Presenting Problem
The patient reported bilateral forearm pain persisting for approximately 3-4 months. Initially, the pain was manageable but had become more frequent in the past month, accompanied by a sensation of heaviness in the arms. She could not recall any specific injury but suspected repetitive strain from recent house re-arranging tasks.
- Pain type: Deep, dull ache with occasional throbbing and heaviness in the hands.
- Neurological Symptoms: Occasional pins and needles, but no persistent numbness or sensory loss.
- 24-Hour Pattern: No clear diurnal variation.
- Medical History: Underactive thyroid, managed with levothyroxine.
- Medications: Levothyroxine.
- Previous Treatment: Rest and occasional paracetamol, with minimal relief.
- Family History: No relevant conditions reported.
- Smoking History: Smokes 2-3 cigarettes per day, currently trying to quit.
- General Health: Reports feeling well overall.
Red Flag Screening
The patient was screened for red flags associated with serious pathology:
- Pins and Needles: Occasionally in both hands but not persistent.
- Numbness: None reported.
- Dizziness: Occasionally feels lightheaded.
- Chest Pain & Breathlessness: Denied.
- Other Joint Pain: Occasional knee aches, possibly due to arthritis.
- Speech or Swallowing Issues: Denied.
- Weakness in Hands: Denied.
- Swelling, Redness, or Skin Changes: None observed.
Objective Assessment
A physical examination was conducted to assess joint mobility, strength, and neurological function.
- Bilateral Shoulder, Elbow, and Wrist: Full active range of motion (FAROM) with mild discomfort in the elbows.
- Palpation: Mild tenderness over the right brachialis.
- Special Tests: Cozen’s and Mill’s tests were negative.
- Blood Pressure Measurements:
- Initial reading: 221/110 mmHg, pulse 95 bpm.
- Repeated after 5 minutes: 220/108 mmHg, pulse 95 bpm.
- Pain Response to Blood Pressure Measurement: The patient experienced significant forearm pain as the cuff pressure increased, resembling her usual symptoms.
Patient History and Concerns
Further questioning revealed that she had visited A&E 1.5 years ago for high blood pressure and was advised to monitor it. Despite receiving a letter for follow-up, she struggled to get a GP appointment and had given up seeking medical attention, assuming the issue was not urgent.
Management Plan
Given the significantly elevated blood pressure readings and the potential cardiovascular implications, urgent intervention was advised:
- Immediate Referral: The patient was advised to attend A&E due to the high risk associated with uncontrolled hypertension. However, she was reluctant, perceiving the issue as non-urgent.
- GP Follow-Up: Arrangements were made with the clinic reception to schedule an urgent GP appointment for blood pressure management.
- Patient Education & Safety Netting: The patient was informed of the risks of stroke and cardiovascular complications and was advised to seek immediate medical attention if she experienced any concerning symptoms, such as chest pain, severe headaches, visual disturbances, or neurological deficits. Instructions to contact 111 or A&E in case of emergency were provided.
- Musculoskeletal Management:
- Circulatory and gripping exercises were prescribed to improve forearm function.
- Mobility exercises for the elbow and wrist were recommended.
- Advice on activity modification to reduce repetitive strain was provided.
Follow-Up
Two months later, the patient returned to the clinic for knee pain. Upon review of her forearm symptoms, she reported complete resolution of arm pain since starting antihypertensive medication, including amlodipine, ramipril, and atorvastatin. She was under regular GP follow-up and scheduled to see the nurse practitioner for medication review and dosage adjustments as needed.
Discussion and Conclusion
This case highlights the importance of a holistic approach to musculoskeletal presentations, recognising underlying systemic conditions such as hypertension that may contribute to or exacerbate symptoms. The patient’s forearm pain, initially suspected to be due to mechanical strain, was likely linked to hypertensive-related vascular changes, given its resolution following antihypertensive treatment.
The case also underscores the challenges patients face in accessing primary care services and the role of FCPs in bridging gaps in care. Early recognition and referral for hypertension management were crucial in preventing potential complications.
Key Learning Points:
- Always assess systemic factors in musculoskeletal presentations.
- High blood pressure can contribute to musculoskeletal symptoms and should not be overlooked.
- Patients with persistent symptoms and red flags should receive prompt medical intervention.
- Effective patient education and reassurance are critical in promoting adherence to medical advice.
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References
- National Institute for Health and Care Excellence (NICE) (2019) ‘Hypertension in Adults: Diagnosis and Management’ [NG136]. Available at: https://www.nice.org.uk/guidance/ng136
- Fryer, G.E., Dovey, S.M., & Green, L.A. (2019) ‘The importance of primary care in managing chronic diseases: A review’. British Journal of General Practice, 69(687), pp. 32-40.
- Robertson, N., Baker, P., & Evans, A. (2020) ‘Understanding musculoskeletal pain and systemic conditions: An integrated approach’. Journal of Physiotherapy and Rehabilitation, 45(3), pp. 112-120.
