Rheumatology and Persistent Pain
Separate inflammatory from mechanical
Inflammatory back pain: insidious onset, age under 45, morning stiffness over 30 minutes, improvement with exercise, night pain, good response to NSAIDs. Axial spondyloarthritis is diagnosed from imaging plus clinical features (ASAS criteria), not HLA-B27 alone. Rheumatoid arthritis uses the 2010 ACR/EULAR score (joint involvement, serology, acute-phase markers, duration of at least six weeks; a score of 6/10 or more supports RA). Gout is confirmed by negatively birefringent needle-shaped crystals.
Safety points examiners love
Giant cell arteritis is an emergency - new headache, jaw claudication, visual symptoms, raised ESR/CRP; give glucocorticoids before imaging. Methotrexate requires FBC, liver and renal monitoring. Biologics require TB and hepatitis screening before starting. Long-term glucocorticoids carry risks of osteoporosis, diabetes and infection.
Persistent pain
Classify mechanisms - nociceptive, neuropathic, nociplastic - and never imply the pain is imagined. Explain central sensitisation in plain language, use pacing and graded exposure, address sleep and distress, and consider CBT, acceptance-based approaches and pain education as adjuncts. Opioids offer small short-term benefit and substantial harm; they are not a treatment for central sensitisation.
Traps
Normal inflammatory markers do not exclude inflammatory disease. Wear-and-tear language increases fear and disability. Fibromyalgia is a clinical diagnosis, not a diagnosis of exclusion requiring exhaustive testing.
Worked example
A 34-year-old with four months of buttock pain, 60 minutes of morning stiffness and improvement with exercise, with normal CRP: the picture is inflammatory - refer to rheumatology and arrange imaging, rather than anchoring on mechanical back pain because the MRI is normal.