Back pain is common with up to 9% of the population consulting their GP with this problem each year. As the vast majority of these patients have non-specific back pain, it is often difficult to identify those with inflammatory disease such as ankylosing spondylitis (AS). It is critical to make this distinction as AS, if untreated, may cause significant morbidity with a substantial socio-economic impact both on the individual and society. Early diagnosis is particularly important as newer therapies are able to contain this condition and even induce remission in some cases. AS affects about 0.2-0.5% of the population. It is at least twice as common in men than women and most often manifests in the third to fifth decades. It is estimated that up to 5% of patients with chronic lower back pain in primary care have inflammatory disease. Diagnosis is usually delayed at least partly through lack of awareness of this condition.

The prevalence of gout increases with age and up to 7% of men aged over 65 and 3% of women aged over 85 have gout. The risk of gout increases significantly with increasing serum uric acid levels. However, hyperuricaemia is far more common than gout implying that additional risk factors play a role in the development of the disease. Alcohol consumption, especially beer and to a lesser extent spirits, increases the risk of both incident and prevalent gout. Purine-rich foods such as red meat and seafood increase the risk of incident gout significantly, while dairy products and increasing coffee, but not tea, intake were found to be protective. A number of medications are well known to be associated with increased risk of gout especially diuretics, including loop and thiazide diuretics. Cyclosporin was also found to increase the risk of incident gout in patients with renal transplants. It is well established that gout is frequently associated with the metabolic syndrome which is characterised by hyperuricaemia, hyperlipidaemia, hypertension, diabetes and insulin resistance, and obesity. In addition, dehydration, increasing creatinine levels, and undergoing surgery are known to precipitate gouty flares.

Rheumatoid arthritis was Previously considered a severe systemic disease leading to inexorable decline. However, the outlook for patients has altered dramatically over the past few years with disease remission now the therapeutic goal. This is dependent on a number of critical interventions and the role of the GP is pivotal in the process. Without early recognition and rapid referral by the GP the ability to achieve the desired outcome of disease remission would be greatly hindered. A recent article in this journal highlighted the benefits of intensive therapy with tight control of disease.

Many current treatments for OA are thought to target the synovium e.g. NSAIDs and this may be why they are effective. Changes in the subchondral bone are also common on MRI and are also associated with pain. At present most data assume that OA pain is nociceptive in origin and there is limited evidence for a neuropathic mechanism. All available treatments for OA are directed at symptom control as there are not yet any widely accepted drugs that can affect the structural progression of OA. Current guidelines recommend a combination of non-pharmacological and pharmacological management. Treatment needs to be adjusted according to individual symptoms, past medical history, comorbidities and lifestyle. NSAIDs, for example, may be inappropriate in a patient with renal impairment, gastrointestinal diseases or a history of ischaemic heart disease.The initial approach centres on self-help and patient-driven treatments and should be started in primary care. This includes: education, advice and access to information. Both verbal information and patient information leaflets should be offered; local strengthening exercises and aerobic fitness training; weight loss in patients who are overweight or obese.

Psoriatic arthritis (PsA) is a common form of inflammatory arthritis but is underdiagnosed. Psoriasis affects more than 1.5% of the UK population so a GP with an average list size is likely to care for around 40 patients with psoriasis.

Twenty to thirty years ago, the mortality rate for SLE was as high as 50% at five years. The current 20-year survival rate is 80%.GPs play a key role in early referral to specialist centres and subsequent shared care pathways for the management of these patients.

The prevalence of shoulder disorders has been reported to range from 7 to 36% of the population accounting for 1.2% of all GP consultations^.1 Shoulder pain has been said to be the second most common musculoskeletal complaint presenting in primary care. On average GPs are consulted approximately seven times each week for a complaint relating to the neck or upper extremity; three of these consultations will be for new complaints or new episodes.