Broad epidemiological information about sporting injuries is lacking, but several studies have examined the spectrum of injuries seen in referral clinics and in particular sporting activities. Attempts have been made to define some of the conditions which increase susceptibility to injury. Other studies have examined the frequency and causes of specific injuries. The increasing popularity of physical exercise and sports participation has almost certainly been followed by an increase of athletic injuries, especially overuse syndromes. The impact of this demand on hospital services has been mitigated in Britain by the growth of private clinics. Nevertheless, back pain and knee disorders caused by sport account for a substantial percentage of hospital rheumatology and orthopaedic referrals. The disabling consequences of some common disorders and the sequelae of serious injury are discussed in relation to society's attitude to body contact sports and the implications for health and social security resources. Evidence that children are especially vulnerable to sporting injuries is not compelling. Long-term adverse effects of childhood athleticism have not been confirmed. Sporting authorities have a duty to lesson the risks of serious injury but cannot do so effectively without allowing proper research. The growth of sports medicine and its professional organization provide opportunities for the instruction of sports-people and their officials. Hospital involvement is important for the academic impetus it may provide. With the exception of knees that have undergone meniscectomy, osteoarthritis is not a well-documented outcome of sporting activity. Evidence that several risk factors for coronary artery disease are reduced by exercise is a major health advantage. Increased bone mass is another benefit, although in females who develop hypogonadism in response to strenuous exercise, osteopenia may follow. The benefits of exercise appear to outweigh the hazards.

This chapter has sought to address three aspects of back pain: the size of the problem, risk factors and preventive measures. In relation to each aspect the epidemiological approach, with particular reference to sociological and environmental factors, has been shown to have a useful role in clarifying what is on the whole a woolly clinical field. Furthermore, the problems of back pain present a challenge to clinicians from the many different specialties, including rheumatologists, orthopaedic surgeons, gynaecologists and psychiatrists, as well as those practising in more general fields as physicians and surgeons. In the face of such diversity of skills it is unlikely that a consensus will be reached without resorting to basic epidemiological principles. Back pain is among the most important cause of absence from work and long-term disability in Britain. Not only is there a formidable cost in terms of lost earnings, but those affected make heavy demands on the medical services and social security. The extent to which occupational hazards contribute to the aetiology by accelerating the onset of degenerative changes in the musculoskeletal system is difficult to assess. More studies need to be made, particularly among those who retire prematurely, change their jobs or stay off work for long periods. Cohort studies carried out prospectively are costly in manpower and time but it is only by such measures that light may be shed on factors about the workers, their low back pain and the tasks required by particular jobs which could affect prognosis. Primary prevention by controlling the weight and bulk of material being handled and also the posture adopted at work could be a possible starting point in preventing low back pain. Here again, more work needs to be done to establish which tasks and methods of performance are particularly hazardous. As far as secondary prevention or the early identification of those at risk is concerned, the low specificity and sensitivity of screening tests cast doubt over their effectiveness at the present time. There remain, therefore, many patients requiring rehabilitation, and this problem seems unlikely to decrease. Closer liaison needs to be established between health authorities and industry--possibly by such methods as attaching Disablement Resettlement Officers to hospital and appointing specialists in rehabilitation whose responsibility is not restricted to hospital-based patients.(ABSTRACT TRUNCATED AT 400 WORDS)

The arthritic process is unlikely to be confined to the foot; similarly the cutaneous lesions associated with the arthritic foot are often widespread. Careful examination of the skin and nails, particularly the finger nails, may be helpful in the differential diagnosis when the patient presents with a painful foot joint. Conversely, certain cutaneous lesions may alert the physician to the possibility of joint disorders presenting at some later date. In this chapter, it is not possible to mention every skin lesion associated with an arthropathy. Some skin lesions are specific but many are non-specific and occur in several rheumatic diseases. The rheumatologist and dermatologist work in closest co-operation when managing patients with lupus erythematosus and psoriatic arthritis and it is for this reason there is particular emphasis on these two diseases. Patients with rheumatoid arthritis and gout usually come within the province of the rheumatologist, but there are often many characteristic dermatological features to these diseases. This chapter also includes some more esoteric diseases such as Familial Mediterranean fever, Behçet's syndrome, disseminated gonococcal infection and Lyme disease which may present a diagnostic problem to the general physician, rheumatologist or dermatologist.

It has been seen that involvement of the foot in the seronegative arthropathies forms a regular and varied part of the clinical picture. This is often quite different from that seen in rheumatoid arthritis; its components, whether in joints, periarticular structures, or as surface manifestations, may be characteristic enough to raise the diagnosis of 'spondarthritis'. The features described, though characteristic of the spondarthritides, are, however, not pathognomonic. Thus, the osteolysis in psoriatic arthritis also occurs in neuropathic arthritis (e.g. syringomyelia, leprosy), psoriatic periosteal changes may mimic osteosarcomatous proliferations, and the calcaneal enthesitis so typical of spondylitis, Reiter's disease and psoriatic arthritis, may also be seen in metabolic arthropathies. It should also be mentioned here that the severe erosive osteolytic changes leading to psoriatic arthritis mutilans may also be seen, albeit rarely, in rheumatoid arthritis. Ankylosis, too, is not totally confined to the spondarthritides, having also been reported in occasional patients with rheumatoid arthritis. Calcaneal erosions, sometimes envisaged as a spondarthritic feature, also occur in rheumatoid patients. Within the spondarthritis matrix, a striking overlap is seen in the pattern of arthritis. Thus, involvement of the feet in psoriatic arthritis and in Reiter's disease shows many similarities, particularly the tendency to involve IP joints in asymmetrical oligoarticular fashion. In the hindfoot, too, parallels can be drawn between the tendency to Achilles and plantar insertion enthesitis in ankylosing spondylitis and Reiter's disease. On the other hand, the arthropathies of the chronic inflammatory bowel diseases, ulcerative colitis, Crohn's disease, and Whipple's disease, share with Behçet's syndrome an asymmetrical involvement of knees and ankles, but relative freedom from foot involvement. Regarding the surface features in the foot of spondarthritides, there is overlap here, too. For example, the nail dystrophy of psoriasis can be indistinguishable from that of Reiter's disease, and pustular psoriasis in its severe form cannot be differentiated from keratoderma blenorrhagica, even at the histological level. Other surface manifestations affecting the lower limb in general distribution may spread to the feet and thus fall within the ambit of this discussion. Such features include the lesions of erythema nodosum, patches of pyoderma gangrenosum, and the tender cords of thrombophlebitis, all of which have a higher prevalence in seronegative arthritis than in seropositive disease.(ABSTRACT TRUNCATED AT 400 WORDS)

The relief of pain remains a delicate balance between the potential toxicity and desired effect of currently available compounds. Physician and patient need to make the optimum use of such therapies. Control of pain and stiffness in rheumatic diseases is a dynamic process. There is a constant need for re-appraisal of aims and objectives and adjustment of treatment according to variations in disease and response. Where 'specific' therapy is available, it is clearly preferable to use it rather than employ large doses of purely symptom-relieving drugs. At present toxicity is inextricably linked to efficacy, and dissociation of these two factors seems unlikely to be achieved in the near future. More efficient 'targeting' of drugs at the site of desired action should help to minimize the adverse effects of therapy. Ultimately the most efficient way of relieving pain and stiffness will be to prevent or suppress the inflammatory disorders which give rise to the symptoms. Unfortunately this is an elusive goal at present.

Management of pain in the person with arthritis requires interdisciplinary team work with the patient being the final manager. It is important that any health care provider perceive the patient as a person who happens to have arthritis--not as 'an "arthritic".' Defining a person by one's disease process is dehumanizing. The patient has the same aspirations as anyone who is ablebodied--to be free from disease. While the patient may know that a cure is not imminent, there is still the hope for one. Therefore, as the patient comes for physiotherapy, there may be a hidden wish that the moist packs, TENS, or therapeutic pool will be curative. It is important that the patient understand that no equipment in the physiotherapy department has curative powers. This will help avoid unnecessary dependency behaviours on the part of the patient. Careful instruction and supervision of the patient by the physiotherapist, in concert with reinforcement from the physician, can prepare the patient to apply heat, cold, or a variety of treatments at home. Although the patient is given the responsibility for this part of his care, periodic follow-up and reassessment should be completed to determine changes in his physiological, psychological, and functional status. Physiotherapists who have a clear understanding of the physical treatment of pain associated with the rheumatic diseases can be a valuable asset to medical care.

Chronic pain is a debilitating and degrading condition. Its aetiology is largely multifactorial, and only proper appreciation of the various factors which can combine to produce the patient's misery will allow appropriate therapies. If the mechanisms of chronic pain were better taught and the therapies available were better used by medical practitioners, then the standard of alleviation of pain would increase greatly. There is an urgent need for greatly improved facilities for treating chronic pain by multidisciplinary groups in specialized clinics, a fact which has been realized for over 30 years. However, in spite of this there is a great delay in the setting up of such units. There is also an urgent need for proper training of doctors in pain relief, and a need for a much larger amount of money to be spent on research into the causes and treatment of human pain. It is disturbing to me that so much money goes on research into possible cures of malignant disease in the future, which is all very well, but which does not help the sufferer from severe pain at the present time; whereas these poor unfortunates, dying with their misery unassuaged, must suffer unnecessarily because of lack of information amongst physicians, and lack of proper facilities for treatment. Likewise, our own unit and many others have extremely long waiting lists, making even more difficult the treatment of an already complex problem. In spite of this, more than 50% of patients who attend multidisciplinary pain clinics obtain long-term benefit from their therapy. The fact that facilities do not exist for many sufferers is not only disgraceful, but also very expensive both from social security payments and from inappropriate use of health care facilities as these patients wander from clinic to clinic in search of a cure which is not available. Chronic pain should be recognized for what it is--a severe and debilitating condition--and proper steps should be taken to provide the treatment within the health service for its alleviation.