Farmers in Ireland are bred tough. They don’t come in to see their Rheumatologist with a bit of muscular pain. They don’t come in with a few Heberden’s nodes. When they do arthritis, they do it properly.
The typical encounter with a farmer would be a chap who hobbles in ruefully, asking politely ‘Sorry to bother you doctor, but is there anything you can do for my knees?’. I usually rub my beard sagely and say – ‘Hmm, let’s have a look at your hips, then’. Chances are that his knees are fine but his hips are shot to pieces. By the time they stumble into clinic you can guarantee that their hip joints are done for. It never ceases to amaze me that someone can develop severe osteoarthritis (OA) of the hips without ever having experienced pain in the hips or groin. And by the way, I still don’t know why OA of the hips is an occupational hazard for farmers. You see people from other heavy occupations who don’t seem to have the same problem. Perhaps it is something to do with the heavy work most of them did on the farm as young teenagers.
Another common example is the farmer with a seemingly straightforward shoulder capsulitis or tendon rupture. When you get down to the story, however, you find – for instance – that he has been dragged halfway up the field hanging on to the back of a tractor driven away by his 12 year old son who had found the accelerator instead of the brake. Perhaps the most memorable ‘rheumatological case’ was a farmer who hobbled painfully into clinic leaning precariously on two walking sticks with the worst knee joints I’ve ever seen. The valgus deformity on each side was at least 45 degrees and the knees had rubbed together with such violence that he had developed huge suppurating rheumatoid nodules.With each step he had to swing from one side to the other using his stick a bit like a pole vault. When I got him up onto the couch his legs seemed to be connected to the thigh by no more than half an ACL. How this man had continued working on the farm for the previous 5 years I will never know. To my amazement, he recovered well after his knees were replaced and he is probably still working on his farm to this day.
Anyway, I digress and really must return to the subject of my story. I could barely contain my excitement when a farmer come in to clinic and showed off his impressive knee swellings. I immediately recognised this as the little known ‘Bactrian camel’ sign. The ‘double hump’ is a dead giveaway. Given the usual yarns, I was not surprised when he told me the story of how this all started with being kicked on the shin by a mischievous young cow. It’s never something mundane like an ingrown toenail. For a farmer this is a regular hazard – but his story was tame compared to one of my patients recently who had barely escaped with his life after having been trampled over by half a dozen stampeding cows. Anyway, our farmer had developed a cellulitis in his ankle which was eventually treated in the local hospital. I say eventually because it is highly unlikely that a farmer would go to see the doctor when there was only a little redness around a scratch. He recounted how the swellings had started after the kick and now they were getting a bit painful. When he took his trousers off I was taken aback. The swelling on top of his right kneecap was like a six inch ‘bap’, and just below that he had a second fluctuant swelling above the tibial tuberosity. Both the pre-patellar and infra-patellar bursae were swollen and clearly displayed in all their glory. The profile was unmistakably that of a double hump-backed or Bantian camel. I wish I had taken a photograph for posterity. A large amount of clear fluid was aspirated from each swelling and steroid injected, to the patient’s evident relief.
As an educational aside, it is well known that infected bursitis often occurs in association with cellulitis, and a good long course of antibiotics is called for. However, this is not the first time I have seen ‘post-infective’ bursitis persisting long after the infection has cleared up. There isn’t a strong evidence base when treating bursitis, but in my experience a small dose of steroid can do the trick quite effectively. Some experts counsel weeks of inactivity, but in my experience if you tell a farmer to rest it is likely that you will be wasting your breath.
The old Irish farmer belongs to a stoical and dependable tradition, in touch with the land and in command of their over-worked but hardy frames. But are they a dying breed? I now see so many of them working on well into their 80s because their children have moved away seeking greener pastures and easier lifestyles. As a rheumatologist who sometimes tends to their ‘war wounds’, I salute them.