Introduction

Inflammatory musculoskeletal conditions comprise a diverse group of disorders characterized by inflammation affecting joints, peri-articular structures, muscles, tendons, ligaments, bursae, fascia, and connective tissues. These conditions may result from autoimmune disease, crystal deposition, infection, trauma, metabolic disorders, or reactive inflammatory processes. Persistent inflammation can lead to pain, swelling, stiffness, progressive joint destruction, disability, and impaired quality of life if not recognized and treated appropriately.

Management aims to reduce inflammation, relieve pain, preserve joint function, prevent structural damage, and improve long-term physical function through pharmacological and non-pharmacological interventions.

Common inflammatory musculoskeletal conditions

Common disorders include:

• Rheumatoid arthritis

• Ankylosing spondylitis

• Psoriatic arthritis

• Reactive arthritis

• Juvenile idiopathic arthritis

• Crystal arthropathies (gout and calcium pyrophosphate deposition disease)

• Polymyalgia rheumatica

• Systemic lupus erythematosus with musculoskeletal involvement

• Bursitis

• Tendinitis and tenosynovitis

• Synovitis

Pathophysiology

Inflammatory musculoskeletal diseases develop when activation of the innate and adaptive immune systems leads to excessive production of inflammatory mediators within joints and surrounding soft tissues. Cytokines such as tumour necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6) stimulate recruitment of inflammatory cells, increase vascular permeability, and promote synovial proliferation. Persistent inflammation results in cartilage degradation, bone erosion, tendon damage, and fibrosis, leading to chronic pain, joint stiffness, deformity, and progressive functional impairment. In crystal-induced diseases, inflammation is triggered by deposition of monosodium urate or calcium pyrophosphate crystals, whereas in autoimmune disorders the inflammatory response is directed against self-antigens.

Clinical presentation

Although clinical features vary depending on the underlying disorder, common manifestations include:

• Joint pain

• Joint swelling

• Morning stiffness

• Warmth over affected joints

• Tenderness

• Reduced range of motion

• Fatigue

• Muscle weakness

• Functional limitation

Systemic inflammatory diseases may also present with:

• Fever

• Weight loss

• Malaise

• Skin rash

• Eye inflammation

• Mucosal ulcers

General principles of management

Treatment should be individualized according to the underlying diagnosis, disease severity, patient comorbidities, and risk factors.

Management generally includes:

• Patient education

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Disease-specific therapy when indicated

• Physiotherapy

• Occupational therapy

• Lifestyle modification

• Regular monitoring for treatment efficacy and adverse effects

Pharmacological management

Non-steroidal anti-inflammatory drugs (first-line therapy)

NSAIDs are the first-line pharmacological treatment for many inflammatory musculoskeletal conditions because they inhibit cyclooxygenase (COX-1 and COX-2) enzymes, reducing prostaglandin synthesis and thereby decreasing inflammation, pain, and stiffness. They provide symptomatic relief but do not alter the underlying disease process in chronic inflammatory arthritides such as rheumatoid arthritis.

Common NSAIDs include:

Ibuprofen

Adults

• 400–600 mg orally every 6–8 hours as required.

• Maximum: 2,400 mg/day under medical supervision (up to 1,200 mg/day for over-the-counter use).

Diclofenac

Adults

• 50 mg orally every 8 hours.

Maximum:

• 150 mg/day.

Aspirin

Adults

• 300–900 mg orally every 4–6 hours as required.

Maximum:

• 4 g/day.

Important precautions when using NSAIDs

NSAIDs should be used cautiously in:

• Older adults

• Pregnancy (particularly after 20 weeks and contraindicated during the third trimester unless specifically indicated)

• Patients with asthma sensitive to NSAIDs

• Chronic liver disease

• Chronic kidney disease

• Hypertension

NSAIDs should generally be avoided in patients with:

• Active peptic ulcer disease

• Previous NSAID-induced gastrointestinal bleeding

• Bleeding disorders

• Severe heart failure

• Established cardiovascular disease where possible

• High cardiovascular risk

• Severe renal impairment

Because NSAIDs increase the risk of gastrointestinal ulceration and bleeding, they should be taken with food or milk whenever possible.

Gastroprotection

Patients at increased risk of gastrointestinal complications should receive gastroprotective therapy.

Preferred options include:

• Proton pump inhibitors (e.g., omeprazole)

If dyspeptic symptoms occur during NSAID therapy:

• Assess for gastrointestinal complications.

• Consider adding an antacid such as magnesium trisilicate mixture for temporary symptom relief.

• If symptoms persist and NSAID therapy remains essential, initiate a proton pump inhibitor or histamine-2 receptor antagonist according to local treatment guidelines and reassess the need for continued NSAID therapy.

Analgesics

Paracetamol is not an anti-inflammatory drug and should not be used as sole therapy for active inflammatory conditions. However, it may be used as an adjunct analgesic when additional pain relief is required.

Corticosteroids

Systemic or intra-articular corticosteroids may be indicated for selected inflammatory diseases such as rheumatoid arthritis, polymyalgia rheumatica, crystal arthritis, or systemic autoimmune diseases. Their use should be based on disease-specific treatment recommendations because prolonged therapy is associated with significant adverse effects.

Disease-modifying antirheumatic drugs (DMARDs)

Patients with chronic inflammatory arthritis should be evaluated promptly for initiation of DMARD therapy, including:

• Methotrexate

• Sulfasalazine

• Hydroxychloroquine

• Leflunomide

These medicines should be initiated and monitored by clinicians experienced in managing inflammatory rheumatic diseases.

Non-pharmacological management

Patient education

Patients should understand:

• The nature of their disease

• Treatment goals

• Importance of medication adherence

• Recognition of adverse drug effects

• Importance of follow-up

Physiotherapy

Physiotherapy is an important adjunctive treatment and should include:

• Range-of-motion exercises

• Muscle strengthening

• Stretching exercises

• Joint protection techniques

• Postural training

• Aerobic conditioning

Occupational therapy

May assist patients with:

• Joint protection

• Energy conservation

• Adaptive equipment

• Workplace modifications

Lifestyle modification

Patients should be encouraged to:

• Maintain a healthy body weight

• Stop smoking

• Engage in regular low-impact exercise

• Consume a balanced diet

• Ensure adequate calcium and vitamin D intake when appropriate

Monitoring

Patients receiving long-term NSAIDs should be monitored for:

• Gastrointestinal bleeding

• Renal function

• Blood pressure

• Cardiovascular events

• Hepatic function when clinically indicated

Patients receiving DMARDs require regular laboratory monitoring according to the specific medicine prescribed.

Referral

Patients should be referred to a higher-level health facility or rheumatology service if they have:

• Suspected inflammatory arthritis requiring DMARD therapy

• Severe rheumatic disease

• Diagnostic uncertainty

• Progressive joint destruction

• Significant functional impairment

• Systemic autoimmune disease

• Recurrent inflammatory arthritis

• Peptic ulcer disease requiring continued NSAID therapy

• Serious adverse reactions to treatment

• Failure of first-line management

Patient education

Patients should be advised to:

• Take NSAIDs exactly as prescribed.

• Take NSAIDs with food.

• Avoid taking multiple NSAIDs simultaneously unless specifically instructed.

• Report black stools, vomiting blood, severe abdominal pain, chest pain, shortness of breath, or reduced urine output immediately.

• Attend regular follow-up appointments.

• Continue prescribed physiotherapy exercises.

• Maintain regular physical activity while avoiding excessive joint strain.

• Inform healthcare providers of all medications they are taking before starting NSAID therapy.