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Soft Tissue Disorders and Fibromyalgia. Jaya Ravindran Consultant Rheumatologist. Introduction. Definitions Approach to soft tissue disorders Overview of some soft tissue conditions Fibromyalgia. Definitions. WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?. Definitions. Ligament
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Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist
Introduction • Definitions • Approach to soft tissue disorders • Overview of some soft tissue conditions • Fibromyalgia
Definitions • WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?
Definitions • Ligament • connective tissue that connects bone to bone • Tendon • connective tissue that connects muscle to bone • Enthesis • the point at which a tendon inserts into bone • Bursa • a fluid filled sac located between a bone and tendon
Approach to soft tissue disorders • anatomy of area and mechanism of injury/overuse (work history) • Differentiate from inflammatory/mechanical arthropathy • ? referred pain eg C5/6 Neck pain radiating to shoulder – ask about neurological symptoms
Approach to soft tissue disorders • May be associated with inflammatory arthritis • Bloods not helpful • Imaging - X-ray and ultrasound may play a role in certain soft-tissue disorders
Is it an articular or extra-articular problem? • ARTICULAR PERI-ARTICULAR • pain all planes pain in plane of tendon • active = passive active > passive • capsular swelling/effusion linear swelling • joint line tenderness localised tenderness • diffuse erythema/heat localised erythema/heat
Flexor tenosynovitis • Inflammation of flexor tendon sheaths • Pain and stiffness in flexor finger/thumb • 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
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 • Other 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
Carpal tunnel syndrome • Compression of median nerve as it passes through carpal tunnel
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
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 Phalen’s Tinel’s
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 • 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)
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 – anatomy • A sheath of conjoint tendons to support glenohumeral joint, made up of: • S supraspinatus - abduction • I infraspinatus – 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
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 • Calcium hydroxyapatite deposition near supraspinatus enthesis • 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
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)
Acromioclavicular OA • High arc pain • Local tenderness • Adduction painful • Impingement
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 • 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 pain • Inflammation - seronegatives (enthesis) • Degeneration (middle avascular portion of tendon) • Retrocalcaneal bursitis
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 • “All over pain” • Fatigue • Sleep disturbance • Depression • Anxiety • Irritable bowel • Tender spots • 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