Inflammatory, metabolic and soft-tissue musculoskeletal pain

Before treating musculoskeletal pain as mechanical, look for inflammation, metabolic disease, hypermobility or neuropathic joint destruction: each changes the first test or treatment, and some threaten the joint or the spinal cord.

1. Polymyalgia and arteritis need different doses. EULAR 2025 advises specialist assessment and a starting prednisone-equivalent of 15–25 mg/day for polymyalgia rheumatica and 40–60 mg/day for giant cell arteritis ¹.
2. Gout flares have three first-line options. ACR 2020 strongly recommends colchicine, NSAIDs or glucocorticoids (oral, intra-articular or intramuscular), chosen by patient factors, and low-dose rather than high-dose colchicine ².
3. Axial spondyloarthritis escalates to TNF inhibition. Active disease despite an adequate NSAID trial warrants a TNF inhibitor (strong recommendation); systemic glucocorticoids are strongly recommended against ³.
4. Early frozen shoulder responds to intra-articular steroid. In a meta-analysis of 65 randomized studies, only intra-articular corticosteroid gave clinically superior short-term pain and function; pair it with home exercise in disease under 1 year ⁴.
5. Rheumatoid neck pain can mean instability. Up to 86% of patients have cervical involvement, including atlantoaxial subluxation, retro-odontoid pannus, cranial settling and subaxial subluxation that can compress brainstem or cord ⁵.
6. Myalgia may be the only sign of hypothyroidism. Stiffness, cramps, myalgia and easy fatigability are common, and creatine kinase may be raised without tracking symptom severity ⁶.

A warm, swollen, mildly painful foot in a patient with diabetic neuropathy suggests active Charcot neuroarthropathy, which is often misdiagnosed as cellulitis, deep vein thrombosis or gout ⁷.

• In active Charcot foot, offloading is the key treatment, ideally an irremovable total contact cast continued until swelling resolves and foot temperatures are within 2°C ⁷.
• MRI shows early Charcot changes while radiographs are still normal; bounding pulses are typical ⁷.
• An adequate axial spondyloarthritis NSAID trial: no response to at least two NSAIDs at maximal doses over 1 month, or incomplete response to two over 2 months ³.
• With strong suspicion of giant cell arteritis, start glucocorticoids without waiting for confirmatory tests; polymyalgia treatment can usually wait for diagnosis ¹.
• In rheumatoid cervical disease, radiographs are used most; MRI and CT assess neural involvement and plan surgery ⁵.
• Hypermobile Ehlers-Danlos syndrome has no known molecular cause, so diagnosis is clinical: Beighton-scored hypermobility, systemic or family features, and exclusion of alternatives ⁸.
• In axial spondyloarthritis, sulfasalazine or methotrexate are considered only with prominent peripheral arthritis or when TNF inhibitors are unavailable ³.
• Rare muscular presentations of hypothyroidism include rhabdomyolysis, acute compartment syndrome and Hoffman's syndrome ⁶.

• Assuming rheumatoid neck pain is facet-mediated when instability can compress the brainstem and cord ⁵.
• Giving antibiotics for a hot Charcot foot that only mimics cellulitis ⁷.
• Starting arteritis-level steroid doses for isolated polymyalgia ¹.
• Prescribing systemic glucocorticoids for axial spondyloarthritis ³.