Clinical approach to patients with joint disease: importance of distinguishing inflammatory from non‐inflammatory conditions

The widening gap between demand and supply of trained rheumatologists to deal with enormous numbers of patients with musculoskeletal (MSK) diseases, especially in the South-East Asian region, was the topic of a recent oration. A possible temporary solution to the problem was offered. It was suggested that the entire time and energy of available rheumatologists may be focused only toward patients with systemic inflammatory autoimmune diseases. The argument was that these are serious life-threatening conditions requiring urgent specialist (rheumatologist-physician) referrals for early aggressive treatment with disease modifying antirheumatic drugs/biologicals to save permanent MSK damage and premature death. Crucial to this arrangement would be to have primary care physicians and orthopaedic surgeons who could quickly recognize serious systemic inflammatory MSK diseases (the so-called ‘red-flag’ conditions) from local/regional/biomechanical structural damage-related MSK diseases (the so-called ‘green-flag’ conditions). Only the ‘red-flag’ conditions may then be referred to the rheumatologist-physician for detailed evaluation and appropriate drug therapy. This article describes a simple clinical approach for quick distinction between these two categories of MSK diseases. Rheumatologists may like to use this approach to conduct continuing medical education (CME) programs targeted towards primary care physicians and orthopaedic surgeons so that ‘red flag’ MSK disease patients reach rheumatologist-physicians as soon as possible.