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  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)

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 disease features? Rotator cuff disease features?

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 features? Trochanteric bursitis features?

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

Trochanteric bursitis  Management  Rest  Analgesia  Steroid injection  Physio

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

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