1. TULSA BONE & JOINT ANTOINE (TONY) JABBOUR, MD ORTHOPAEDIC SPORTS MEDICINE SURGEON KNEE AND SHOULDER SUBSPECIALTY CHAPTER 20 PAIN SYNDROMES CHAPTER 21 NERVE INJURIES CHAPTER 22LIGAMENT INJURIES CHAPTER 23ATHLETIC INJURIES CHAPTER 24PEDIATRIC MUSCULOSKELETAL ABNORMALITIES TONY JABBOUR, MD SPORTS MEDICINE

2. CHAPTER 20 CHRONIC PAIN SYNDROMES Pain lasting greater than 6 weeks. Associated psychiatric diagnosis (cause vs effect). If no structural disease present, consider MALINGERING. TONY JABBOUR, MD SPORTS MEDICINE

3. FIBROMYALGIA Controversial diagnosis. Syndrome of: 1. Diffuse musculoskeletal pain. 2. Sleep disturbance. 3. Exhaustion. Most common cause of generalized musculoskeletal pain in female 20-25 years old. Physical examination normal except for disproportionate tenderness to palpation. X-rays and labs are within normal limits. TONY JABBOUR, MD SPORTS MEDICINE

4. FIBROSITIS ACR criteria from 1990. Chronic widespread pain both sides of body, above and below waist. 11-18 tender point spots. TONY JABBOUR, MD SPORTS MEDICINE

5. EPIDEMIOLOGY Females 10 x more often than males. No known objective markers of the disease. No genetic predisposition. TONY JABBOUR, MD SPORTS MEDICINE

6. CLINICAL PRESENTATION 20-55 YEAR OLD FEMALE. Pain over entire body especially neck, shoulders and low back pain. Poor sleep 75%. Headaches. Numbness. Tender points of palpation. TONY JABBOUR, MD SPORTS MEDICINE

7. OTHER CONDITIONS CONFUSED WITH FIBROMYALGIA Depression. Irritable bowel syndrome. Chronic fatigue syndrome. TONY JABBOUR, MD SPORTS MEDICINE

8. ETIOLOGY Unknown. TONY JABBOUR, MD SPORTS MEDICINE

9. TREATMENT Difficult. Psychologically prepare patient for chronicity of symptoms. No drugs currently indicated (Analgesics and Anti- depressants). Physical Therapy. Lidocaine trigger point injections. TONY JABBOUR, MD SPORTS MEDICINE

10. COMPLEX REGIONAL PAIN SYNDROME Synonyms : RSD/Algodystrophy/Causalgia/Shoulder-Hand Syndrome/Sudek’s dystrophy. Disorder of extremities characterized by severe and continuous pain, decreased range of motion and demineralization of adjacent bony structures. Vasomotor instability (changes in skin color and temperature. 1994 WHO coined term “Complex Regional Pain Syndrome”. Two Types: Type 2 – symptoms are attributable to nerve lesions. Type 1 – no nerve lesions. TONY JABBOUR, MD SPORTS MEDICINE

11. LABS Within normal limits. TONY JABBOUR, MD SPORTS MEDICINE

12. CLINICAL PRESENTATION 20-25 years of age female after wrist fracture, no peripheral nerve injury. TONY JABBOUR, MD SPORTS MEDICINE

13. THREE STAGES ACUTE Several weeks to several months, there is increasing pain, decreased range of motion and edema. Warmth initially, then coolness. Sensitivity to light touch. TONY JABBOUR, MD SPORTS MEDICINE

14. MIDDLE (DYSTROPHIC PHASE) Three to six months after injury. Increased soft tissue edema secondary to increased regional sympathetic activity. Skin changes (thickening, brawny changes). Early atrophy. TONY JABBOUR, MD SPORTS MEDICINE

15. THIRD STAGE (LATE ATROPHIC PHASE) Most severe. Hair falling out, nails brittle. Decreased range of motion with contractures. X-rays – demineralization and osteoporosis. TONY JABBOUR, MD SPORTS MEDICINE

16. PATHOPHYSIOLOGY Not well understood. TONY JABBOUR, MD SPORTS MEDICINE

17. TREATMENT Early mobilization, aggressive physical therapy. Non-steroidal anti-inflammatories, corticosteroids. Regional nerve blocks (decreased overactivity of sympathetic nervous system; 2/3 respond favorably). Surgical sympathectomies. Spinal cord stimulation. Intrathecal Baclofen. TONY JABBOUR, MD SPORTS MEDICINE