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Key facts
- Musculoskeletal conditions affect millions of people in the UK
- They account for more than 20 per cent of years lived with disability
- With correct diagnosis and appropriate treatment, muscle and joint pain can be managed and quality of life improved.
Learning objectives
After reading this feature you should:
- Be able to recognise the symptoms of osteoarthritis and rheumatoid arthritis
- Understand the recommended treatment strategies for both conditions
- Know how to help and advise patients who present with sprains and strains.
According to the charity Versus Arthritis, more than 20 million people in the UK are living with a musculoskeletal condition. Some 9.5 million report low back pain each year, 10 million have a probable diagnosis of osteoarthritis, 1.6 million have gout and 450,000 have rheumatoid arthritis.
People with these conditions are likely to have a reduced quality of life, with 21 per cent of years lived with disability accounted for by musculoskeletal problems. Pain is the main factor cited as having an impact, with 29 per cent of people saying that this impact is significant.
“With any type of joint pain, the earlier we see people, the better they do,” says GP, rheumatologist and Versus Arthritis clinical champion Dr Danny Murphy. “In most cases, it will be caused by osteoarthritis, especially if sufferers are over
45 years of age and the pain is of gradual onset. Once identified, they can start making lifestyle changes, which will make all the difference.”
Mark Burdon, pharmacist adviser to OTC company Mentholatum, says: “Muscle and joint problems are common but not inevitable. Where they do occur, they can have a catastrophic effect on the person – but there is a lot we can do as pharmacists. It is important to make sure patients know they don’t have to live with the pain.”
Osteoarthritis
Osteoarthritis is the most common cause of joint pain pharmacy teams are likely to see. It can affect any joint, but most commonly the knee, hip and hand joints. In affected areas, the cartilage thins and becomes rougher, so the joint cannot move smoothly. Changes to the joint structure can cause pain and inflammation.
“Pharmacists can play an important role as they may be the first point of contact,” says Dr Murphy. “They can be a ‘permission giver’ and encourage patients to remain active. Be positive in advice- giving, telling patients that it can get better and there is lots they can do to help themselves.”
With osteoarthritis, there is usually a history of activity-related joint pain, normally only affecting a few joints, with the pain worsening gradually. The condition is not associated with morning stiffness, but there will be some functional impairment. Signs to look for include:
- Bony swelling and joint deformity
- Soft tissue swelling, warmth and tenderness
- Muscle wasting and weakness
- Restricted and painful range of movement.
Ask patients about the site of their pain, how long it has lasted, how severe it is, and if there is joint swelling or stiffness. Refer people to their GP for investigation and diagnosis if necessary.
Spotting joint pain red flags
Clara Kervyn, physiotherapist and adviser to the Deep Heat and Deep Freeze brands, says: “Most red flags where pharmacists should direct patients to their GP are easily spotted: if a joint is too painful to move or cannot bear weight; if the joint looks deformed; severe swelling; discolouration; red, hot joints; bleeding; fever; or the pain doesn’t respond to self-care treatments.” Other red flags include:
Septic joint: This is a rare but serious type of joint infection that needs urgent treatment. Symptoms include severe and sudden joint pain, usually in one joint; swelling around the joint; severely restricted movement; a change in skin colour around a joint; feeling unwell; fever. Treatment is usually intravenous antibiotics in hospital. It is essential for patients to continue antibiotic treatment post-discharge.
Persistent pain: “If a patient with osteoarthritis has made lifestyle changes and is taking analgesia but is still in a lot of pain, they should be referred, but not necessarily to their GP – a physiotherapist, occupational therapist or even a community group may be more helpful,” says Versus Arthritis clinical champion Dr Danny Murphy. He recommends the ESCAPE pain programme, a group rehabilitation scheme for people with chronic joint pain, which can be found online at escape-pain.org.
Persistent and progressive bone pain not related to any activity: If the pain has worsened quickly, there is pain at night and an unexplained mass or swelling. This may indicate bone or soft tissue sarcoma and needs urgent referral.
Suspected fracture especially if there is a history of trauma.
Risk factors
Age: people over the age of 40 years
Gender: osteoarthritis is more common and more severe in women
Overweight/obesity: weight increases the load on knees and hips, and worsens disease progression
Joint injury: a major injury or surgery on a joint can increase risk
Genetics: family history can increase disease likelihood, especially of hand arthritis
Physically demanding jobs
High levels of exercise.
Pain management
Drug treatments: “It is important to recommend pain relief,” says Dr Murphy, “because if a patient has their pain controlled, they are more likely to stay active.”
First-line treatment, particularly for knee involvement, is a topical NSAID, such as ibuprofen 5% gel up to three times a day, if there are no contraindications. If a topical NSAID is not effective or is contraindicated, an oral NSAID can be suggested. It should be used at the lowest effective dose for the shortest time possible.
Paracetamol or weak opioids can be used short-term if other drugs are not effective, suitable or tolerated. Capsaicin cream is an alternative and should be used for at least two weeks.
COX-2 inhibitors, including celecoxib and etoricoxib, can be prescribed orally for pain relief and are less likely to cause gastric side-effects than traditional NSAIDs.
Corticosteroid injections can be given for severely painful joints or when other treatments are ineffective or unsuitable.
Heat and cold therapy: Applying warmth to a painful joint can give relief. This could be a hot water bottle, heat pad or a heat treatment cream, gel or spray. For swollen joints, cold therapy can be recommended to reduce inflammation.
“For muscle and joint pain, topical therapy should usually be the first treatment – cold therapy in the first few days to ease swelling, then heat therapy to improve blood flow to affected area and promote healing,” explains physiotherapist Clara Kervyn.
Aids and supports: Splints, braces and supports can help with joint pain and instability. Orthotics can give extra support and help to correct structural changes in the feet.
Lifestyle advice: Weight loss will make the biggest difference to joint pain caused by osteoarthritis. Pharmacy teams can advise on a healthy, balanced diet and increasing physical activity to aid loss of weight.
Activity and exercise can help with joint pain
“The single most important thing people with joint pain can do is to keep active and exercising. This strengthens the muscles that support the joints. The joints can recover and repair if they are kept moving and this helps with the pain as well,” says Dr Danny Murphy from Versus Arthritis.
According to physiotherapist Matthew Harrison, there isn’t one particular type of exercise that is better than another. “I always advise people to adopt a routine based on the activities they enjoy,” he says. For osteoarthritis, he has this guidance: “It is important to understand the levels of activity that will flare up symptoms. General physical activity will help relieve stiffness in joints. However, more activity than the body is used to can increase pain, so it is vital for patients to gradually increase activity and listen to their body.”
For rheumatoid arthritis patients, he says: “Exercise advice is the same as for osteoarthritis, but the key difference for rheumatoid arthritis is acknowledging a sudden change in the condition. Specific symptoms to be aware of that require urgent care are change in vision or eye health, a change in joint appearance or loss of limb power.”
Versus Arthritis advises a mixture of exercises that can help to avoid repetitive stress on joints. A downloadable factsheet of exercises that can be recommended to patients is available on the versusarthritis.org website. People can also be signposted to ‘Move with Leon’, a 12-week programme of 30-minute movement sessions from fitness expert Leon Wormley. This is also available on the Versus Arthritis website.
For relief from muscular pain after a sprain or strain, Harrison says: “After the first 24-48 hours, the patient should gradually start moving as feels comfortable in short bursts to assess how their body reacts. Activity should then be gradually increased back to normal levels.”
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune condition that attacks joints, causing pain and inflammation. If it is left untreated, it can damage joints, cartilage and bones. The condition is most common in people aged 30-50 years and is two to four times as common in women than in men.
“A significant majority of rheumatoid arthritis patients experience chronic pain due to inflammation and joint damage,” says a spokesperson from the National Rheumatoid Arthritis Society (NRAS). “Early diagnosis and prompt treatment are crucial as they can help limit damage to joints, slow progression and improve quality of life.”
“The joints most affected by rheumatoid arthritis are the smaller joints of the hands and feet, particularly the metatarsophalangeal joints in the forefoot and knuckle joints. It tends to affect joints symmetrically, but not always.”
Other signs to look out for include fatigue, loss of appetite, weight loss, fever, sweating, dry eyes and chest pain.
There are several risk factors that can make rheumatoid arthritis more likely:
- Family history: increases risk two- to four-fold
- Age: most people are diagnosed at age 30-50
- Gender: women are two to four times more likely to be affected
- Weight: being overweight or obese increases a person’s risk
- Smoking: also increases risk.
Pain management
Once rheumatoid arthritis is confirmed, patients should be referred to a rheumatology clinic for
assessment and a treatment plan. Patients are usually given a DMARD (disease-modifying antirheumatic drug such as methotrexate, leflunomide or sulfasalazine). These slow disease progression and improve symptoms but can take a number of weeks to kick in, says NRAS.
Biological therapies (abatacept, rituximab, tocilizumab) are newer treatments and can be offered to patients who are unable to take other DMARDs. “Unlike conventional DMARDs that broadly suppress the immune system, biologics offer more targeted therapy, potentially with better symptom control and fewer side-effects,” says NRAS.
Analgesics such as NSAIDs can be used to relieve pain and reduce inflammation. A traditional NSAID (ibuprofen, diclofenac, naproxen) or a COX-2 inhibitor can be recommended. A proton pump inhibitor may be offered at the same time to minimise gastric side-effects. NSAIDs should be used at the lowest effective dose and if possible withdrawn when there is a good response to mainstay treatment with DMARDs.
Short-term treatment with glucocorticoids can be used for treating flare-ups to reduce inflammation. The NRAS Smile-RA (Self-Management Individualised Learning Environment) programme is also recommended by NICE to reduce flare-ups. This can be found at nras.org.uk/SMILE.
“Pharmacists would benefit themselves from doing the courses to help understand how to self-manage rheumatoid arthritis and they can signpost patients to it,” says NRAS.
“The single most important thing people with joint pain can do is keep active and exercising”
Muscular pain
Sprains and strains are the most common causes of muscular pain that community pharmacists are likely to encounter.
A sprain is a stretch or tear of a ligament due to excessive force on a joint. Symptoms include pain around the joint, swelling, bruising, tenderness and pain on weight bearing.
A strain is a stretch or tear of muscle fibres or tendons, either because a muscle has been stretched too far or forced to contract too quickly. Signs include muscle pain, cramping, spasm, muscle weakness, inflammation and bruising.
“Typically, this is the result of a change in activity,” says physiotherapist Matthew Harrison from the Chartered Society of Physiotherapists. “This can be doing a familiar activity but performing it more intensely or for a more prolonged period, or taking up a new activity or something that hasn’t been done for a long time.”
Treatment and advice
Customers should be referred to A&E if there is a suspected fracture, dislocation, damage to nerves or circulation, a wound penetrating the joint, a serious tear or a large haematoma.
Otherwise, for the first 48-72 hours after injury, self-management with PRICE can be advised:
Protection: use a support to protect from injury
Rest: avoid activity for 48-72 hours
Ice: apply an ice pack for 15-20 minutes every two to three hours or use a cold spray as directed on the product
Compression: use an elasticated bandage (snug but not tight) to control swelling and provide support. Remove before bed
Elevation: keep the injured area elevated and supported on a pillow until the swelling is controlled.
Paracetamol can be recommended for pain relief and a topical anti-inflammatory can also be effective.
Mild sprains and strains usually heal within a few weeks. Moderate injuries should improve after a few weeks, but there is a high risk of re-injury in the first four to six weeks. Strenuous exercise should be avoided for up to eight weeks to prevent further damage.
It is also useful to remind customers of the importance of warming up and cooling down before/after exercise to prevent further muscle pain or damage.
- See also Clinical update: acute pain and transformational care, January 2025 issue,
and at pharmacymagazine.co.uk/clinical
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