Soft Tissue Rheumatism

1. SoftTissueRheumatism Prof. Dr. Şansın Tüzün

2. FIBROMYALGIA • Chronicmusculoskeletalsyndromecharacterizedbydiffusepain and tender points • No evidencethatsynovitisormyositisarecauses • Occursin thecontext of unrevealingphysicalexamination, labaratory and radiologicexamination • % 80-90 of patientsarewomen, peakage is 30-50 years

3. Clinical Features • Generalized chronic musculoskeletal pain • Diffuse tenderness at discrete anatomic locations termed tender points • Other features, diagnostic utility but not essential for classification of fibromyalgia are; fatique, sleep disturbances, headaches, irritable bowel syndrome, paresthesias, Raynaud’s-like syndromes, depression and anxiety

4. For classification criteria, patients must have pain for at least 3 months involving the upper and lower body, right and left sides, as well as axial skeleton, and pain at least 11 of 18 tender points on digital examination

6. Classification For CFS • Classify as CFS or idiopathic Chronic Fatique if; Fatique persists or relapse for > 6 months History, physical examination and appropriate laboratory tests exclude any other cause for the chronic fatique

7. Classify as CFS if along with fatique, four or more of the following are present for >6 months; Impaired memory of concentration, sore throat, tender cervical or axillary lymph nodes,muscle pain, multijoint pain, new headaches ,unrefreshing sleep, postexertion malaise

8. MYOFASCIAL PAIN SYNDROMES Presence of trigger points, which include a localized area of deep muscle tenderness, located in a taut band in the muscle, and a characteristic reference zone of the perceived pain that is aggravated by the palpation of the trigger point

9. Comparison of FM and MPS

10. Treatment • NSAID • Tricyclic antidepresants ( i.e. amitriptyline, desipramine 1-3h before bedtime) • Cardiovasculer fitness training • Biofeedback • Hypnotherapy • Cognitive behavioral therapy • Educating patient

11. Entrapment Neuropathies • Resultsfromincresedpressure on a nerve as it passesthrough an enclosedspace • Knowledge of anatomy is essentialforunderstanding of theclinicalmanifestations of thesesyndromes • Splinting, NSAIDs and localcorticosteroidinjectionsusuallysufficewhensymptomsaremild and of short time. • Surgicalprocedurestodecompressthenerveareindicated in more severe cases

12. Thoracic Outlet Syndrome • Results from compression of one or more of the neurovasculer elements that pass through the superior thoracic aperture • Anatomic abnormalities and trauma to the shoulder girdle region play a far more pivotal role

13. Potential narrowing areas • Between the scalenius anterior and scalenius medius • Costoclavicular space • Under the coracoid process and beneath the pectoralis minor tendon

14. Signs and symptoms • Paresthesias • Achingpain, radiatingtotheneck, shoulder and arm • Motor weakness • Atrophyof thenar, hypotenar and intrinsicmuscles of thehand • Vasomotordisturbances

15. Diagnosis • Neurologic examination • Certain clinical stress tests (Adson and hyperabduction maneuvers) • A radiograph of cervicothoracic region (cervical rib, elongated transverse process of C7)

16. Treatment • Exercise designed to improve posture by strengthening the rhomboid and trapezius muscles • Avoidance of hyperabduction • Surgical intervention if; muscle wasting, intermittent fleeting paresthesias replaced by continous sensory loss, incapacitating pain,worsening of circulatory impairment

17. Cubital Tunnel Syndrome • Compressionneuropathy of theulnarnerve as it transversestheelbow • Causesare; history of a trauma, chronicpressurebyoccupationalstressorfromunusualelbowpositioning • Arthriticconditionsthatresults in synovitis • Osteophyteproduction

18. Signs and symptoms • Paresthesias in thedistribution of theulnarnerve • Aggrevatedbyprolongeduse of theelbow in flexedposition • (+) Tinel’ssign • Atrophyof intrinsicmuscles and weakness in pinch and grasp • Wastingof thehypothenarmuscles and slightclawing of the 4th and 5th fingers • Weaknessin adduction of the 5th finger

19. Diagnosis • Physical examination (Tinel’s sign, Wartenberg’s sign i.e.) • Radiographs • Electrodiagnosis

20. Treatment • Avoidance of prolonged elbow flexion • Local steroid injection along the ulnar groove • Surgical procedures to decompress the nerve

21. Ulnar Tunnel Syndrome • Entrapment of theulnarnerve in Guyon’scanal at thewrist • Compressionis duetoganglia • Causesare; Aberrantmuscles, Dupuytren’sdisease, RA, OA • Chronictraumaduetocertaintools and occupations

22. Signs and Symptoms • Combined sensory and motor deficits • Hypoesthesia in the hypothenar region and 4th and 5th fingers • Weakness of the intrinsic muscles of the hand

23. Diagnosis • Pyhsicalexamination • Electrodiagnosisis helpful in determiningthe site of theentrapmant Treatment • Avoidance of trauma • Physicaltherapy • Surgicaldecompression

24. Carpal Tunnel Syndrome • Mostcommonentrapmentneuroropathy • Compressionof themediannerve at thewrist • Causesare; occupation, crystal-inducedrheumaticdisorders • Complicationof connectivetissuedisorders • Uremia, metabolic and endocrinediseases, infections, familialoccurrance, duringpregnancy

25. Signs and Semptoms • Sensoryloss in theradialthreefinger and one-half of the ring finger • Burning, pins-and-needlessensations, numbness and tingling in thefingers • Painmayradiatetotheantecubitalregionortothelateralshoulderarea • Awakenat nightbyabnormalsensation

26. (+)Tinel’s sign • (+) Phalen’s sign (wrist flexion) • Thenar atrophy

27. Diagnosis • History and physical examination • Radiographs • Electrodiagnosis

28. Treatment • Splints • Localcorticosteroidinjection • NSAIDs • Physicaltherapy • Surgery ; patientswithprogressiveincreases in distal motor latencytimes