4th Year Rheumatology Lecture 1c Soft tissue rheumatism

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4th Year RheumatologyLecture 1(c) Soft tissue
rheumatism
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These are the commoner problems affecting the
shoulder

• Frozen shoulder (adhesive capsulitis)
• Rotator cuff syndrome (impingement or painful arc
  syndome)
• Biceps tendonitis
• Subacromial bursitis
• Acromium clavicular OA
• Sternoclavicular OA
• Neck pain

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Elbow

• Lateral epicondylitis (tennis elbow)
• Medial epicondylitis (golfers elbow)
• Olecranon bursitis

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Wrist/hand

• Carpal tunnel syndrome
• Reflex sympathetic dystrophy (algodystrophy/region
  al osteoporosis)
• De Quervains tenosynovitis
• Repetitive strain injury (RSI)
• Dupytrons contracture

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Frozen shoulder

• Reduced glenohumeral movement (abduction and
  internal/external rotation)
• There are 3 phases, each lasting 6 months
• Pain --- adhesion --- resolution
• 40 have some restriction in movement at 3 years
• Pathology - tightening of capsule with fibrosis
• Associations - thyroid disease, hyperparathy, DM,
  cardiothoracic surgery
• Therapy - analgesia, physio, i/a injection, GA
  mobilisation

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Rotator cuff syndrome

• Secondary to failure of rotator cuff mechanism or
  reduced space in which humeral head moves
• Cuff rupture allows humeral head to go up ---gt
  impingement
• Supraspinatus (abduction), infraspinatus
  (external rotation), subscapularis (internal
  rotation)
• Therapy - physio, i/a injection, surgery

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Tennis elbow

• Pain at origin of extensors of wrist from lateral
  humeral epicondyle
• Pain locally and on wrist extension
• History of overuse
• ?chronic enthesitis or tendon tear
• Therapy - modify use, topical NSAID, steroid
  injection, epicondylar clasp, surgery

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Reflex sympathetic dystrophy

• Pain, vasomotor disturbance and trophic changes
  in limb (also called regional osteoporosis)
• Different phases
• burning pain and hyperalgesia
• tissue swelling and oedema
• local osteoporosis
• After 6/12, atrophic cold and shiny limb ---gt
  tissue contracture
• Secondary to increase sympathetic activity?
• Therapy - calcitonin, physio, psychology

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Carpal tunnel syndrome

• Median nerve compression in carpal tunnel
• Pain worse at night and may be in forearm
• 30-50 bilateral
• Sensory changes and weakness of thenar eminence
• Tinels and Phalens sign. NCS.
• Associations - pregnancy, RA, amyloid, myeloma,
  hypothyoidism, acromegaly, idiopathic
• Therapy - splints, NSAIDs, diuretics, steroid
  injections, surgery

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Fibromyalgia

• femalemale 91
• Pain, fatiguability --gt disability
• Poor sleep pattern, awake exhausted and tired
• Odd symptoms - headache, urinary and abdo
  symptoms
• No inflammation but multiple hyperalgesic sites
  (8/17)
• May be primary or superimpose on existing
  condition (seconadary) such as OA or RA
• Differential diagnosis
• hypothyoidism, SLE, myositis, osteomalacia,
  myeloma
• If patient is tender all over, consider
  fabrication/psychogenic if above causes excluded

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Fibromyalgia

• Other similar conditions - fibrositis, pain
  amplification syndrome, myalgic
  encephalomyelitis, chronic fatigue syndrome
• Therapy - explanation, improve sleep, increase
  fitness.
• Myalgic encephalomyelitis (ME)
• often after viral illness
• relapsing remitting courses
• fatiguability (50 of normal activity)
• Myalgia vague CNS symptoms (forgetfulness,
  decreased concentration)