“My back hurts. My shoulder hurts. I can no longer hold the computer mouse.” Such common complaints fall under the realm of rheumatology, a field encompassing over 200 conditions, according to Professor Fouad Fayad.

“Rheumatology addresses issues related to joints, bones, tendons and the spine, regardless of whether these problems are mechanical, inflammatory auto-immune or metabolic. It is distinct from orthopedics, which is a surgical specialty. To draw a parallel, rheumatology is like cardiology, while orthopedics is akin to cardiovascular surgery.”

Rheumatologists are consulted for pain affecting the musculoskeletal system, including muscles, tendons, joints and the spine. In contrast, orthopedic surgeons handle fractures, perform joint replacements and operate on herniated discs and spinal canal stenosis.

Given the complexity and variety of conditions treated, a rheumatology consultation typically lasts an hour. Diagnosis involves a detailed medical history, thorough symptom description and comprehensive clinical examination, supplemented by imaging and lab tests if needed.

In Lebanon, rheumatology is comparatively scarce, with around 30 specialists practicing, primarily in the Greater Beirut area. The field is further complicated by its impact on multiple body systems, making it a focus of multisystem diseases.

Mechanical, inflammatory, or metabolic origins

“Osteoarthritis, a leading mechanical joint condition, is the most prevalent disease worldwide. This cartilage degeneration is not solely age-related; obesity and a sedentary (inactive) lifestyle are contributing factors to its rising prevalence in younger populations,” explained the specialist.

Mechanical tendinopathies often arise from excessive tendon use during physical activities or sports, such as tennis elbow — known scientifically as lateral epicondylitis. Other mechanical articular and periarticular conditions include algodystrophy, bone necrosis in the shoulder and hip, adhesive capsulitis (frozen shoulder) and canal syndromes like carpal tunnel syndrome.

In inflammatory rheumatism, rheumatoid arthritis is a chronic auto-immune disease affecting 0.5 to 1 percent of the adult population. It is two to three times more common in women and typically develops between ages 30 and 50. The disease causes joint inflammation, primarily in the hands and feet, leading to swelling, pain, prolonged morning stiffness and potential joint destruction if untreated. Rheumatism can also be associated with chronic inflammatory diseases of the digestive system, such as Crohn’s disease and ulcerative colitis, which can also affect the joints and spine.

Another source of daily pain and disability is enthesitis, an inflammation of the area where tendons attach to bones. This condition is often linked to spondylitis, a chronic inflammatory disease affecting vertebral joints and the (sacroiliac) joint between the spine and pelvis, or psoriatic arthritis, which is better known for impacting the skin but can also affect the joints and spine.

Among metabolic or microcrystalline pathologies, gout is marked by hyperuricemia (excess uric acid in the blood) and uric acid crystal deposits in the joints and surrounding tissues. Pseudogout or chondrocalcinosis (calcium pyrophosphate crystal deposits in the cartilage) can also cause symptoms similar to other rheumatisms and may lead to fever or inflammatory syndromes that are challenging to diagnose.

Managing hyperuricemia is crucial to prevent renal and cardiac complications in patients with gout. While dietary attention is necessary, not all cases of hyperuricemia become symptomatic. The genetic factors in gout involve both overproduction of uric acid and inadequate elimination by the kidneys.

Understanding fibromyalgia and osteoporosis

Fayad highlights two lesser-known conditions.

“Fibromyalgia, or chronic fatigue syndrome, has a significant prevalence in industrialized countries [around 8 percent]. It is characterized by chronic pain, intense fatigue, concentration and memory problems, sleep disturbances and gastrointestinal symptoms. Primarily affecting women [80 percent of patients] between 20 and 40 years old, it is marked by heightened pain sensitivity. It is a central nervous system disorder that may have multiple contributing factors, including genetic, immune or early stress,” explained the doctor.

Diagnosis involves ruling out endocrine issues, vitamin D deficiency, rheumatic conditions, neurological disorders and certain infections. While fibromyalgia is not life-threatening, it is a debilitating condition. Treatment includes both pharmacological approaches (pain relievers, antidepressants) and non-pharmacological methods — such as regular exercise, like walking and aquagym, and avoiding a sedentary lifestyle.

Osteoporosis is a major public health concern, affecting mainly women after menopause and older men. “According to the International Osteoporosis Foundation, from age 50-onwards, one in three women and one in five men suffer a fracture, with a high risk [80 percent] of recurrence. Osteoporosis can also affect people as a result of certain illnesses or treatments [like corticosteroids,]” Fayad noted.

Diagnosis is confirmed through a test called osteodensitometry, which measures bone mineral density and assesses fracture risk. This test is typically performed from age 60 but may be indicated earlier if risk factors are present, such as smoking, alcohol use, family history of hip fractures, rheumatoid arthritis, corticosteroid use or anti-hormonal treatment for cancer. Effective treatments are available.

This article was originally published in French in L'Orient-Le Jour.

Vitamin D
In addition to the many pharmacological treatments and physical therapies prescribed in rheumatology, Fayad emphasized the crucial importance of vitamin D in the management of many rheumatological conditions. "Vitamin D not only promotes bone calcification, but it also plays a crucial role in modulating the immune system — offering protection against certain autoimmune and inflammatory diseases such as rheumatoid arthritis."
The Covid-19 pandemic highlighted the importance of maintaining adequate levels of vitamin D, with studies showing a significant reduction in deficiency thanks to supplements taken to counter the effects of the virus. Vitamin D deficiency in Lebanon fell from 76% in 2016 to 57% in 2022.
Vitamin D supplements should preferably be taken daily but can also be taken weekly or monthly. Megadoses (a single, very large dose) of vitamin D should be avoided. For deficient patients, the doctor prescribes a loading dose to replenish the stock, followed by a maintenance dose. In the Near and Middle East, vitamin D deficiency remains a significant issue despite the abundant sunshine. "Local populations have a problem manufacturing vitamin D in the skin," stated Fayad. "Vitamin D is required for people suffering from muscular pain, fatigue, osteoporosis ... In young subjects, rickets must be diagnosed as early as possible", concluded the doctor.