

Another form of arthritis that affects the spine is ankylosing spondylitis. This is a rare form of inflammatory arthritis and it has been described earlier.

Osteoporosis

In older people, especially women, pain in the upper back may be the result of osteoporosis (‘thinning of the bones’). Everyone loses calcium from their bones as they get older, especially women after the menopause. The process is usually very slow, but there may come a point when the bones have lost so much calcium that they are thin and prone to fracture. The vertebrae in the upper back may become distorted so that the back becomes very rounded (‘dowager’s hump’). There may be chronic pain, or episodes of acute pain, when a single bone collapses slightly. If you think that you may have osteoporosis, consult your doctor.

There are now treatments available that can slow down the loss of calcium from the bones and even make them a little stronger. You can help by giving up smoking, making sure that your diet has plenty of calcium and taking regular exercise – even a brisk walk for half an hour three times a week can make a difference.

Much more detailed information about osteoporosis is contained in the book Understanding Osteoporosis in the Family Doctor series, or can be obtained from the National Osteoporosis Society (see Useful addresses).

Problems in and around individual joints

‘Soft-tissue rheumatism’ is the term used to describe a group of painful conditions that are caused by problems with the soft tissues around joints, rather than problems with the joints themselves. Tendons, which join muscles to bone, ligaments, which join bones together, and bursas can all be responsible.

The general principles of treatment of these conditions involve steroid injections to settle the pain and inflammation in the acute phase, a splint to rest the painful area and, most important of all, recognising what activity caused the problem and either avoiding the activity altogether or changing the way that it is done. If this aspect of the treatment is neglected, then there is a risk that the problem will recur. Many sports injuries fall into this category.

Shoulder pain

Pain felt around the shoulder can sometimes be caused by neck problems. This is particularly true if the pain is felt on top of the shoulder in the large trapezius muscle that runs between the shoulder joint proper and the neck.

Pain arising from the shoulder joint itself is often felt in the upper arm rather than over the point of the shoulder. Common causes are frozen shoulder (also known as ‘adhesive capsulitis’) and tendinitis.

Frozen shoulder

This mainly affects older people and is rare under the age of 50. The symptoms usually begin suddenly and may follow a minor injury, such as a knock or a fall, although the injury may be so minor as to be forgotten. Occasionally, frozen shoulder can follow an attack of shingles or even a heart attack.

We do not know what causes frozen shoulder but we do know that the capsule surrounding the joint becomes thickened and inflamed, causing pain. The inflamed capsule is ‘sticky’ and adhesions form between the capsule and the bones, restricting the movement of the joint.

Symptoms of frozen shoulder

• Constant pain which can be very severe, even when the shoulder is held still.

• Difficulty sleeping because of the pain – it may also be impossible to lie on the affected side.

• Severe stiffness, which may make it very difficult to reach up to a shelf or into a back pocket or, in some cases, to move the joint at all.

Treatment

Even without treatment, the pain of a frozen shoulder will usually settle within 18 months, but most people don’t want to wait that long! When the shoulder is intensely painful, the most effective treatment is steroid injection into the joint. This relieves the pain, although sometimes more than one injection is needed.

The other, equally important, aspect of treatment is regular exercise to bring back the range of movement and prevent the shoulder becoming stiff and stuck once the pain has gone.

When doing the exercises described, don’t stretch or move beyond the point where you feel slight pain. Forcing your shoulder through a wider range of movement will just make the problem worse. But with careful attention to regular exercise, you should regain useful movement in your shoulder, although it may always remain slightly restricted compared with your normal side.

Exercises for frozen shoulder

• Stand up and lean your trunk slightly over towards the side of the affected shoulder, so that your arm hangs away from your body. Swing the arm gently backwards and forwards, keeping your elbow straight and avoid shrugging your shoulder as you swing. Swing backwards and forwards 10 times and repeat the whole exercise several times a day.

• Lean forwards and gently swing your arm from side to side across your body, moving the shoulder joint in a different direction, then swing the arm in a circular movement. As the shoulder becomes freer, you will find that you can swing further and further and in ever larger circles.

• Reach behind your waist with your good arm and grasp the wrist of the arm with the frozen shoulder. Gently pull the arm behind your back, being careful not to force the movement.

Shoulder tendinitis

Inflammation of the tendons or the sheaths containing them is a common cause of shoulder pain. A normal shoulder has an enormous range of movement – you can put your arms up above your head, bring them out to the sides and swing them up behind your back.

This is a legacy from our evolutionary ancestors who needed this range of movement to swing through trees. Unfortunately, it means that the tendons of the shoulder are easily damaged and subject to wear. They can fray and bleed a little, leading to inflammation. This causes pain which is always worse when the shoulder is moved and less severe at rest.

Treatment

Injection of steroid into the area around the inflamed tendon can be very effective. After a couple of days, you can start on a gentle programme of exercise to restore normal movement to your shoulder. The exercises are likely to be similar to those for frozen shoulder, but your doctor or physiotherapist will explain precisely what you need to do.

Once the pain has settled, you must resist the temptation to perform heavy lifting and you should pace any work that is heavy on the shoulders, such as cleaning windows, digging in the garden and using a vacuum cleaner.

You should also beware the ‘perils of the plastic carrier bag’! Plastic shopping bags are very strong and have small handles. They can be loaded up with heavy shopping and the small handles mean that the bags have to be carried with the arms held vertically downwards. The weight drags on the elbows and shoulders and also the neck, straining the tissues and causing pain.

Heavy shopping should ideally be carried in a trolley on wheels. If this is not possible (trolleys can be difficult to take on and off the bus), then small amounts of shopping can be carried in a stiff basket with a wide handle, carried over the forearm. Most of the weight of the basket can then be carried on the hip avoiding undue strain on the arms.

Tennis elbow and golfer’s elbow

These conditions cause pain at the points at which the tendon attaches to the bone around the elbow. Tennis elbow causes pain on the outer side of the elbow, where the extensor muscles on the outer side of the forearm are attached (see diagram opposite). These muscles bend the wrist back and straighten the fingers. Golfer’s elbow is much less common and causes pain on the inner side of the elbow, at the attachment of the flexor muscles which bend the wrist forwards and flex the fingers.

Both conditions were first described in sportsmen but most sufferers develop them as a result of everyday activities, such as repeated heavy lifting, pushing and pulling. Sometimes a single episode of awkward lifting, such as lifting a heavy case down from an overhead locker, may be the trigger. The lifting need not be heavy: office workers who repeatedly pull files out of tight, over-stuffed cabinets are also at risk.

Treatment

A steroid injection into the painful area is usually helpful. Physiotherapy may also be beneficial. But most important is to work out what caused the problem in the first place and avoid the activity in future, otherwise the symptoms may recur and can become chronic.

Tennis elbow

Right arm seen from the right side. When the extensor muscle contracts, to bend the wrist back, the muscle pulls on the bone. This causes pain if the area is inflamed, as in ‘tennis elbow’.

Overuse syndrome (repetitive strain injury, RSI)

There has been much discussion in the courts (where sufferers have claimed compensation from their employers) as to whether this condition really exists, but most doctors agree that it does.

Like many other soft-tissue problems, this condition is triggered by misuse or overuse of the affected part of the body. It is also called ‘upper limb syndrome’ and affects the neck, shoulders, arms and hands of keyboard workers and other people who continually repeat the same tasks and movements in their work. In fact, people employed to pluck chickens were the first group in whom the condition was identified.

The pain is not confined to any one area but is most severe in the backs of the hands and forearms, and is clearly related to work. At the beginning, it may come on only towards the end of a busy day. If left untreated, it can progress and then the time between starting work and developing the pain gets shorter.

In severe cases, there is some pain all the time, even when not at work, and normal daily activities outside work may also trigger pain.

Treatment

If the symptoms have been neglected and the condition has been allowed to become severe and chronic, treatment is difficult and not always successful. It is vital to act promptly as soon as you suspect that you may be developing problems. Look very carefully at the nature of your work and your workstation. Physiotherapists and occupational therapists are experts in these assessments but there are a number of things that you can change yourself. Discuss the situation with your employers and see your GP or the company’s occupational health doctor, if there is one.

Although most cases of overuse syndrome occur as a result of practices at work, if you use a computer (or other equipment, such as a sewing machine or DIY tools) a lot at home, you can develop exactly the same problems. The principles of pacing, technique, proper positioning and posture still apply. With careful attention to these principles, most people are able to continue with their work.

Self-help tips to avoid RSI

• Alternate your work. Split it up and mix different tasks – instead of spending two whole days typing and then two days filing, alternate every few hours.

• Take regular breaks. If your job involves mainly one activity such as using a computer, then it is vitally important that you take regular breaks. Every hour, stand up, stretch your legs, lift your arms above your head, and open and close your hands. Focus on distant objects through the window to rest your eyes. This takes only a couple of minutes but will make all the difference to how long you can work without discomfort.

• Improve your technique. If you’re a keyboard worker and can’t touch-type, it is worth learning to do so because this allows you to spread the work of typing over all your fingers and thumbs and means that you can hold your head up instead of looking down at the keyboard.

• Make sure that your equipment and furniture are properly positioned. You should have a height-adjustable chair on wheels, with a backrest and without arms so that you can sit close up to your desk. Your computer screen and keyboard should be placed directly in front of you – just a few inches to one side will place strain on your arms and neck. The screen should be slightly lower than your sight-line – any lower and you will hunch your shoulders and lean forward, any higher and you will crane your neck. All other equipment that you use regularly, such as the telephone, should be placed close to you so that you are not continually reaching across the desk.

• Pay attention to your posture. The best-designed equipment will do nothing for you if it is not used properly. Adjust the height of your chair so that your feet are comfortably placed on the floor on a foot-rest and your forearms rest comfortably on the desk. Don’t slouch in the chair but sit up straight, preserving the curve in your lower back. Sit close to your desk so that your hands rest on the keyboard without stretching your arms forward. Your shoulders should be relaxed, your upper arms should hang vertically downwards and your forearms should be held at right angles when typing.

Carpal tunnel syndrome

In this very common condition, there is pressure on the median nerve as it passes through the wrist. The bones of the wrist (the carpal bones) are arranged in a horseshoe shape. The free ends of the horseshoe are joined together by a tough piece of tissue, forming a narrow tunnel through which the median nerve passes.

Any swelling of the tissues in the area can cause pressure on the nerve and irritate it. Signals sent from the median nerve to the brain are interpreted as coming from the area supplied by this nerve – that is, from the hand (see below). Carpal tunnel syndrome can be caused by fluid retention, such as occurs in pregnancy or when the thyroid gland is underactive, or be a symptom of rheumatoid arthritis, but very often no underlying cause is identified.

Symptoms of carpal tunnel syndrome

• Numbness, tingling or pain in the hand, worse in the thumb, index and middle fingers.

• Symptoms are much worse during the night or first thing in the morning and may disappear completely during the day.

• Rubbing or shaking the hand eases the pain and tingling.

Treatment

The priority is to relieve the pressure on the nerve, which increases when your wrist is bent forwards and reduces when it is bent back. A simple splint worn around your wrist at night to stop it bending forward may be enough to solve the problem; your GP or a physiotherapist can supply one for you. You can also help yourself by making sure that your wrists are not bent forwards when you are sitting with your hands in your lap or with your arms folded. If this does not work, then an injection of steroid into the carpal tunnel can shrink the tissues enough to relieve the pressure. If this is not effective either, a simple operation under local anaesthetic will relieve the pressure on the nerve.

Thumb tendinitis (de Quervain’s tenosynovitis)

In this condition, the pain arises from the tendons that work the thumb. Tendons run inside a lubricated sheath but, when they become inflamed, movement causes the surfaces to grate against each other. The base of the thumb and the lower end of the forearm become painful, and the area may be tender and even swollen. Parents who lift their young children by holding them under the armpits are particularly prone to this complaint; so are restaurant staff who carry heavy plates of food in each hand with the weight balanced by the thumb.

Osteoarthritis of the joint at the base of the thumb, where it is attached to the wrist, can cause similar symptoms.

Treatment

Thumb tendinitis usually responds very well to a steroid injection into the sheath of the tendon together with a splint to rest the thumb. It is also very important to identify the activity that caused the problem and avoid it.

Trigger finger

Make a fist and then straighten your fingers. If one finger lags behind the others, at first refusing to straighten and then suddenly straightening with a ‘click’, you have trigger finger. The condition is the result of a nodule that develops on the tendon as it runs through the palm of the hand. The nodule catches on the edge of the tendon sheath during movement.

Treatment

If the nodule is painless and does not affect the use of your hand, it is probably best left alone because it may settle by itself. If necessary, you can be given a steroid injection to shrink the nodule and free the tendon.

Knee pain

Most people have painful knees at some time in their lives. In older people, osteoarthritis is common but there are many other causes of knee pain, especially in younger people. The knee is subjected to considerable stresses, especially if you are very overweight. Some sports, such as skiing and football, require your knees to rotate and bend and bear your weight at the same time, placing the knees under great strain.

All this means that the knees are susceptible to a wide range of injuries, often affecting the shock-absorbing cartilage pads within the joint and the many ligaments that hold the joint together. Many injuries will heal naturally but some may need splints or even surgery.

Pain under the heel

Pain in the sole of the foot, directly under the heel, is often caused by plantar fasciitis. This troublesome condition causes pain which is particularly severe when you first get out of bed in the morning but then eases a little as you continue to walk. The plantar fascia is a tough fibrous band, shaped like a triangle, which joins the ball of the foot with the heel bone. The strain and inflammation occur at the point where the fascia joins the heel bone. Sometimes, an extra bit of bone, known as a spur, may grow at this point.

Plantar fasciitis often affects people who are on their feet a lot in their work and those who are overweight, so good footwear and losing weight can help. It can also be a feature of some types of inflammatory arthritis, but this is unusual.

In older people, pain under the heel can also be the result of thinning of the fat pad. There is normally a dense cushion of tissue, mostly fat, under the heel, which acts as a shock absorber when walking. This cushion may become thin as you get older and the heel bone is no longer so well protected. Well-fitting shoes with soft, sponge rubber soles and heels, perhaps with a soft insole as well, will protect the heels.

Look after your knees

• Avoid squatting and kneeling, which strain the knees.

• Keep your weight down. If you are overweight, losing just a few pounds can help your pain and make all the difference to the strain on your knees.

• Avoid sitting in low, soft chairs. Getting out of them can be difficult if you have painful knees.

• Keep your thigh muscles strong with exercises, especially if you play sports.

• Do not sleep with a pillow under your knees. It may feel comfortable but your knees can become permanently bent.

Treatment

Steroid injection often helps plantar fasciitis but, because the injection can be very painful, other options may be tried first. These include an anti-inflammatory drug, wearing heel cups made of dense, shock-absorbing foam inside your shoes and strapping put on by a physiotherapist. Losing weight, if you are overweight, and avoiding prolonged standing can also help.

KEY POINTS

• Pain in the muscles and joints is not always caused by arthritis

• Widespread musculoskeletal pain may be caused by conditions such as fibromyalgia and hypermobility, which are different from arthritis

• Pain in one region may be the result of problems with soft tissues, such as tendons and ligaments, and is often caused by overuse