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Welcome Back Rheumatology Fans,

The case study series is back and explores an important challenge encountered in clinical practice: what should we do when a patient’s existing rheumatology diagnosis no longer fully explains their symptoms?

The case follows a patient with an 18-month history of inflammatory arthritis who had responded well to biologic therapy but continued to experience persistent insertional heel pain and fatigue. Rather than focusing on treatment techniques, this discussion examines the clinical reasoning behind recognising when new symptoms may indicate an incomplete diagnosis rather than a simple flare or mechanical musculoskeletal problem.

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Welcome Back Rheumatology Fans,

This is a new series of explainer videos (where I literally explain) a variety of things. Essentially me explaining topics as if I was in front of a patient.

This is the first one where I go through a disease explaination for Rheumatoid Arthritis.

The full video is available to paid subscribers, online course enrollees and …

This is a free preview of a paid episode. To hear more, visit rheumatologyphysio.substack.com

Welcome Back Rheumatology Fans,

In 2025 I recorded a Bone Health Module for my online course. It wasn’t something I particularly planned on but a series of events meant that the material was all but written and it seemed a sensible move.

Fast forward to now and it has rather smashed it to be honest, I have had some really great feedback so I thought I would share with you the intoductory part of the module.

For my paid subscribers, scroll down and you will find a second part entitled “Factors Affecting Bone Mass”.

If anyone would like to enroll in the full module it is HERE. Available as a standalone option or as an add-on to the full Rheumatology.Physio online course which is the best value in my opinion :)

Also check out this webinar we have coming up with the legend that is Adam Dobson:

Welcome Back Rheumatology Fans,

Recently we explored high-intensity exercise in Rheumatological Diseases with insights from Jean-Pascal Grenier. The conversation challenged a belief that has lingered in rheumatology forever That people with inflammatory arthritis should exercise gently.

Moderate exercise? Yes. Gentle strengthening? Of course. Hydrotherapy? Yes Please!

But high intensity? Long duration? Pushing physiological limits? This has been where clinicians have become nervous. It is natural of course, an assumption that utilising inflamed joints will cause that inflammation to increase or an acceleration of joint damage leads to caution. Especially if there is also an associated increase in pain levels.

Which is why it is worth talking about Natalie Dau - Follow her Instagram here.

Natalie is an ultrarunner who holds the Guinness World Record for crossing Peninsular Malaysia on foot. In the process she ran roughly 700 km in just over eight days as part of a 1,000 km endurance project from Thailand to Singapore. (I once got a train from London to Edinburgh and thats 630km and I was absolutely exhausted).

Natalie Dau has Rheumatoid Arthritis.

For many clinicians trained even 10–15 years ago, that combination of facts would have sounded contradictory. RA was traditionally framed through the lens of protection: protect the joints, protect the energy envelope, protect against flare.

And yet here we have someone running the equivalent of two marathons a day.

Now, before anyone concludes that this is a prescription rather than an observation, it’s worth being clear: Natalie’s story is not an argument that everyone with RA should become an ultramarathon runner.

But her story is useful because it forces us to interrogate our assumptions.

One of the themes Jean-Pascal raised was that the human body – even with inflammatory disease – is often far more adaptable than we think. With appropriate training progression, recovery, and load management, people can tolerate much higher intensities than traditional guidance might imply.

Graded individualised exposure, consistency, individualised adaptation and a good amount of reassurance. This can enable people to achieve a lot more than they thought they might be able to.

I used to run a version of this for people newly diagnosed with RA in the NHS, they were offered to attend an exercise group and we started every session with static bike. The person had control, I gave them the instruction to bike at a 5-6/10 on an effort scale. The difference between session 1 and session 2 was STAGGERING. I tracked their settings in super none-vigorous manner and they increased their settings a lot more than you would anticipate.

So to conclude, no you can’t exercise “too much” with Rheumatoid Arthritis, the amount you SHOULD exercise is variably individual but a good starting point is to aim for 150 minutes of moderate intensity per week. Some is better than none, more is usually better and enjoying it is probably the most important ingredient.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit rheumatologyphysio.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit rheumatologyphysio.substack.com

Welcome Back Rheumatology Fans,

You can get access to this article but upgrading your subscription, enrolling in my online course or becoming a member of Physio Matters Advanced Practice

We got ANOTHER media request, I am starting to wonder who is giving out my email address, if it is you then can you tell them I would like paying next time… haaaaaa.

Ok, so back to being serious, this request was advice for returning to tennis or squash when arthritis had stopped the person from playing. This was actually a new one for me so here we are with an expansion on my responses.

You can get access to this article but upgrading your subscription, enrolling in my online course or becoming a member of Physio Matters Advanced Practice

Welcome Back Rheumatology Fans!

Swimming is often recommended for people with arthritis, but is it actually better than other types of exercise? The short answer: it depends on the individual.

Swimming and water-based exercise can be helpful because the buoyancy of water reduces the amount of weight going through the joints. For example, when standing in water up to belly-button depth, the body is only bearing around 40% of its usual weight . This reduction in joint loading can allow people with painful hips, knees, or feet to move more comfortably and exercise for longer.

Water immersion also provides a cardiovascular benefit. The pressure of the water increases venous return — meaning more blood is pushed back to the heart — which makes the heart work slightly harder and therefore provides a cardiovascular training effect . In addition, buoyancy can make it easier to move stiff joints and take them through their range of motion.

However, swimming is not without downsides. Many barriers are logistical: travelling to the pool, changing clothes, slippery surfaces, cold environments, and cost. Some people also accidentally overdo activity in the water because the reduced joint loading masks normal pain signals.

Ultimately, swimming is a good exercise option for arthritis, but it is rarely the only or “best” option. The most effective exercise is usually the one a person can do consistently and safely.

* Water reduces joint loadingBuoyancy can significantly decrease the weight passing through painful joints, making movement easier.

* Swimming provides cardiovascular benefitsWater pressure increases venous return, which places a mild training demand on the heart.

* Movement can be easier in waterBuoyancy can help people move joints and the spine through their range of motion with less discomfort.

* Logistics often limit swimming as exerciseTravel, changing facilities, cost, and cold environments can be significant barriers.

* Exercise choice should be individualisedSwimming is helpful for some people with arthritis, but it is not inherently superior to other forms of exercise.

Check out our new CPD from PMAP!

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Welcome Back Rheumatology Fans,

I had the ABSOLUTE pleasure to talk to Jean-Pascal Grenier who published this great review on high-intensity exercise and Rheumatic Diseases.

You can find Jean-Pascal on LinkedIn or Research Gate or Instagram

Full Article Link: https://pubmed.ncbi.nlm.nih.gov/41566885/

Clinical Takeaways From The Podcast

• High-intensity exercise is not harmful for people with rheumatic disease according to current evidence.

• Outcomes such as pain, disability, and function are at least as good with high-intensity exercise as with lower-intensity approaches.

• Some functional outcomes (e.g., activities of daily living tests) may actually improve more with higher-intensity interventions.

• Persistent clinical caution around intensity may reflect historical beliefs rather than current evidence.

• Exercise prescription should still be individualised, considering disease activity, patient confidence, and training tolerance rather than relying on blanket intensity restrictions.

Podcast Summary

In this episode of The Rheumatology Physio Podcast, Jack is joined by researcher Jean-Pascal Grenier (JP) to explore a long-standing clinical question: Is high-intensity exercise harmful for people with rheumatic disease? The short answer, according to JP’s recent review, is no.

The conversation unpacks evidence examining high-intensity exercise interventions across conditions such as rheumatoid arthritis and other rheumatic diseases. High intensity was broadly defined in the literature as exercise performed at ≥70% of maximum heart rate, including aerobic training, resistance training, and interval-based protocols.

Across the studies reviewed, high-intensity exercise was found to be at least as effective as low- or moderate-intensity approaches for key outcomes such as pain, function, and disability. In several secondary outcomes—including activities of daily living and functional capacity tests—high-intensity exercise even showed superior improvements in some patient groups.

JP explains that the motivation for the review came from a persistent culture of caution around exercise for inflammatory disease. Patients are often advised to “take it easy” or avoid heavy exertion due to concerns about joint damage or disease flares. However, the evidence does not support the idea that higher exercise intensities are harmful.

Instead, the discussion highlights a mismatch between clinical messaging and available evidence. While exercise is widely recommended in rheumatology guidelines, caveats around intensity often remain despite limited supporting data.

Ultimately, the episode reframes the conversation around exercise prescription in rheumatology. Rather than defaulting to conservative, low-intensity programmes, clinicians may be able to confidently consider higher-intensity training when appropriate, recognising that patient preference, tolerance, and individual context still matter.

If you subscribe to Physio Matters Advanced Practice you immediately gain full access to my Online Course, paid posts on substack and 2 EBooks!

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit rheumatologyphysio.substack.com/subscribe

Welcome Back Rheumatology Fans!

What on earth does a Rheumatologist do? What ingredients make up the secret sauce?

Watch the video to find out and I have sorted a little summary below if you are strapped for time.

Video Summary

What actually happens after you refer someone to rheumatology with suspected psoriatic arthritis (PsA)? It’s a question many clinicians ask — particularly because PsA doesn’t come with a neat, definitive diagnostic test.

This episode walks through what really goes on behind the clinic door.

Psoriatic arthritis is a clinical diagnosis. While investigations can support it, they are often inconclusive. Around 90% of patients will have a negative rheumatoid factor. HLA-B27 is negative in roughly half of cases (higher in axial presentations), and inflammatory markers such as ESR and CRP are only elevated about 50% of the time.

Imaging isn’t foolproof either — ultrasound and MRI may show inflammatory changes, but only if the right structures are scanned at the right time.

So what are rheumatologists doing differently?

Primarily, they are applying highly developed clinical reasoning. The initial consultation looks remarkably similar to a skilled MSK assessment: detailed history, joint examination, skin assessment, pattern recognition. The difference lies in the depth of exposure to inflammatory disease and the synthesis of information across multiple domains.

Broadly, three scenarios tend to emerge:

* Clinical suspicion + supportive investigations → straightforward diagnosis and initiation of DMARD therapy such as methotrexate.

* Strong clinical suspicion but negative tests → cautious treatment trial (NSAIDs, steroid injection) with close follow-up.

* Uncertain clinical picture + negative tests → further differentials considered, or a watch-and-wait strategy with review over time.

Importantly, there is no “magic blood test.” The real expertise lies in pattern recognition, probabilistic thinking, and appropriately managing uncertainty.

For physiotherapists, understanding this process helps refine referrals, manage patient expectations, and appreciate why a definitive answer isn’t always immediate. Rheumatology isn’t about hidden investigations — it’s about high-level clinical reasoning applied consistently and responsibly.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit rheumatologyphysio.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit rheumatologyphysio.substack.com

Welcome Back Rheumatology Fans,

Fatigue! The overlooked, underappreciated, oft ignored symptom associated with Arthritis. In this video I go into some detail about why it occurs and why it is so hard to manage, then explain the parameters we can use to actually make improvements!

Ideally watch the video but I have put a summary for you below.

Fatigue: The Most Under-Appreciated Problem In Inflammatory Rheumatology

In this episode, Jack explores what he believes is one of the most under-recognised and poorly managed problems facing people with inflammatory rheumatological conditions: fatigue. While joint pain, stiffness, and function quite rightly receive clinical attention, fatigue is often sidelined—despite being one of the most debilitating symptoms patients report and one of the hardest to treat medically.

Jack focuses specifically on auto-inflammatory rheumatological conditions such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus, Sjögren’s syndrome, and polymyalgia rheumatica, rather than osteoarthritis or gout. He argues that fatigue in these conditions sits firmly within the therapist’s remit—not just physiotherapists, but all MSK professionals—because medication alone often fails to meaningfully improve it.

The episode breaks fatigue down into several key contributing factors. First is a literal sleep deficit. Many inflammatory conditions disrupt sleep, often waking patients in the early hours of the morning due to pain and stiffness. Over years, this creates a chronic lack of restorative sleep, often in people who are still working, raising families, and unable to flex their schedules.

Second is immune-driven fatigue. An overactive immune system requires energy and actively promotes tiredness as a protective mechanism—much like the exhaustion felt during flu or infection. In inflammatory disease, this process is switched on constantly, leading to a persistent, unrefreshing fatigue that is largely resistant to disease-modifying drugs.

Finally, Jack highlights muscle loss and deconditioning. Chronic inflammation can reduce muscle bulk, activity levels often fall after diagnosis, and even when disease control improves, muscle mass rarely returns fully to baseline. This means everyday tasks require more effort, accelerating fatigue.

At around the nine-minute mark, Jack emphasises a key clinical reality: fatigue is multifactorial, chronic, and difficult to “fix.” Patients cannot consciously control their immune system, and pacing strategies—while useful for some—are often impractical, particularly for younger patients with busy lives.

Welcome Back Rheumatology Fans,

You have Gout to be joking that I am discussing Gout again! Seriously, fascinating.

Article Link: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2844321

Watch the video → check out the article!

Or below is a summary:

People with gout are at significantly higher risk of cardiovascular disease, and this risk should be central to how we assess and manage them in clinical practice. In this episode, the focus shifts beyond gout as an episodic inflammatory arthritis and instead frames it as a condition with important long-term systemic consequences—particularly for cardiovascular health.

Evidence consistently shows that individuals diagnosed with gout have an elevated five-year risk of major cardiovascular events such as myocardial infarction and stroke. This increased risk is driven by two main factors. First, gout is a chronic inflammatory condition, and systemic inflammation is a well-established contributor to cardiovascular disease. Second, many of the risk factors associated with gout—such as obesity, hypertension, metabolic syndrome, smoking, and alcohol consumption—overlap with those seen in people at high cardiovascular risk. The combination of these mechanisms means that gout should prompt clinicians to think well beyond joint symptoms alone.

A large, robust study involving over 100,000 patients explored whether achieving effective urate control could influence cardiovascular outcomes. Participants with gout were treated with urate-lowering therapy, commonly allopurinol, and outcomes were compared between those who achieved a serum urate level below 6 mg/dL and those who did not. This “treat-to-target” approach resulted in a meaningful reduction in cardiovascular disease risk over five years when compared with usual care.

Importantly, the benefits were not limited to cardiovascular outcomes. Patients who achieved the target serum urate level also experienced fewer gout flares, reinforcing that this biochemical target is clinically meaningful and reflective of effective disease control. In addition, subgroup analysis showed that patients who already had a higher baseline cardiovascular risk—such as those with hypertension or a family history of cardiovascular disease—derived the greatest relative benefit. In other words, the people who stand to lose the most from cardiovascular events may also gain the most from optimal gout management.

For clinicians working in rheumatology and musculoskeletal care, the implications are clear. A diagnosis of gout should act as a trigger for broader cardiovascular risk assessment. This includes monitoring serum urate levels and aiming for a target below 6 mg/dL, but also addressing modifiable lifestyle factors. Reducing alcohol intake, managing body weight (particularly abdominal adiposity), smoking cessation, and supporting physical activity are all key components of comprehensive care. Pharmacological urate-lowering therapy and lifestyle interventions should be viewed as complementary rather than competing strategies.

Physiotherapists and other allied health professionals have an important role to play in recognising cardiovascular risk factors, reinforcing health behaviour change, and ensuring that concerns are escalated appropriately to medical colleagues when needed. Even when cardiovascular management falls outside our direct scope, identifying and flagging risk can make a meaningful difference.

Ultimately, treating gout effectively is not just about preventing flares—it is about improving long-term health outcomes. By adopting a treat-to-target approach and integrating cardiovascular risk reduction into routine care, we can significantly improve both joint health and overall wellbeing for people living with gout.

Further Resources

https://rheumatologyphysio.substack.com/p/investigating-gout

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