Soft Tissue Rheumatism Gary Kunkel, M.D. Division of Rheumatology November, 2005

Objectives Recognize key features of the most common types of bursitis and tendonitis. Describe the general approach to management of bursitis and tendonitis. Recognize the clinical presentation and features of polymyalgia rheumatica and distinguish it from temporal arteritis. Identify the key clinical features and approach to management of fibromyalgia.

Soft Tissue Rheumatism A diverse group of disorders related to musculoskeletal symptoms and disturbances which do not involve intraarticular structures. Passive/active range of motion is a useful tool in distinguishing these conditions from joint problems. –Bursitis/Tendinitis –Polymyalgia Rheumatica –Fibromyalgia

Bursitis Bursa –Sac-like structure –Facilitates motion of muscles and tendons over bony prominences Bursitis –“itis” = inflammation –Inflammation and/or degeneration

Etiology of Bursitis Trauma Chronic overuse or irritation Infection –DM, EtOH, Immunosuppression –Skin portal of entry –Inflammatory bursal fluid (>50,000 wbc/µl) Systemic inflammatory diseases –RA, Gout, CPPD

Symptoms of Bursitis Localized tenderness Swelling if near body surface Warmth and Erythema Pain with local pressure Pain with motion in some cases, but normal passive range of motion.

Olecranon bursitis

Olecranon Bursitis Swelling over point of elbow Usually minimally painful except with direct pressure Elbow motion is normal (typically) Common site for septic bursitis –Erythema –Warmth

Trochanteric bursitis Located at gluteal insertion into greater trochanter Aching lateral hip and thigh –Lying down –Walking Exam –Tender to deep palpation –Pain with active hip abduction against resistance

Trochanteric Bursa

Bursitis – other common locations Ischial bursitis – “weaver’s bottom” Prepatellar bursitis – “housemaid’s knee” Anserine bursitis –Medially 4 cm below the knee joint line –Pain climbing stairs –Women –Obesity –Diabetes mellitus –Knee osteoarthritis

Treatment Avoidance and Joint Protection Pain relief –Rest, Ice, Compression –NSAIDs Aspiration Intrabursal steroid injections Septic bursitis – Antibiotics/Aspiration Refractory cases – surgical removal

Tendinitis Tendon = dense fibrous connective tissue connecting muscle to bone –Tendon sheath – covers tendons in friction areas Synovial and fibrous layer –Paratenon Tendinitis –injury, inflammation, or degeneration of tendon (tendinosis) Tenosynovitis –inflammation of the tendon sheath

Tendon Anatomy

Etiology of Tendinitis Overuse Inflammatory rheumatic disease Crystalline deposition Infection (gonococcus, mycobacteria) Drugs

Symptoms and Signs of Tendinitis Pain with motion, especially against resistance Night pain Exam –Swelling, warmth, tenderness on palpation –Pain with passive stretching –Pain with active motion against resistance –Normal joint range of motion on passive testing

/ego/spanishmosquito/images/

Lateral epicondylitis “tennis elbow” Origin of hand and wrist extensors –Repetitive wrist extension and pronation/supination Exam –Point tender over lateral epicondyle –No swelling –Normal elbow motion –Pain with resisted wrist extension Path – degeneration >> inflammation –Vascular and fibroblastic hyperplasia –Abnormal collagen deposition

Lateral epicondylitis

Resisted wrist extension

look at that forehand.jpg

Medial Epicondylitis “Golfer’s Elbow” AKA – forehand elbow! Origin of flexor carpi radialis Exam: –Point tender over medial epicondyle –Resistance to wrist flexion exacerbates pain

Resisted wrist flexion

DeQuervain’s tenosynovitis --Inflammation and narrowing of the tendon sheath of the abductor pollicis longus and the extensor pollicis brevis at the radial styloid Etiology –Repetitive grasping with thumb while radially moving wrist –Pregnancy and especially after the baby is born!

Finkelstein’s test Induces significant pain in DeQuervain’s tenosynovitis Thumb flexed into palm and covered with fingers Wrist is passively moved ulnarly – stretching the involved tendons

Triggering Sudden locking of digit that must be pulled passively to release Due to –Nodular enlargement of tendon –Stenosis of tendon sheath –Both

Treatment of Tendinitis Avoid aggravating activities. Joint protection – strength/stretch/splint Rest Ice/Heat NSAIDs Steroid injections Surgery

Polymyalgia Rheumatica Age > 50 Bilateral aching and stiffness at shoulders/neck and pelvic girdle –Prolonged morning stiffness –Persistent beyond 1 month ESR > 40 Exclusion of other diseases Prompt response to low dose steroids

PMR -- Epidemiology 7/1,000 over age 50 Increased in caucasians of Northern European descent Females 2X more frequently than males.

PMR – Clinical Presentation Often acute onset Marked stiffness and pain –Mornings especially –ADL’s often affected Systemic symptoms –Fatigue –Fever(mild) –Malaise –Anorexia –Weight loss(mild)

PMR – clinical presentation Exam –Typically normal aside from pain limited motion at shoulders and hips –Probable subtle synovitis and effusions at shoulders and hips Labs –Nonspecific –Markers of inflammation ESR Anemia of chronic disease Elevated platelets

PMR -- Treatment Low dose steroids –Prednisone 7.5 to 15 mg daily –Expect prompt and dramatic response Treatment duration –Often times requires a year or more

PMR and Giant Cell Arteritis Giant cell arteritis (GCA) – specific vasculitis involving the cranial branches of the aorta – (also called Temporal Arteritis) –Important complication without treatment can be blindness. 15% of PMR pts will have GCA 50% of GCA pts will have PMR Treatment of GCA is much more aggressive – high dose steroids

Clues to Dx of GCA in PMR patient Headaches Visual changes(especially double vision or sudden visual loss) Asymmetric arm pulses(large vessel variant) Spiking fevers Significant weight loss(>10 #) Jaw claudication Lack of prompt response to low dose steroids

Fibromyalgia Chronic pain disorder Classification criteria –Widespread musculoskeletal pain –Tender to palpation at 11 of 18 specified tender points

Pathogenesis of FM Fibromyalgia is not an inflammatory disorder. Muscles, tendons, and ligaments from sites of pain are pathologically normal. FM is most likely an disorder of pain processing and subsequent inactivity and deconditioning. –Sleep disturbance –Mood disorders

FM – Epidemiology 10X more common in females 2% prevalence in U.S. – increases w/ age Onset – ages 30 to 55 50% of cases occur after specific emotional or physical trauma/illness

FM – Clinical presentation Diffuse musculoskeletal pain –Neck and shoulders often predominate Pain “in the muscles” Subjective joint stiffness and joint swelling (though not seen on exam)

FM – associated symptoms Fatigue > 90% Nonrestorative sleep Mood disorders Cognitive complaints Headaches Paresthesias Lightheadedness Unexplained abdominal or chest pains Irritable bowel syndrome Pelvic pain Bladder symptoms –Urgency/Frequency

Fibromyalgia Tender Points

FM – clinical presentation Exam –Excessive muscle tenderness everywhere on exam –Even moreso tender over specified tender points Labs (routine) –Normal Evaluation of associated symptoms –Unrevealing

Fibromyalgia -- Treatment Patient education – reassurance Analgesics Sleep –Exclude treatable sleep disorder Aerobic exercise Depression/Anxiety management

FM -- Prognosis Not generally disabling, but symptoms can persist. University-based studies –Most patients had sx’s even 14 years later Community studies –65% had resolution of sx’s at 2 years