Presentation on theme: "Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist."— Presentation transcript:
Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist
Introduction Definitions Approach to soft tissue disorders Overview of some soft tissue conditions: Flexor tenosynovitis De Quervain’s Carpal tunnel Golfer’s/Tennis elbow Rotator Cuff Trochanteric bursitis Achilles tendonitis Fibromyalgia
WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA? WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?
Definitions Ligament A band of tough connective tissue that connects bone to bone Tendon a tough band of fibrous connective tissue that connects muscle to bone Enthesis the point at which a tendon inserts into bone, where the collagen fibres are mineralised and integrated into bone tissue Bursa a fluid filled sac located between a bone and tendon which normally serves to reduce friction between the two moving surfaces
THOUGHT PROCESS/ISSUES IN SOFT TISSUE DISORDERS? THOUGHT PROCESS/ISSUES IN SOFT TISSUE DISORDERS?
Approach to soft tissue disorders History and examination paramount Differentiate from inflammatory/mechanical arthropathy Think about anatomy of area and mechanism of injury/overuse to understand pathology Work history Precipitating activity
Approach to soft tissue disorders Could it be referred pain eg C5/6 Neck pain radiating to shoulder – ask about neurological symptoms May be associated with inflammatory arthritis eg RA or psoriatic arthritis or systemic illness Bloods not helpful in making diagnosis Imaging - X-ray and ultrasound may play a role in certain soft-tissue disorders
JOINT vs PERIARTICULAR? JOINT vs PERIARTICULAR?
Is it an articular or extra-articular problem? ARTICULARPERI-ARTICULAR ARTICULARPERI-ARTICULAR pain all planespain in plane of tendon pain all planespain in plane of tendon active = passiveactive > passive active = passiveactive > passive capsular swelling/effusion linear swelling capsular swelling/effusion linear swelling joint line tenderness localised tenderness joint line tenderness localised tenderness diffuse erythema/heatlocalised erythema/heat diffuse erythema/heatlocalised erythema/heat
Management Rest Simple analgesia NSAIDs Local steroid injection Physiotherapy/Occupational therapy Surgery in certain cases e.g. carpal tunnel
Features of flexor tenosynovitis ? Features of flexor tenosynovitis ?
Flexor tenosynovitis Inflammation of flexor tendon sheaths Pain and stiffness in flexor finger/thumb, may extend to wrist Reduced active flexion, crepitus, thickened tender tendon sheaths May be associated with nodule – “trigger finger” Can be associated with RA, Diabetes Treatment – injection hydrocortisone, surgery
Features of De Quervains? Features of De Quervains?
De Quervain’s (tenosynovitis) Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons
De Quervain’s (tenosynovitis) Pain, swelling radial wrist Localised tenderness, crepitus, pain worse over radial styloid Finkelstein’s test
De Quervain’s (tenosynovitis) Finkelstein With the thumb flexed across the palm of the hand, ask the patient to move the wrist into flexion and ulnar deviation. Positive if reproduces pain
De Quervain’s (tenosynovitis) Management Rest from precipitating activity Splintage Steroid injection surgery
Features and causes of carpal tunnel syndrome? Features and causes of carpal tunnel syndrome?
Carpal tunnel syndrome Compression of median nerve as it passes through carpal tunnel
Carpal tunnel syndrome - anatomy Median nerve supplies: Motor (beyond carpal tunnel in hand) L lateral two lumbricals Oopponens pollicis A abductor pollicis brevis F flexor pollicis brevis Sensory Palmar surface thumb, lateral 2 ½ digits
Carpal tunnel syndrome Clinical features Numbness/parasthesia in median nerve distribution Pain, can radiate up arm Worse at night ‘Hang hand over end of bed’ Weakness of thumb (abduction) Thenar wasting Positive Tinel’s/Phalen’s
Carpal tunnel syndrome Tinel’s Phalen’s
Carpal tunnel syndrome Investigation Nerve conduction studies show reduce nerve conduction velocities across wrist Management Avoidance of precipitating activity Night time splints Local steroid injection Surgery – division of flexor retinaculum and decompression of carpal tunnel (80% success)
Features of epicondylitis ? Features of epicondylitis ?
Tennis & Golfer’s Elbow Both enthesopathies Tennis elbow = lateral epicondylitis = inflammation common extensor origin Golfer’s elbow = medial epicondylitis = inflammation common flexor origin Tennis elbow more common than Golfer’s
Tennis & Golfer’s Elbow Pain localised to specific area Elbow flexion/extension does not cause pain Pain upon: resisted wrist extension (Tennis) resisted wrist flexion (Golfer’s)
Tennis & Golfer’s Elbow Management Rest from precipitating activity Elbow clasps Local corticosteroid injection Physiotherapy – ultrasound and acupuncture Surgery (often ineffective)
Rotator Cuff Pathology A range of various conditions, including: Supraspinatous tendinitis/rupture Rotator cuff tear Adhesive capsultitis (frozen shoulder) Acute calcific supraspinatous tendonitis Subacromial bursitis Acromioclavicular joint OA Overlap in clinical features but distinct entities
Rotator Cuff – anatomy A sheath of conjoint tendons to support glenohumeral joint, made up of: S supraspinatous - abduction Iinfraspinatous – external rotation T teres minor – external rotation S subscapularis – internal rotation
Rotator Cuff Syndrome Spectrum from mild supraspinatus tendinitis to complete tendon rupture Chronic impingement of cuff under acromial arch Pain often over acromial area extending into deltoid
Rotator Cuff Syndrome Painful mid arc Impingement test – abducted, flexed and internally rotated Supraspinatus stress
Rotator cuff investigation - ultrasound Full thickness tear Full thickness tear
Rotator Cuff Syndrome Management Rest, NSAIDs Local steroid injection around tendon – subacromial space and PT If chronic/rupture refer to Orthopaedics for surgical opinion
Acute calcific supraspinatus tendinitis Young adults, F>M, acute pain over several hours Normally resolves over few days Treatment Minor – NSAID Moderate – consider steroid injection Severe – consider aspirating calcified material Calcium hydroxyapatite deposition near supraspinatus enthesis
Adhesive capsulitis (Frozen shoulder) Progressive pain and stiffness Global reduction in movement, but particularly external rotation Three phases Pain (3-5 months) Adhesive phase (4-12 months) Recovery phase (12-42 months)
Adhesive capsulitis (Frozen shoulder) Associated with diabetes Most patients recover by 30 months, but still have reduced movements Management Analgesia, NSAIDs, Physiotherapy, steroid injection Surgical opinion in difficult cases (manipulation under anaesthesia)
ACJ disease features ? ACJ disease features ?
Acromioclavicular OA High arc pain High arc pain Local tenderness Local tenderness Adduction painful Adduction painful Impingement Impingement
Trochanteric bursitis Inflammation of the superficial and deep bursa that separates the gluteus muscles from the posterior and lateral side of the greater trochanter of the femur
Trochanteric bursitis Boring pain over lateral aspect of hip May radiate down lateral thigh Worse on walking or lying in bed at night Localised tenderness upon pressure over greater trochanter
Achilles tendonitis Inflammation of the achilles tendon Sometimes at enthesis Sometimes in middle avascular portion of tendon Can be seen with seronegatives
Achilles tendonitis Chronic tendonitis can lead to Achilles tendon rupture Aetiology of tendonitis though to be avascular degeneration of tendon Tenosynovitis does not lead to rupture Also can get acute traumatic rupture All have localised pain and swelling of Achilles tendon, with difficulty walking
Achilles tendonitis Investigation - ultrasound Management Rest, NSAIDs, physiotherapy Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear
Achilles rupture Acute rupture – sudden calf pain as if being hit on back of leg Palpable gap in tendon Some but little plantarflexion Squeeze calf whilst prone - no plantarflexion in affected leg (Simmond’s) Management Surgery to repair tendon Conservative – below knee cast in ankle equinus 6 weeks
Fibromyalgia features ? Fibromyalgia features ?
Fibromyalgia “All over pain” “All over pain” Fatigue Fatigue Sleep disturbance Sleep disturbance Depression Depression Anxiety Anxiety Irritable bowel Irritable bowel Tender spots Tender spots Diagnosis of exclusion Diagnosis of exclusion
Prevalence/Risk Factors Common Approx 2-5% depending upon definition Female (F:M ratio between 3:1 and 7:1) Middle age (typically 30-60)
Differential diagnosis Other conditions can mimic fibromyalgia: Systemic lupus erythematosus (SLE) Hypothyroidism Polymyalgia rheumatica Malignancy Myopathy Metabolic bone disease
Management Patient education About condition Reassure that no serious pathology No harm in exercising Cognitive behavioural therapy (CBT) Low dose amitriptyline Graded aerobic exercise regime