Download Regional Rheumatism

Regional Rheumatism
Andres Quiceno, MD
Rheumatology Division PHD
Clinical Assistant Professor of
Medicine UTSW
Regional Rheumatism
These conditions are among the most
poorly taught subjects in medical school.
Even in the orthopedic and rheumatology
programs.
These ailments are extremely common in
medical practice.
The medical conditions included here are
tenosynovitis, bursitis, fasciitis,
enthesopathy and compression
neuropathy.
Regional Rheumatism
Approximately 33% of United States
adults have a musculoskeletal complaint.
In patients over 65, musculoskeletal
symptoms are the most common
complaint reported and the most common
cause of functional limitation.
Musculoskeletal and rheumatological
conditions are frequently chronic and have
a significant social and economical cost.
Regional Rheumatism
IMPINGEMENT SYNDROME
Chronic shoulder pain is the most common upper
extremity problem in recreational, competitive
and elite athletes.
This problem is more common in throwing
athletes, racquet sports, volleyball, gymnasts and
swimmers.
This kind of athletes need full, unrestricted upper
extremity function to perform in their sport.
Even mild degree of pain and dysfunction can
result in complete disability for their respective
sports.
Regional Rheumatism
The glenohumeral joint represents the
articulation of the humerus and glenoid fossa.
It is the most mobile joint in the body.
The joint is stabilized by multiple ligaments and
muscles including the rotator cuff.
The rotator cuff comprises four muscles and their
tendons: the subscapularis, the supraspinatus,
the infraspinatus and the teres minor.
The most commonly affected tendon is the
supraspinatus.
Regional Rheumatism
Regional Rheumatism
Regional Rheumatism
Problems of the rotator cuff involve many
tendon abnormalities.
The most common cause full-thickness
rotator cuff tears are chronic and most
likely represent the final pathway of
chronic subacromial pathology.
Other conditions in the spectrum of this
syndrome includes: rotator cuff tendinitis,
subacromial bursitis and partial rotator
cuff tears.
Regional Rheumatism
The earliest stage of rotator cuff pathology is
rotator cuff tendinitis, this is a condition of
athletes in their 20s and 30s.
There are many hypothesis for this tendinopathy.
These includes mechanical impingement of the
coracoacromial arch onto the supraspinatus
tendon with the arm abducted or forward-flexed
position.
This position is part of the throwing motion in
overhead throwers such us baseball pitchers and
quarterbacks.
Regional Rheumatism
Impingement also affects the subacromial bursa.
Weakness or imbalance in the rotator cuff is
associated with increase risk of subacromial
pathology.
Clinical Manifestations
A relative gradual onset of symptoms associated
with activity and that increase with overhead
activities.
Pain can be diffuse and difficult to localize.
Often they refer the pain to the deltoid muscle
area.
Regional Rheumatism
Patients with acromioclavicular pathology usually
are able to point directly to this joint.
Limitation in the passive range of motion suggest
adhesive capsulitis.
Patients with rotator cuff impingement avoid
abduction
Abduction is more painful between 70 and 120
degrees.
Imaging
Plain radiographs are usually no needed.
MRI can reveal many details of this pathology.
Regional Rheumatism
Regional Rheumatism
Treatment
Activity modification or even completely avoiding the
impingement position.
A physical therapy program that focuses in flexibility and
strength of the rotator cuff is recommended.
NSAID are often used but is not clear if they are effective.
Conservative approach is keep for 2 to 3 months.
Other options include subacromial corticosteroid injection.
If no improvement in 4 to 6 months of conservative therapy
consider surgery.
Arthroscopic treatment has similar results to open surgery
with less complications.
Success rate is between 70% to 80%.
Regional Rheumatism
Regional Rheumatism
Elbow Region
The elbow is formed by three articulations: the humerus
with the radius, the humerus with the ulna and the radius
with the ulna.
The ulnar nerve passes medial to the olecranon process and
behind the medial epicondyle in the cubital tunnel.
Lateral epicondyle is the site of origin of the wrist extensorsupinator muscle group.
The medial epicondyle is the site of origin of the wrist
flexor-pronator.
Pathology includes chronic degenerative changes of the
tendons.
Regional Rheumatism
Lateral epicondylitis or tennis elbow, is a
syndrome of pain in the wrist extensor muscles.
Clinically the patient presents with discomfort if
the lateral elbow.
Point of tenderness is at the epicondyle or slightly
distal, pain at resisted wrist extension is
suggestive of the diagnosis.
Risk factors include high hand force with
repetitive use, repetitive rotation of the forearm
and forceful gripping with wrist extension.
Regional Rheumatism
Regional Rheumatism
Treatment
This disorder may be slow to improve.
Initial therapy includes rest, splinting, ice and
heat application.
Anti-inflammatories or pain medications could be
helpful.
Steroid injection is consider when conservative
treatment fails.
Injections are relatively safe and give relief for
two to six weeks.
Steroid injection is not recommended in medial
epicondylitis.
Regional Rheumatism
Olecranon Bursitis
Commonly occurs after repetitive trauma to the
elbow.
Other etiologies include: rheumatoid arthritis and
crystalloid arthritis.
Aspiration of the bursa can be performed to relief
discomfort.
If symptoms recur Steroid injection can be done.
This bursa is a common site of infection
frequently caused by Staphylococcus aureus.
Regional Rheumatism
DE Quervain's Disease
This is the name given to the tenosynovitis to the
extensor tendons of the thumb.
The most clinical manifestation is pain over the
styloid process.
Swelling and warmth over the radial wrist is
common.
A positive Finkelstein test is the classic diagnostic
maneuver.
Differential diagnosis include osteoarthritis and
Ulnar nerve compression at the wrist.
Regional Rheumatism
Risk factors include: assembly line work, small
goods manufacturing, meat and poultry
processing, textile production and computer use.
Treatment includes rest with a thumb in a spicasplint, NSDAIDS and physical therapy.
Steroid injection is an option after conservative
treatment.
If symptoms persist changes in the work place
could be necessary.
Regional Rheumatism
Regional Rheumatism
Regional Rheumatism
Trigger Finger
Trigger finger is caused by swelling of the flexor tendon or
narrowing of the tendon pulley superficial to the MCP joint.
Trigger finger manifests with pain or crepitus in the flexor
sheath and impaired finger flexion with triggering or
locking.
Pain over the MCP joint is a classic feature.
Risk factors include pressure over hard objects, such us tool
handles and repeated movements.
Often is seen middle age women and can be associated
with endocrinologic or rheumatoid diseases.
Regional Rheumatism
Regional Rheumatism
Hip pain involves a wide differential diagnosis.
The anatomy of this region is complex.
The hip is ball-and-socket joint.
The bone structures that conform this area
include: acetabulum, femoral head, ischium,
ilium and pubis.
A large number of muscles enable the hip to
move in a wide range of motion.
Flexion is performed by the iliopsoas and
quadriceps, extension by the hamstring.
The nerves that more commonly cause pain are
the Sciatic and the femoral cutaneus.
Regional Rheumatism
The age of the patient suggest different
diagnostic possibilities.
Younger patients are more prone to apophyseal
injuries.
Avulsion fractures are more common in skeletally
immature patients.
Bursitis and muscle strains are more common in
skeletally mature patients and DJD is more
common in older adults.
Regional Rheumatism
Physical examination is similar for all groups of
age.
Observation includes determining whether the
affected leg can bear weight. Observe the patient
posture and evaluate height symmetry of the iliac
crests.
Palpation can help localize vague complains to an
specific structure.
Range of motion is dependent of patient’s age,
with range decreasing with age.
Some specific tests such us the Trendelenburg’s
and Ober’s are helpful to diagnose specific
pathologies.
Regional Rheumatism
Regional Rheumatism
Regional Rheumatism
Radiology is not as helpful as is in ankle or knee
pain.
Radiographs anteroposterior and frog leg lateral
hip are recommended in all acutely injured
patients, patients with marked reduced range of
motion, point tenderness at the site of muscular
insertion and inability to bear weight.
Plain films are helpful in the diagnosis of slipped
capital femoral epiphysis, Legg-Calve-Perthes,
dysplasia and apophyseal injuries.
Regional Rheumatism
Ultrasound is limited in the evaluation of the adult hip, but
can be helpful in the evaluation of the intraarticular
effusions and soft tissue swelling.
In pediatric patients could be helpful in the diagnosis of hip
subluxation.
CT scan provides an excellent detail of the osseus
structures, can define fractures and intraarticular loose
bodies.
Bone scan is sensitive for stress fractures but lacks
specificity.
MRI is helpful defining soft tissue inflammation, synovitis,
neoplasm, infection and stress fractures.
Regional Rheumatism
Age-Specific Hip Problems
Prepubescent:
Transient synovitis is the most common cause of
hip pain in children.
Legg-Calve-Perthes is an inflammatory disease of
the femoral head, with a male-female ratio of 5
to 1, peak incidence is between four to eight year
old.
Regional Rheumatism
Adolescence:
Slipped femoral epiphysis is another age specific
entity. It is most common in kids 11 to 14 year
old. Obesity and male sex increase the risk.
This disease increase the risk of avascular
necrosis of the femoral head or ostearthritis in
the adults.
This entity requires early referral to and
orthopedic surgeon because this disease benefits
from surgical pinning of the slipped bone.
Regional Rheumatism
Young Adult
Young adults have the longest list of possible
diagnoses. Because the practice of high intensity
sports, avulsion fractures, femoral neck stress
fractures, iliotibial band syndrome are more
common in this group of age.
The most critical diagnosis to make early is stress
fracture.
Females are in higher risk such us endurance
athletes.
This fractures can progress to unstable fractures
and increase the risk for avascular necrosis.
Regional Rheumatism
Older Adult:
The most common cause
of pain is DJD.
Other causes is
trochanteric bursitis.
Regional Rheumatism
Patellar tendinopathy
The quadriceps tendon connects the rectus
femoris, the vastus intermedius and the vastus
lateralis to the patella.
The tendon inserts in the proximal pole of the
patella and continues distally as the Galea
aponeurotica to merge with the patella tendon.
The tendon of the inferior pole of the patella to
the tibial tuberosity is a 30% thinner than the
quadriceps tendon and is most susceptible to
overuse injury.
Regional Rheumatism
Regional Rheumatism
The pathophysiology of patellar tendinopathy
shows mucoid degeneration of the tendon.
At light microscopy the tendon show abnormal
collagen, tenocytes and abnormal blood vessels
ingrowth.
A major feature is the absence of inflammation,
for this reason some authors call this finding as
tendinosis instead of tendinitis.
This suggest that this condition is more a
degenerative condition.
Regional Rheumatism
Patellar tendinoapthy is more often located in the
lower pole of the patella.
The cause is repeated overloads on the extensor
mechanism.
It is more common in that requires maximal
muscle-tendon unit exertion such us jumping.
Pain is elicited by activity, pain when sitting for
long periods and going up and down stairs.
The most common physical finding is tenderness
and in chronic cases swelling.
MRI and US are the modalities of choice to
evaluate patellar disorders.
Regional Rheumatism
Conservative management includes correction of
the predisposing factors, stretching and
strengthening, physical therapy, NSDAID and
steroid injection.
Surgery is indicated in patients that not improve
after three to six months of conservative therapy.
Iliotibial band
Iliotibial band friction syndrome results of
excessive friction between the band and lateral
femoral condyle.
Regional Rheumatism
The iliotibial band originates proximally from the
confluence of the fascia from the tensor fascia
lata, the gluteus maximus and gluteus medius.
At the knee the iliotibial band attaches to the
patella, crosses the knee and attach in the
Gerdy’s tubercle and lateral to the tibial tubercle.
The pathogenesis of this condition is attributed to
the friction of the deep layer of the band and the
lateral femoral epicondyle.
Clinically presents with pain or burning over the
lateral aspect of the knee.
Regional Rheumatism
Activities such as distance running or running downhill
aggravate the symptoms.
Physical examination reveals tenderness over the lateral
femoral epicondyle, greater with knee at 30 degrees of
flexion.
Ober’s test indicates tightness of iliotibial band.
In ITB syndrome, there should be no knee effusion,
instability or positive McMurray test.
MRI confirms the diagnosis in patients considered for
surgery.
Majority of the patients improve with conservative
management, if symptoms persist for more than six
months, surgery should be considered.
Regional Rheumatism
Regional Rheumatism
Conditions of the Achilles tendon
The Achilles tendon is the largest tendon in the
body.
Its limited blood supply and the combination of
forces which is subjected increase the risk of
injury.
Achilles tendinosis occurs in 10% of the runners,
but is also common in dancers, gymnasts and
tennis players.
Regional Rheumatism
Injury typically occurs in active persons.
The typical symptoms is pain or tenderness
proximal or at the insertion of the calcaneus.
Peritendinitis, inflammation of the tendon sheath,
causes localized tenderness and burning about 2
to 6 cm above the tendon insertion.
At exam the patient should lying prone, feet
hanging out of the examination table.
Palpation often elicits pain.
Thompson test the physician squeezed the calf
and watches for plantar flexion.
Regional Rheumatism
In patient with tendinosis the treatment should
be conservative using ice, rest and NSAIDS.
Control of the biomechanical factors and a slow
gentle warm-up before exercise and icing after
exercise help patients that want to continue
athletic training.
In patients with Achilles tendon rupture, the
treatment is controversial.
The main treatment is surgery plus
immobilization or immobilization alone.
The trend in younger patients is surgery and
immobilization in the elderly patient.
Regional Rheumatism
References
Tallia, Alfred and Dennis Cardone. Diagnostic and
Therapeutic Injection of the Shoulder Region.
American Family Physician. Volume 67, Number
6, March 15, 2003
Almekinders, Louis. Impingement Syndrome.
Clinics is Sport Medicine. Volume 20, Number 3,
July 2001.
Cardone, Dennis and Alfred Tallia. Diagnostic and
Therapeutic Injection of the Elbow Region.
American Family Physician. Volume 66, Number
11, December 1, 2002.
References
Mani, Lisa and Fredric Gerr. Work Related Upper
Extremity Musculoskeletal Disorders. Primary
Care: Clinics in Office Practice. Volume 27,
Number 4, December 2000.
Adkins, Samuel and Richard Figler. American
Family Physician. Volume 61, Number 7, April 1,
2000.
Scopp, Jason and Claude Moorman. The
Assessment of Athletic Hip Injury. Clinics in
Sports Medicine. Volume 20, Number 4, October
2001.
References
Cardone, Dennis and Alfred Tallia. Diagnostic and
Therapeutic Injection of the Hip and Knee.
American Family Physician. Volume 67, Number
10, May 15, 2000.
Mazzone, Michael and Timothy MC Cue. Common
Conditions of the Achilles Tendon. American
Family Physician. Volume 65, Number 9, May 1,
2002.
Canoso, Juan. Regional Rheumatic Diseases.
Rheumatology in Primary Care. W.B Saunders
Company, 1997.
References
Cush, John and Arthur Kavanaugh.
Rheumatology Diagnosis and Therapeutics.
Lippincott Williams & Wilkins, 2000.
Canoso, Juan and Simon Carette. Rheumatology
Second Edition. Mosby, 1998.