Download SOFT TISSUE RHEUMATISM Upper Extrimity

SOFT TISSUE RHEUMATISM
Dr.A.noori
Rheumatologist
www.arrh.ir
A number of periarticular disorders
have become increasingly common
over the past two to three decades,.
Periarticular disorders most
commonly affect the knee or
shoulder.
Excessive frictional forces from
overuse,
trauma,
systemic disease (e.g.,
rheumatoid arthritis, gout),
infection may cause bursitis
and tendinitis.
Soft Tissue Rheumatism
Shoulder
Periarthritis (80%)
Glenohumeral joint (1%)
Refferal pain (15%)
Soft Tissue Rheumatism
shoulder Region
Rotator Cuff Tear
Bicipital Tear
Bicipital tendinitis
Rotator Cuff tendinitis
Adhesive capsulitis
Calcific tendinitis
Rotator Cuff
tendinitis
Tendinitis of the rotator cuff is the
major cause of a painful shoulder
and is currently thought to be
caused by inflammation of the
tendon(s). The rotator cuff consists
of the tendons of the
supraspinatus, infraspinatus,
subscapularis, and teres minor
muscles, and inserts on the
humeral tuberosities.
Soft Tissue Rheumatism
Rotator Cuff Tendinitis
 Epidemiology: F>M, age>40
 Most common cause of shoulder pain
 Etiology: overuse, especially with activities
involving elevation of the arm with some degree of
forward flexion. Impingement syndrome occurs in
persons participating in baseball, tennis,
swimming, or occupations that require repeated
elevation of the arm
Soft Tissue rheumatism
Impingement Of Rotator Cuff
Soft Tissue Rheumatism
Rotator Cuff Tendinitis
 Clinical manifestation:
Patients complain of a dull aching in the
shoulder, which may interfere with sleep.
Severe pain is experienced when the arm
is actively abducted into an overhead
position. The arc between 60° and 120° is
especially painful. Tenderness is present
over the lateral aspect of the humeral head
just below the acromion
Soft Tissue Rheumatism
Painful Arc
Treatment
NSAIDs,
local
glucocorticoid
:
injection, and physical therapy
may relieve symptoms.
Surgical decompression of the
subacromial space may be
necessary in patients
refractory to conservative
treatment.
Soft Tissue Rheumatism
Injection of Subacromion Bursa
Soft Tissue Rheumatism
Rotator Cuff Tear
 Epidemiology: F>M, middle and old ages
 Etiology: trauma, fracture or dislocation of
shoulder joint, degeneration, rotator cuff
tendinitis
 Clinical manifestation: pain and weakness
on abduction, drop arm sign
 Diagnosis: X-Ray, ultrasound, arthrography;
MRI
 Treatment: acute tearing in young patients
(surgery), steroid injection (after 6 weeks
in acute form), physical therapy
Soft Tissue Rheumatism
Rotator Cuff Tear
Epidemiology: F>M, middle and old
ages
Etiology: trauma, fracture or
dislocation of shoulder joint,
degeneration, rotator cuff tendinitis
Clinical manifestation: pain and
weakness on abduction, drop arm sign
Diagnosis: X-Ray, ultrasound,
arthrography; MRI
Patients may tear the
supraspinatus tendon acutely by
falling on an outstretched arm or
lifting a heavy object.
Symptoms :pain along with
weakness of abduction and
external rotation of the shoulder.
Atrophy of the supraspinatus
muscles develops.
The diagnosis :arthrogram,
ultrasound, or MRI.
Surgical repair may be necessary
in patients who fail to respond to
conservative measures. In patients
with moderate-to-severe tears and
functional loss, surgery is indicated.
Soft Tissue Rheumatism
Shoulder Arthrogram (Rotator Cuff)
Soft Tissue Rheumatism
Bicipital Tendon
Bicipital Tendinitis and Rupture
 Bicipital tendinitis, or tenosynovitis, is
produced by friction on the tendon of the long
head of the biceps as it passes through the
bicipital groove. When the inflammation is
acute, patients experience anterior shoulder
pain that radiates down the biceps into the
forearm
Soft Tissue Rheumatism
Bicipital Tendinitis
Etiology: sport injury, special
activity
Clinical manifestation: acute or
chronic pain on anterior of
shoulder, tenderness on palpation
of bicipital groove, associated
with
Rotator cuff tendinitis
Soft Tissue Rheumatism
Bicipital Tendinitis
Diagnosis: yergason’s sign,
speed test, pope eye sign
(tendon rupture)
Treatment: rest, physical
therapy, NSAIDs, steroid
injection, surgery
. Abduction and external rotation
of the arm are painful and limited.
Pain may be elicited along the
course of the tendon by resisting
supination of the forearm with the
elbow at 90° (Yergason's
supination sign).
Soft Tissue Rheumatism
Yergason’s Sign And Speed Test
Acute rupture of the
tendon may occur with
vigorous exercise of the
arm and is often painful.
In a young patient, it
should be repaired
surgically.
Rupture of the tendon in an older
person :
little or no pain and is recognized
by the presence of persistent
swelling of the biceps ("Popeye"
muscle) produced by the retraction
of the long head of the biceps.
Surgery is usually not necessary in
this setting
Calcific Tendinitis
deposition of calcium salts, primarily
hydroxyapatite, within a tendon. The
exact mechanism of calcification is not
known but may be initiated by ischemia
or degeneration of the tendon. The
supraspinatus tendon is most often
affected because it is frequently
impinged on and has a reduced blood
supply when the arm is abducted.
Calcific Tendinitis
The condition usually develops after age
. 40.Calcification within the tendon may
evoke acute inflammation, producing
sudden and severe pain in the shoulder.
However, it may be asymptomatic or not
related to the patient's symptoms
Soft Tissue Rheumatism
Calcific Tendinitis
Adhesive Capsulitis
Often referred to as "frozen
shoulder," adhesive capsulitis
:pain and restricted movement of
the shoulder, usually in the
absence of intrinsic shoulder
disease. Adhesive capsulitis may
follow bursitis or tendinitis of the
shoulder .
Adhesive Capsulitis
associated with systemic
disorders such as chronic
pulmonary disease, myocardial
infarction, and diabetes mellitus.
Prolonged immobility of the arm
contributes to the development of
adhesive capsulitis.
Pathologically, the capsule of the
Adhesive capsulitis :commonly in
women after age 50. Pain and stiffness
usually develop gradually but progress
rapidly in some patients. Night pain is
often present in the affected shoulder
and pain may interfere with sleep. The
shoulder is tender to palpation, and
both active and passive movement are
restricted. Radiographs of the shoulder
show osteopenia. .
The diagnosis is typically made
by physical examination but can
be confirmed if necessary by
arthrography, in that only a
limited amount of contrast
material, usually <15 mL, can be
injected under pressure into the
shoulder joint.
In most patients, the condition improves
spontaneously 1–3 years after onset.
While pain usually improves, many
patients are left with some limitation of
shoulder motion. Early mobilization of
the arm following an injury to the
shoulder may prevent the development
of this disease. Physical therapy: the
foundation of treatment for adhesive
capsulitis.
Local injections of glucocorticoids
and NSAIDs may also provide relief
of symptoms. Slow but forceful
injection of contrast material into the
joint may lyse adhesions and stretch
the capsule, resulting in
improvement of shoulder motion.
Manipulation under anesthesia may
be helpful in some patients.,.;/
Soft Tissue Rheumatism
Adhesive Capsulitis (2)
 Diagnosis: underlying disease (FBS), X-Ray
MRI, arthrography (loss of joint cavity
space)
 Treatment: NSAIDs, steroid (local injection
or systemic), physical therapy (pendulum
exercise, wall climbing), manipulation under
anesthesia in refractory cases
Soft Tissue Rheumatism
Elbow Region
Lateral epicondylitis
Medial Epicondylitis
Olecranon bursitis
Ulnar nerve entrapment
Soft Tissue Rheumatism
Olecranon Bursitis
 Etiology: low grade chronic trauma
_inflammatory arthritis, septic
 Clinical manifestation: pain and tenderness
is minimal , clear or blood tinged fluid in
aspiration
 Treatment: avoid special habit, fluid
aspiration and steroid injection, antibiotic in
septic bursitis, surgery in refractory cases
Soft Tissue Rheumatism
Muscle Insertions Around The Elbow Joint
Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, or tennis elbow, :
painful condition involving the soft tissue over
the lateral aspect of the elbow. The pain
originates at or near the site of attachment of
the common extensors to the lateral
epicondyle and may radiate into the forearm
and dorsum of the wrist. The pain usually
appears after work or recreational activities
involving repeated motions of wrist extension
and supination against resistance.
Soft Tissue Rheumatism
Resisted Wrist Extension Test
Soft Tissue Rheumatism
Muscle Insertions Around The Elbow Joint
Soft Tissue Rheumatism
Lateral Epicondylitis
Epidemiology: ages (35-50), F=M
Etiology: inflammation of common
extensor tendon, tennis player,
gardening,
Clinical manifestation: pain in
lateral epicondyle, radiation to
forearm, weakness on grasping,
differentiation with radial nerve
entrapment
Treatment
usually rest along with
administration of an
NSAID. Ultrasound,
icing, and friction
massage may also help
relieve pain. When pain
is severe, the elbow is
placed in a sling or
splinted at 90° of flexion.
Soft Tissue Rheumatism
Lateral Epicondylitis
Diagnosis: pain on resisted
wrist extension, X-Ray
(calcification, exostosis)
Treatment: NSAIDs, physical
therapy, steroid injection,
surgery (>6 months),
Medial Epicondylitis
Medial epicondylitis is an overuse syndrome
resulting in pain over the medial side of the
elbow with radiation into the forearm. The
cause of this syndrome is considered to be
repetitive resisted motions of wrist flexion
and pronation, .
. patients >35 years and is much less
common than lateral epicondylitis.
It occurs most often in work-related
::swinging a golf club (golfer's elbow) or
throwing a baseball.
On physical examination, there is
tenderness just distal to the medial
epicondyle over the origin of the forearm
flexors. Pain can be reproduced by resisting
wrist flexion and pronation with the elbow
extended.
Soft Tissue Rheumatism
Resisted Wrist Flexion Test
Treatment s conservative, involving rest,
NSAIDs, friction massage, ultrasound, and icing
splinting. Injections of glucocorticoids at the painful
site may also be effective
. Patients should be instructed to rest for at least
one month. Also, patients should start physical
therapy once the pain has subsided. In patients
with chronic debilitating medial epicondylitis that
remains unresponsive after at least a year of
treatment, surgical release of the flexor muscle at
its origin may be necessary and is often
successful.
Soft Tissue Rheumatism
wrist And Hand Region
Carpal tunnel syndrome
De quervain’s tenosynovitis
Trigger finger
Ganglion
Dupuytren’s contracture
Soft Tissue Rheumatism
Anatomy Of Carpal Tunnel
Soft Tissue Rheumatism
Carpal Tunnel Syndrome (1)
 Epidemiology: F/M=5/1, symptomatic CTS
(3% F, 2% M), peak age (30-60)
 Etiology: Inflammatory disease (RA, SLE,
PSS), crystal arthropathy, job trauma, local
(osteophyte, tumors), metabolic (DM 6%,
myxedema, acromegaly), infection
(tuberculosis, fungal, rubella), pregnancy,
idiopathic
 Clinical manifestation: nocturnal symptom (
Soft Tissue Rheumatism
Sensory Supply To The Hand
Soft Tissue Rheumatism
Carpal Tunnel Syndrome (2)
 weakness and atrophy in chronic cases,
Phalen’s maneuver (40-80% sensitivity and
specificity), Tinel’s sign (sensitivity 25-60%,
specificity 68-87%), tourniquet test
 Diagnosis: physical examination, EMG-NCV
Treatment: treating :
 splinting, NSAID’s, steroid (local injection or
systemic),, surgery (sever symptom>1
year, atrophy
Soft Tissue Rheumatism
Tinel’s Sign And Phalen’s Test
Soft Tissue Rheumatism
Thenar Muscle Atrophy
Soft Tissue Rheumatism
Carpal Tunnel Syndrome (Local
Injection)
Soft Tissue Rheumatism
De Quervain’s Tenosynovitis
 Epidemiology: age>40, F>M
 Etiology: repetitive activity with thumb
pinching and moving wrist, inflammation of
tendon sheath (abductor pollicis longus and
extensor pollicis brevis)
 Clinical manifestation: pain and tenderness,
swelling over the radial styloid, Finkelstein
test
 Treatment: rest, NSAID’s, local steroid
injection, surgery in refractory cases
Soft Tissue Rheumatism
De Quervain’s Tenosynovitis
Soft Tissue Rheumatism
Finkelstein Test
Soft Tissue Rheumatism
Dupuytren’s Contracture
Soft Tissue Rheumatism
Flexor Tendon Sheaths Of The Hand
Soft Tissue Rheumatism
Dupuytren’s Contracture
 Epidemiology: F/M 1/5, white man
 Etiology: shortening and thickening of
palmar fascia, hereditary, alcoholism,
epilepsy, DM, any chronic disease
 Clinical manifestation:4th, flexion
contracture of one or more digits, in
decreasing order (5th 3th, 2th fingers)
 Treatment: physical therapy, steroid
injection, colchicin, vitamin E, surgery
Soft Tissue Rheumatism
Volar Flexor Tenosynovitis (Trigger
Fingers)
 Etiology: inflammation of tendon sheaths of
flexor digitorum, trauma, inflammatory
disease (RA, psoriatic arthritis, crystal
arthropathy, overused, osteoarthritis
 Clinical manifestation: painful finger flexion
(middle and index fingers), swelling,
tenderness and nodule proximal to MCP
joint in the volar side,
 treatment: rest, physical therapy, NSAID’s,
steroid injection, surgery
Soft Tissue Rheumatism
Ganglion
 Epidemiology: ages 20-40, F=M
 Etiology: cystic swelling arising from a joint
or tendon sheath, trauma, prolonged wrist
extension
 Clinical manifestation: swelling and
discomfort on wrist extension
 Treatment: splint, rest, physical therapy,
NSAID’s, steroid injection, surgery
Soft Tissue Rheumatism
Ganglion
 Epidemiology: ages 20-40, F=M
 Etiology: cystic swelling arising from a joint
or tendon sheath, trauma, prolonged wrist
extension
 Clinical manifestation: swelling and
discomfort on wrist extension
 Treatment: splint, rest, physical therapy,
NSAID’s, steroid injection, surgery
SOFT TISSUE RHEUMATISM
LOWER EXTREMITY
Soft Tissue Rheumatism
Hip Region
Trochantric bursitis
Iliopsoas bursitis
Ischial bursitis
Soft Tissue Rheumatism
The Bursa Of The Hip Joint
Soft Tissue Rheumatism
Trochantric Bursitis
 Epidemiology: age 30-70, F>M
 Etiology: local trauma, osteoarthritis of hip
and lumbar spine, scoliosis, leg-length
discrepancy, inflammatory conditions
 Clinical manifestation: pain on moving and
lying on the involved side, pain in external
rotation and abduction against resistance,
calcification in X-Ray
 Treatment: NSAID’s, steroid injection
Soft Tissue Rheumatism
Iliopsoas Bursitis
 Etiology: trauma, inflammatory conditions,
septic, communication with hip joint (15%)
 Clinical manifestation: groin and anterior
thigh pain, exacerbation of pain with
hyperextension of hip, cystic mass (30%),
femoral venous obstruction
 Diagnosis: X-Ray with contrast media, MRI
 Treatment: NSAID’s, steroid injection,
surgery
Soft Tissue Rheumatism
CT Scan Of Iliopsoas Bursitis
Soft Tissue Rheumatism
Ischial Bursitis
 Etiology: trauma, prolonged sitting on hard
surface, weaver’s bottom
 Clinical Manifestation: radiation of pain to
back of the thigh, local tenderness
 Treatment: modified activity, cushion’s,
NSAID’s, steroid injection with caution
Soft Tissue Rheumatism
Meralgia Paresthetica
 Etiology: obesity, pregnancy, diabetes, direct
trauma, compression from corset, leg-length
discrepancy
 Clinical manifestation: hyperesthesia and
numbness of anterolateral thigh,exacerbation of
pain with ,extension and abduction of thigh,
prolonged standing and walking,
Decreased touch and pinprik sensation
 Diagnosis: NCV
 Treatment: weight loss, steroid injection (medial to
anterior superior iliac spine
Soft Tissue Rheumatism
Meralgia Paresthetica
Soft Tissue Rheumatism
knee Region
Popliteal cyst
Prepatellar and infrapatellar bursitis
Anserine bursitis
Patellar tendinitis
Soft Tissue Rheumatism
Popliteal Cyst (Baker’s Cyst)
 Etiology: any knee disease with synovial
effusion (mechanical and inflammatory),
naturally occurring communication between
knee joint and semimembranosusgastrocnemius bursa (40%)
 Clinical manifestation: diffuse swelling and pain
of calf, erythema and edema of ankle (ceresent
sign), mimiking thrombophlebitis
 Diagnosis: ultrasound, arthrography, MRI
 Treatment: rest, aspiration and steroid
injection, surgery
Soft Tissue Syndrome
Prepatellar and Infrapatellar
Bursitis
 Etiology: trauma, frequent kneeling
(housemaid’s knee), inflammatory (gout,
septic)
 Clinical manifestation: pain, tenderness,
swelling, hotness and redness (septic)
 Treatment: aspiration and culture, steroid
injection, modified activity
Soft Tissue Rheumatism
Anserine Bursitis
 Epidemiology: age 30-50, F>M
 Etiology: inflammation ) include, tendons of
gracilis, sartorius,
semitendinosus,osteoarthritis of knee,
obese
 Clinical manifestation: pain and tenderness
over the medial aspect of the knee (2 inch
below the joint margin
 Treatment: rest, stretching of adductor and
quadriceps muscles, NSAID’s, steroid
injection
The diagnosis of plantar fasciitis can usually be
made on the basis of history and physical
examination alone. Patients experience severe
pain with the first steps on arising in the
morning or following inactivity during the day.
The pain usually lessens with weight-bearing
activity during the day, only to worsen with
continued activity. Pain is made worse on
walking barefoot or up stairs. On examination,
maximal tenderness is elicited on palpation
over the inferior heel corresponding to the site
of attachment of the plantar fascia
Soft Tissue Rheumatism
Retrocalcaneal Bursitis
 Etiology: inflammation of the bursa between
the posterior surface of the achille tendon
and the calcaneous, trauma, inflammatory
arthritis (especially spondyloarthropathy)
 Clinical manifestation: pain on dorsiflexion,
tenderness, local swelling and bulging
 Diagnosis: physical diagnosis, MRI,
ultrasound
 Treatment: rest, splint, NSAID’s,
Soft Tissue Rheumatism
Subcutaneous Achilles
Bursitis
Etiology: pressure of shoes, bony
exostoses; sondyloarthropathy
Clinical manifestation: pain, swelling and
redness
Treatment: relief from shoe pressure,
treatment of underlying disease
Soft Tissue Rheumatism
Achilles tendinitis
 Etiology: trauma, athletic injury, fitting
shoes, inflammatory conditions (especially
spondyloarthropathy)
 Clinical manifestation: pain on dorsiflexion,
swelling, crepitus on motion
 Diagnosis: MRI, ultrasound
 Treatment: rest, splint (slight plantar
flexion), NSAID’s
Soft Tissue Rheumatism
Plantar Fascia
Soft Tissue Rheumatism
Plantar Fasciitis
 Etiology: athletic over activity, prolonged
walking, improper shoes,
spondyloarthropathy
 Clinical manifestation: pain (morning upon
arising, initial improvement, worsen later in
the day), burning, aching, tenderness on
palpation of medial calcaneal tubercle
 Diagnosis: rest, heel pad, NSAID’s,
orthoses, steroid injection
Soft Tissue Rheumatism
Hallux Valgus-Bunion
 Etiology: deviation of the large toe, genetic
tendency, improper shoes, inflammatory
arthritis, osteoarthritis
 Clinical manifestation: deformity, local
tenderness and redness (bunion), X-Ray
(osteoarthritis of first MTP)
 Treatment: orthoses and bunion pads,
NSAID’s, surgery