Case study: Bill, 51 year old self-employed plasterer and painter
G’day, I’m Bill. I’m 51 years old and I work as a self-employed plasterer and painter.
I’ve had this pain in my right shoulder for about 6 months now. It’s really sore and quite sharp, especially when I’m painting and using my arm above my head. When I stop using it, it aches for several hours. I’ve noticed it’s also quite stiff in the morning, so setting up on a worksite is taking longer than it used to, and this is really frustrating. I’ve also been feeling really tired, especially in the afternoons, but I suppose that’s from taking on extra jobs lately. I’m saving up for a holiday.
I haven’t got much help at home. I separated from Jenny, my wife, just recently. I see my 2 boys though, every Wednesday and every other weekend. The damn shoulder is making it hard to play footy with the boys and do stuff around the house; like hanging out the washing. I’m not sleeping that well as I keep waking with the shoulder pain and it takes me an hour or two to fall asleep again. Can you help me?Bill, plasterer and painter.
Bill smokes 2-3 cigarettes each day. He reports being generally well and healthy with no past medical history of note. He usually does not take any medication nor has he taken any medication for his sore shoulder. No radiological investigations have been conducted for his shoulder pain.
On physical examination Bill is a stocky-framed male with good sitting and standing posture. Active right shoulder flexion and abduction are both painful at ~90° increasing through range to 160° where pain limits further movement. Passive right shoulder flexion is painful only at ~160° and passive abduction is painful at 90° with pain staying the same to end of range at ~160°. Passive and active right shoulder internal and external rotation in neutral are both painful at end of full range of motion. Passive and active right horizontal flexion are both painful through range with some limitation of range. Left shoulder active movements are full range with a feeling of tightness (no pain) at the end of range. Orthopaedic tests (rotator cuff and Hawkins Kennedy) are inconclusive, reproducing some right shoulder discomfort, but not Bill’s specific pain. Palpation reveals tenderness over the acromioclavicular joints (right > left) and palpation on the right acromioclavicular joint reproduces Bill’s symptoms.
An assessment of active and passive range of motion of the elbow, forearm, wrist and digits reveals resistance at end range of motion in all directions (right = left). Bill reports his feeling of stiffness (both right and left sides) as these movements are performed.
Question 1Which clinical features described by Bill may indicate features consistent with an inflammatory joint disease such as rheumatoid arthritis?
The cluster of clinical features described by Bill (rather than a single symptom or sign) that may indicate features consistent with an inflammatory joint disease include:
- A long history of right shoulder pain - 6 month history of sharp pain
- The pain persists as an ache for several hours after activity
- Prolonged morning stiffness
- Work and activities of daily living are more difficult and take longer than usual
- Fatigue, particularly by the afternoon
- Life stress: separation from wife and children
According to the EULAR [.pdf 222 kB] and Early Inflammatory Arthritis Detection Tool [.pdf 949 kB], subjective clinical features that may alert the physiotherapist to suspect rheumatoid arthritis include pain, prolonged morning stiffness and loss of function (where no other cause can be found to explain these clinical features). The symptoms are usually worse at rest or during periods of inactivity. Systemic features of malaise and fatigue may also be present. Most people have an insidious onset, but others can have a rapid, or relapsing and remitting course. A thorough subjective assessment should establish if symptoms are persistent in nature, i.e. lasting a few weeks rather than days.
ImportantIt is important to consider the cluster of signs and symptoms in this case. In isolation, individual signs and symptoms may suggest a range of alternative diagnoses.
Question 2What additional screening would be appropriate to undertake to further investigate the possibility of an inflammatory joint disorder?
Further appropriate subjective questioning may include:
- Specific current or past symptoms relating to:
- the small joints in the hands
- joints in the lower limbs, particularly the ankle and foot
- extra-articular features such as nodules (not necessarily visible “lumps”, however, the patient may feel them), weight loss, generally feeling intermittently or persistently unwell over previous months
Further appropriate physical examinations may include:
- The metacarpal squeeze test/metatarsal squeeze test
- Limb or joint circumference measurements to objectively record swelling
Physiotherapists are well placed to identify criteria that may suggest an inflammatory disorder, specifically:
- Symptom duration and symmetrical joint involvement. Rheumatoid arthritis typically presents as symmetrical joint synovitis, primarily in the small joints of the hands and feet, although any synovial joint may be affected
- Extra-articular features associated with rheumatoid arthritis due to vasculitis. Organ-specific manifestations may result due to ischaemic changes in a number of body systems, most commonly the cutaneous, neurological and pulmonary systems
- Features consistent with a systemic disorder, such as malaise, fatigue, fever, sweats, weight loss.
If you are unsure, why not use a screening tool such as the Early Inflammatory Arthritis Detection Tool [.pdf 949 kB].
Question 3You suspect Bill may have an inflammatory joint disorder such as rheumatoid arthritis. At this stage, what would you identify as your main clinical priority?
The main clinical priority is to refer Bill to a GP for further investigation and if necessary, a referral to a rheumatologist within 6 weeks. This management strategy will ensure the necessary assessment/evaluations are performed and appropriate medical/pharmacologic management commenced. Early diagnosis and initiation of therapy increases the likelihood of a better prognosis.
While awaiting confirmation of diagnosis, physiotherapeutic strategies to manage presenting symptoms should be implemented with considerations/modifications for inflammatory arthritis. Additionally, education that includes strategies for activity modification/joint protection may be provided as well as strong advice to quit smoking.
You decide to refer Bill to his GP for further investigations. Bill returns to your practice 4 weeks later with a diagnosis of rheumatoid arthritis from his rheumatologist. Bill is surprised and slightly distressed by the news and believes his career as a painter may be over. He is also concerned that the medications he has started taking aren’t really making any substantial differences to his aching shoulder, stiff hands/wrists and feelings of fatigue.
Question 4What would your management plan for Bill be at this stage?
- Validate the diagnosis and acknowledge distress
- Life as a painter/plasterer is not over! There is a lot that can be done– good to get it early
- Therapeutic window for medication. Advise to speak with GP if concerned that medication is not helping
- Address presenting symptoms of pain and inflammation
- Electrotherapy, joint protection, ice/heat
- Education re: pacing and planning activities for earlier in the day
- Advice about sleeping posture
- Address presentation of joint stiffness
- Active Range of Motion (AROM) exercises within pain limits
- Improve functional capacity
- Educate about alternative methods of managing overhead tasks while waiting for pain to settle. For example, use a clothes horse instead of the washing line; rearrange kitchen so regularly used items are stored at a height level that does not induce pain
- Encourage non-contact footy playing with boys. For example, kick to kick; kicking for goals and; kicking to boys so they can have marking practice so that he can avoid overhead contests
- Advise re: time-contingent rather than pain-contingent pacing for on-site jobs and encourage discussion with colleagues on-site. Engage in general muscle strengthening exercises. In particular, focus on leg muscles so that he may load legs instead of arms. Check lifting techniques
- Adopt a self-management support approach using principles of chronic disease self-management such as: goal setting, understanding the disease, identifying needs