1. Soft Tissue Disorders and Fibromyalgia
Jaya Ravindran
Consultant Rheumatologist

2. Introduction Definitions Approach to soft tissue disorders
Overview of some soft tissue conditions
Fibromyalgia

3. Definitions
WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?

4. Definitions Ligament Tendon Enthesis Bursa
connective tissue that connects bone to bone
Tendon
connective tissue that connects muscle to bone
Enthesis
the point at which a tendon inserts into bone
Bursa
a fluid filled sac located between a bone and tendon

5. CLUES IN SOFT TISSUE DISORDERS?

6. Approach to soft tissue disorders
anatomy of area and mechanism of injury/overuse (work history)
Differentiate from inflammatory/mechanical arthropathy
? referred pain eg C5/6 Neck pain radiating to shoulder – ask about neurological symptoms

7. Approach to soft tissue disorders
May be associated with inflammatory arthritis
Bloods not helpful
Imaging - X-ray and ultrasound may play a role in certain soft-tissue disorders

8. JOINT vs PERIARTICULAR?

9. Is it an articular or extra-articular problem?
ARTICULAR PERI-ARTICULAR
pain all planes pain in plane of tendon
active = passive active > passive
capsular swelling/effusion linear swelling
joint line tenderness localised tenderness
diffuse erythema/heat localised erythema/heat

10. Features of flexor tenosynovitis ?

11. Flexor tenosynovitis Inflammation of flexor tendon sheaths
Pain and stiffness in flexor finger/thumb
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

12. Features of De Quervains?

13. De Quervain’s (tenosynovitis)
Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons

14. De Quervain’s (tenosynovitis)
Pain, swelling radial wrist
Localised tenderness, crepitus, pain worse over radial styloid
Other test?

15. 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

16. De Quervain’s (tenosynovitis)
Management
Rest from precipitating activity
Splintage
Steroid injection
surgery

17. carpal tunnel syndrome?

18. Carpal tunnel syndrome
Compression of median nerve as it passes through carpal tunnel

19. Carpal tunnel syndrome - anatomy
Median nerve supplies:
Motor (beyond carpal tunnel in hand)
L lateral two lumbricals
O opponens pollicis
A abductor pollicis brevis
F flexor pollicis brevis
Sensory
Palmar surface thumb, lateral 2 ½ digits

20. 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

21. Carpal tunnel syndrome
Phalen’s
Tinel’s

22. Carpal tunnel syndrome
Common, F>M, elderly/middle aged
Mostly idiopathic
Associated with (particularly if bilateral):
Diabetes
Hypothyroidism RA
Pregnancy
Acromegaly
Vasculitis
Trauma
Others (e.g. amyloid, sarcoid)

23. 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)

24. Features of epicondylitis ?

25. 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

26. 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)

27. Tennis & Golfer’s Elbow
Management
Rest from precipitating activity
Elbow clasps
Local corticosteroid injection
Physiotherapy – ultrasound and acupuncture
Surgery (often ineffective)

28. Rotator cuff disease features?

29. Rotator Cuff – anatomy
A sheath of conjoint tendons to support glenohumeral joint, made up of:
S supraspinatus - abduction
I infraspinatus – external rotation
T teres minor – external rotation
S subscapularis – internal rotation

30. 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

31. Rotator Cuff Syndrome Painful mid arc
Impingement test – abducted, flexed and internally rotated
Supraspinatus stress

32. Rotator cuff investigation - ultrasound
Full thickness tear

33. Rotator Cuff Syndrome Management Rest, NSAIDs
Local steroid injection around tendon – subacromial space and PT
If chronic/rupture refer to Orthopaedics for surgical opinion

34. Acute calcific supraspinatus tendinitis
Calcium hydroxyapatite deposition near supraspinatus enthesis
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

35. 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)

36. 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)

37. ACJ disease features ?

38. Acromioclavicular OA High arc pain Local tenderness Adduction painful
Impingement

39. Trochanteric bursitis features?

40. 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

41. Trochanteric bursitis
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

42. Trochanteric bursitis
Management
Rest
Analgesia
Steroid injection
Physio

43. Achilles pain Inflammation - seronegatives (enthesis)
Degeneration (middle avascular portion of tendon)
Retrocalcaneal bursitis

44. 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

45. 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

46. Fibromyalgia features ?

47. Fibromyalgia “All over pain” Fatigue Sleep disturbance Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion

48. 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)

49. Differential diagnosis
Other conditions can mimic fibromyalgia:
Systemic lupus erythematosus (SLE)
Hypothyroidism
Polymyalgia rheumatica
Malignancy
Myopathy
Metabolic bone disease

50. Management Patient education Cognitive behavioural therapy (CBT)
About condition
Reassure that no serious pathology
No harm in exercising
Cognitive behavioural therapy (CBT)
Low dose amitriptyline
Graded aerobic exercise regime

51. THANK-YOU