physiotherapy Local steroid injection under U/S guidance

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Soft Tissue Disorders and Fibromyalgia
Jaya Ravindran Consultant Rheumatologist
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Introduction

• Definitions
• Approach to soft tissue disorders
• Overview of some soft tissue conditions
• Flexor tenosynovitis
• De Quervains
• Carpal tunnel
• Golfers/Tennis elbow
• Rotator Cuff
• Trochanteric bursitis
• Achilles tendonitis
• Fibromyalgia

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• WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?

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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

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• THOUGHT PROCESS/ISSUES IN SOFT TISSUE DISORDERS?

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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

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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

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• JOINT vs PERIARTICULAR?

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Is it an articular or extra-articular problem?

• ARTICULAR PERI-ARTICULAR
• pain all planes pain in plane of tendon
• active passive active gt passive
• capsular swelling/effusion linear swelling
• joint line tenderness localised tenderness
• diffuse erythema/heat localised erythema/heat

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Management

• Rest
• Simple analgesia
• NSAIDs
• Local steroid injection
• Physiotherapy/Occupational therapy
• Surgery in certain cases e.g. carpal tunnel

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• Features of flexor tenosynovitis ?

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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

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• Features of De Quervains?

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De Quervains (tenosynovitis)

• Inflammation of tendon sheath containing extensor
  pollicis brevis and abductor pollicis longus
  tendons

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De Quervains (tenosynovitis)

• Pain, swelling radial wrist
• Localised tenderness, crepitus, pain worse over
  radial styloid
• Finkelsteins test

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De Quervains (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

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De Quervains (tenosynovitis)

• Management
• Rest from precipitating activity
• Splintage
• Steroid injection
• surgery

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• Features and causes of carpal tunnel syndrome?

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Carpal tunnel syndrome

• Compression of median nerve as it passes through
  carpal tunnel

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Carpal tunnel syndrome

• Common, FgtM, elderly/middle aged
• Mostly idiopathic
• Associated with (particularly if bilateral)
• Diabetes
• Hypothyroidism
• RA
• Pregnancy
• Acromegaly
• Vasculitis
• Trauma
• Others (e.g. amyloid, sarcoid)

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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

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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 Tinels/Phalens

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Carpal tunnel syndrome
Phalens
Tinels
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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)

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• Features of epicondylitis ?

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Tennis Golfers Elbow

• Both enthesopathies
• Tennis elbow lateral epicondylitis
  inflammation common extensor origin
• Golfers elbow medial epicondylitis
  inflammation common flexor origin
• Tennis elbow more common than Golfers

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Tennis Golfers Elbow

• Pain localised to specific area
• Elbow flexion/extension does not cause pain
• Pain upon
• resisted wrist extension (Tennis)
• resisted wrist flexion (Golfers)

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Tennis Golfers Elbow

• Management
• Rest from precipitating activity
• Elbow clasps
• Local corticosteroid injection
• Physiotherapy ultrasound and acupuncture
• Surgery (often ineffective)

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• Rotator cuff disease features?

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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

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Rotator Cuff anatomy

• A sheath of conjoint tendons to support
  glenohumeral joint, made up of
• S supraspinatous - abduction
• I infraspinatous external rotation
• T teres minor external rotation
• S subscapularis internal rotation

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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

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Rotator Cuff Syndrome

• Painful mid arc
• Impingement test abducted, flexed and
  internally rotated
• Supraspinatus stress

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Rotator cuff investigation - ultrasound

• Full thickness tear

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Rotator Cuff Syndrome

• Management
• Rest, NSAIDs
• Local steroid injection around tendon
  subacromial space and PT
• If chronic/rupture refer to Orthopaedics for
  surgical opinion

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Acute calcific supraspinatus tendinitis

• Calcium hydroxyapatite deposition near
  supraspinatus enthesis

• Young adults, FgtM, acute pain over several hours
• Normally resolves over few days
• Treatment
• Minor NSAID
• Moderate consider steroid injection
• Severe consider aspirating calcified material

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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)

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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)

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• ACJ disease features ?

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Acromioclavicular OA

• High arc pain
• Local tenderness
• Adduction painful
• Impingement

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• Trochanteric bursitis features?

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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

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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

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Trochanteric bursitis

• Management
• Rest
• Analgesia
• Steroid injection
• Physio

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Achilles tendonitis

• Inflammation of the achilles tendon
• Sometimes at enthesis
• Sometimes in middle avascular portion of tendon
• Can be seen with seronegatives

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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

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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

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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 (Simmonds)
• Management
• Surgery to repair tendon
• Conservative below knee cast in ankle equinus 6
  weeks

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• Fibromyalgia features ?

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Fibromyalgia

• All over pain
• Fatigue
• Sleep disturbance
• Depression
• Anxiety
• Irritable bowel
• Tender spots
• Diagnosis of exclusion

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Prevalence/Risk Factors

• Common
• Approx 2-5 depending upon definition
• Female (FM ratio between 31 and 71)
• Middle age (typically 30-60)

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Differential diagnosis

• Other conditions can mimic fibromyalgia
• Systemic lupus erythematosus (SLE)
• Hypothyroidism
• Polymyalgia rheumatica
• Malignancy
• Myopathy
• Metabolic bone disease

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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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• THANK-YOU