Backache is possibly the most common symptom complained of by an Arab visitor.

Following are the types of backache mentioned by Arab patients—

(1) Pain in the neck—This is often caused by areas of fibrositis. Compared to lumbar spondylosis, cervical spondylosis is much less common in Arab population.

(2) Thoracic Backache—Areas of fibrositis along the medial border of scapula are common. Another cause of upper thoracic backache is "Bursitis" at the medial end of the spine of scapula. Local tenderness at the site would identify this entity.

(3) Loinache—is complained of maximum by Yemenis. Unfortunately they use the word "pain" in the area of "Kiliyaa" which means "kidney". Kidney stones being so common, it is impossible to exclude them without getting the X-rays done. But once an Arab complains of pain showing tenderness at the same time, (associated by wincing) it is then a localized area of fibrositis in the loin which is most often responsible for this ache. (see fig. alongside).

(4) Low backache—This is the most common site of backache. The common causes of backache in this area are:—

(a) Lumbar disc disease and osteoarthritis of lumbar spine -

This entity is commonly seen in Arabs right from the age of thirties onwards, and is severe in their fifties and sixties. It is more often seen in males. It is equally seen in non-obese, tough, muscular or even thin Yemeni Arabs.

Compared to the frequency of lumbar disc disease in this population, "sciatica" is significantly less common. Foramenal osteophytes also seem to be less common.

But off and on, patients are seen with symptoms of "lumbar canal stenosis". These patients present with low back pain and stiffness. On exertion, pain radiates to both the thighs and legs.

It is interesting to note that most of the Arabs live happily with their lumbar disc disease and go back "cured" temporarily, after having had a successful course of short wave diathermy and back exercises. Sometimes I have felt that the physiotherapy has frequently had a psychological effect.

Most of the Arabs readily "buy" a lumbosacral belt ("Hazaam"). But later on it is often difficult to wean them off the belt.

(b) Sprain of interspinous ligaments—is a common cause of lumbar backache. Localised areas of tenderness can be elicited in the midline. Often these sprains are caused by lifting weights. One of the situations is while travelling. Like many Westerners, they do not believe in "light" travelling. Lifting heavy baggage is one of the causes of injury to interspinous ligaments. Similarly except in the houses of "Sheikhs", most of the Arabs have no domestic servants and frequently have to lift weights and often climb up two to three flights of stairs with the luggage. All these factors increase the frequency of sprain of interspinous ligaments.

(c) Sprain of ligaments of sacroiliac joints—This is often seen in young Arabs as the cause of unilateral or bilateral pain over the sacroiliac joints which spreads to the whole lower back. These injuries also occur while lifting weights.

(d) "Sexual" backache—An average Arab looks forward to visit his wife atleast once a day and feel satisfied with his performance. Therefore, any of the following factors—absence of good erection, poor duration of the performance, premature ejaculation or the "quality" and the "quantity" of the semen ejaculated not to his satisfaction, will result in backache next morning. This presentation is very common in an Arab who is a tall, hefty and pink gentleman. He looks hale and hearty and has swift movements of his back, while you conduct the clinical examination.

Similarly, spot diagnosis can be made in a thin, worried, tense, anxious, Yemeni patient. Ask him a leading question—"Does this backache come in the morning whenever you have sexual intercourse the previous night?"

In many Arabs, constant worry of impotency or any disease connected with sexual organs is one of the most common causes of "psychogenic" backache.

(e) Anxiety and depression—("Taab" or "Tafkeer" or "Fikar") is the most common cause of low backache in a young (male or female) Arab. Many of these patients have had a lot of analgesics, physiotherapy and local injections of hydrocortisone without any relief. The X-rays of the spine are normal. Often, they "also" complain of other symptoms involving multiple systems of the body as described in the chapter on "Functional Arab Syndrome".

In many menopausal Arab ladies from Bahrain, endogenous depression is a common cause of backache. Surprisingly, it is rare in Bahraini men and merchants from Saudi Arabia and Qatar.

(f) Postural backache—is less common in Arabs. Though I see a few shopkeepers of Dubai, Oman and Bahrain having this complaint, it is otherwise not a common cause of backache. May be in early days, an Arab learnt to sit in a proper upright posture while riding a camel!

(g) Piles and backache—Arabs take "Piles" very seriously. Many of them have a feeling that "piles" can lead to a number of symptoms in the body—the most common being backache. Exclusive attention should be given to the perineum during examination in Arabs complaining of backache. Really speaking it is a type of "psychogenic" backache.

(h) Sacral backache—associated with leucorrhoea, seen commonly in Indian female population is rare in Arab population.

(i) Pain over the coccyx—is not uncommon. The presentation is just like chondritis. It is equally common in Arab males and females. The patient often "borrows" your hand and carrying it to the perineum presses the coccyx with "your" fingers to show the local area and elicit tenderness, "wincing" at the same time.

(j) Osteomalacia—is a very rare entity in Arab females (compared to Indians). This is true inspite of these women delivering a baby every year or two and having no exposure to the sunlight because of their veils.

(k) Osteoporosis—a common cause of lumbar backache, especially in elderly Indian females, is uncommon in Arab population! In Bahrainis the reason may be excess of fluoride in water, as confirmed by their teeth which often show brownish pigmentation due to fluorosis (see fig. alongside) .

Finally the amount of non-articular rheumatism or musculoskeletal aches which the Arab patients present with, would hardly be seen in any other population in the world. Whether psychoneurosis caused these or vice-versa is like deciding whether it was the chicken or the egg which came first!

Pain in the knee joints ( "Vajaa" – "Rokabae" )

This is a very common symptom. Some patients are disturbed by noises ("crepitus") produced in the knee joints. It is interesting to note that while osteoarthritis of spine has a predominant male distribution, osteoarthritis of the knee which is nearly always the only cause of knee pain, is seen equally in both the sexes. In males, it is seen both in thin and overweight Arabs, but in females, obesity is a predisposing factor. Many of these patients have been told that this is "Rheumatism". Those patients who connect "Rheumatism" with a serious, systemic crippling disease develop super-added symptoms of anxiety and fear.

Many of them develop a "Varus" deformity of the knee because of the ligamentous instability resulting in joint degeneration of the medial side which seems to be very preponderant in the Arab population. Occasionally, Valgus deformity is seen. And yet most of them keep on moving, without getting operated.

It is interesting to note that all the other causes of arthritis like Rheumatic, Rheumatoid or Gout are rare in Arab population.

Pain in the shoulder ( "Wajaa Kitf" or "Chibt" )

The most common cause of pain in shoulder area in this population is frozen shoulder. I have hardly come across any case of arthritis of shoulder joint. Also as mentioned elsewhere, referred shoulder root pains of cervical spondylosis or Anginal pains are uncommon.

Pain in the calves – Following are the causes :-

• Neurogenic claudication is off and on seen in patients having spinal canal stenosis.
• Only rarely "Venous Claudication" is seen, specially in females having signs of old deep vein thrombosis.
• Ischaemic arterial clauication is the rarest cause.
• Peripheral neuritis—diabetic neuropathy seen off and on can cause this symptom.
• High heeled shoes worn by young Bahraini men and women can cause pain in the calves.

The most common cause of the calf pain is idiopathic". This includes tension which is the most common cause of calf pains. Occasionally in Yemenis in whom "tension" is maximum, the pain is also felt in the tibia. These patients always show tender areas on the shin of the tibia, at the same time expressing their "agony" through facial gestures.

The other contributory factors may be excessive smoking and lack of regular physical exercise.