'Tips and tricks' for improving diagnosis, treatment of musculoskeletal disease
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A reminder of some common and not-so-common clinical scenarios can make every rheumatologist more capable of delivering optimal patient care, according to a presenter at the 2021 Congress of Clinical Rheumatology-West.
“I want to go through some tips and tricks, some of the more common things we see in clinic,” Jason R. Kolfenbach, MD, associate professor of medicine and ophthalmology and director of the rheumatology fellowship program at the University of Colorado, Boulder.
Kolfenbach provided information on a smattering of autoimmune and rheumatic diseases, from rheumatoid arthritis and regional musculoskeletal (MSK) disease.
The first over-arching point Kolfenbach made was that patients with rheumatic disease can get non-inflammatory diseases, as well. “We know that, but we need to be able to keep that at the forefront of our mind,” he said.
For example, a patient with RA may come in complaining of shoulder pain. But if their RA is well-controlled and they have no issues otherwise, the shoulder issue may be due to tendonitis or neuromuscular pain. “You can have a lot of different etiologies of pain,” Kolfenbach said.
The next pearl dealt with lower extremity complaints. He noted that most rheumatologists will have a patient take off her shoes and walk across the room as part of routine care. When the fat padding underneath the metatarsal heads moves, patients can experience pain while walking. “It is a difficult thing to address medically with any kind of therapy,” Kolfenbach said. “But we can offer shoes with wide toe boxes, we can consider referral to podiatry or even buy metatarsal pads.”
Another practical tip dealt with early hip osteoarthritis in individuals with no previous history of OA or inflammatory arthritis. “Look for signs of femoral acetabular impingement,” Kolfenbach said.
This can manifest as what Kolfenbach referred to as a “pistol grip” deformity. “This could be a sign for early OA in young folks,” he said.
Providing advice to a patient with lower extremity OA is another pivotal conversation a rheumatologist can have. “Some people might benefit from a cane, both for stability and to provide them relief for their joint,” Kolfenbach said.
The issue is that many patients buy the cane online and then begin using it with no instructions. “You might be the first point of contact for that,” Kolfenbach said. He suggested that the cane should be used with a light bend at the elbow.
The final point Kolfenbach offered pertained to patients with arthritis going up and down stairs. He stressed that if one side, hip or leg is better than the other, it is ideal to lead with the good leg going up and with the bad leg going down. “The mnemonic is up to heaven, down to hell," he said.
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Kolfenbach JR. Top Secrets in Rheumatology. Presented at: Congress of Clinical Rheumatology-West annual symposium; September 18-21, 2021 (hybrid meeting).
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