Post on 19-Jan-2016
description
Soft Tissue Rheumatism
Prof. Dr. Şansın Tüzün
" Soft tissue Rheumatism" refers to aches or pains which arise from structures surrounding the joint such as tendons, muscles, bursae and ligaments.
This may be localized when pain is felt in one region or generalized when pain is felt either all over or in many parts of the body.
FIBROMYALGIA
Chronic musculoskeletal syndrome characterized by
diffuse pain and tender points
No evidence that synovitis or myositis are causes
Occurs in the context of unrevealing physical
examination, labaratory and radiologic examination
% 80-90 of patients are women, peak age is 30-50
years
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
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
Classification Criteria
ChronicChronicFatigueFatigue
SyndromeSyndrome
FibromyalgiaFibromyalgia
Central Sensitization Syndromes
Irritable BowelIrritable BowelSyndromeSyndrome
Primary dysmenorrheaPrimary dysmenorrheaMigraineMigraine
Tension-typeTension-typeHeadacheHeadache
MPSMPS
Restless LegRestless LegSyndromeSyndrome
GulfGulf WarWarSyndromeSyndrome
OTHERSOTHERS
Central Sensitization
An exaggerated response of the central
nervous system to a peripheral stimulus
that is normally painful (hyperalgesia) or
non-nociceptive, such as touch
(allodynia)
Prolongedor
Persistence Pain
Central Sensitization
Hyperexcitability Hypersensitivity
CNS function is not fixed but is capableCNS function is not fixed but is capableof alterations depending on various peripheral and/orof alterations depending on various peripheral and/or
environmental factorsenvironmental factors
The ability of CNS to undergo these changes is called
““NEUROPLASTICITY”NEUROPLASTICITY”
“Common”s among CSSs
Gender (Female)
Family history
Chronic pain/fatigue
Abnormal neuroendocrine functions
Absence of pathological findings
FMS and MPS
Myofascial pain syndromes....... (20 - 30%) Fibromyalgia.............................. (3 - 5%)
Are they part of a continuum?
TrP PATHOGENESIS
TraumaTrauma StressStress
Muscle SpasmMuscle Spasm SympatheticSympathetic ActivationActivation
TRIGGER POINTTRIGGER POINT
MUSCLE SPASMMUSCLE SPASM(Taut Band)(Taut Band)
PainPain
Pain
CentralCentralSensitizationSensitization
EndocrineEndocrineDisordersDisorders
??
PAINPAINGENERATORGENERATOR
MPS & FMS
Trigger points Tender points
The most important criteria for
differential diagnosis
The presence of tender points (TeP) and widespread muscle pain in
FMS
compared with
Regional and characteristic referred pain patterns with discrete
muscular trigger points (TrP) and taut bands of skeletal muscle in
MPS
Myofascial Trigger Point Diagnosis
Palpable Taut Palpable Taut BandBand
Local TwitchLocal Twitch Response Response
Jump SignJump Sign
Referred painReferred pain
Fibromyalgia
Pain in 11 of 18 tender point sites on digital palpation
““tender does not meantender does not meanpainful”painful”
Fibromyalgia Tender Points
CHRONIC FATIGUE SYNDROME
CFS has recently emerged as a popular
diagnostic label for a centuries-old disorders
of fatigue and multiple somatic complaints.
“ Yuppie flue “
It shares many features with fibromyalgia
including the lack of objective physical or
laboratory abnormalities.
Syndrome Relationship with Fibromyalgia
Depression
Irritable bowel
Migraine
Chronic fatiqe Syndrome
Myofascial pain
25-60 % of FM cases
50-80 % of FM cases
50 % of FM cases
70 % of CFS cases meet FM
May be localized form of FM
Classify as CFS if;
Fatique persists or relapse for > 6 months
History, physical examination and appropriate
laboratory tests exclude any other cause for the
chronic fatique
Additionally;
Impaired memory of concentration, sore throat,
tender cervical or axillary lymph nodes,muscle
pain, multijoint pain, new headaches and
unrefreshing sleep
Treatment
Tricyclic antidepresants ( i.e. amitriptyline, desipramine
1-3h before bedtime)
Cardiovasculer fitness training
Biofeedback
Hypnotherapy
Cognitive behavioral therapy
Educating patient
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
Comparison of FM and MFS
Variable Fibromyalgia Myofascial pain
Examination Tender points Trigger points
Location Generalized Regional
Response to local therapy
Not sustained Curative
Sex Females vs Males
9:1
F vs M
3:1
Systemic features
characteristic ?
Treatment
Physical therapy
"Stretch and spray" technique: This treatment
involves spraying the muscle and trigger
point with a coolant and then slowly
stretching the muscle.
Massage therapy
Trigger point injection
Entrapment Neuropathies Results from incresed pressure on a nerve as it passes through an
enclosed space Knowledge of anatomy is essential for understanding of the clinical
manifestations of these syndromes
Splinting, NSAIDs and local corticosteroid injections usually suffice when symptoms are mild and of short time.
Surgical procedures to decompress the nerve are indicated in more severe cases
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
Potential narrowing areas
Between the scalenius anterior and scalenius medius
Costoclavicular space
Under the pectoralis minor tendon
Signs and Symptoms
Paresthesias
Pain, radiating to the neck, shoulder and arm
Motor weakness
Atrophy of thenar, hypotenar and intrinsic
muscles of the hand
Vasomotor disturbances
Diagnosis Neurologic examination Certain clinical stress
tests (Adson and hyperabduction maneuvers)
A radiograph of cervicothoracic region (cervical rib, elongated transverse process of C7)
Treatment
Exercise designed to improve posture by
strengthening muscles
Avoidance of hyperabduction
Surgical intervention if; muscle wasting,
paresthesias replaced by continous sensory
loss, incapacitating pain,worsening of
circulatory impairment
Cubital Tunnel Syndrome Compression neuropathy of
the ulnar nerve as it
transverses the elbow
Causes are; history of a
trauma, chronic pressure by
occupational stress or from
unusual elbow positioning
Arthritic conditions that results
in synovitis and osteophyte
production
Signs and symptoms Paresthesias in the distribution
of the ulnar nerve
Aggrevated by prolonged use of
the elbow in flexed position
(+) Tinel’s sign
Atrophy of intrinsic muscles and
weakness in grasp
Wasting of the hypothenar
muscles and slight clawing of
the 4th and 5th fingers
Weakness in adduction of the
5th finger
Cubital Tunnel Syndrome
Diagnosis
Physical examination
(Tinel’s sign,
Wartenberg’s sign i.e.)
Radiographs
Electrodiagnosis
Treatment
Avoidance of prolonged elbow flexion
Local steroid injection along the ulnar groove
Surgical procedures to decompress the nerve
Ulnar Tunnel Syndrome
Entrapment of the ulnar nerve in
Guyon’s canal at the wrist (os
hamatum-os pisiform)
Compression is due to ganglia
Causes are; RA, OA
Chronic trauma due to
occupations
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
Diagnosis
Pyhsical examination Electrodiagnosis is helpful in determining the site of
the entrapmant
Treatment Avoidance of trauma Physical therapy Surgical decompression
Carpal Tunnel Syndrome Most common entrapment
neuroropathy
Compression of the median
nerve at the wrist
Causes are; occupation,
crystal-induced rheumatic
disorders
Complication of connective
tissue disorders
Uremia, metabolic and
endocrine diseases, infections,
pregnancy
Signs and Semptoms
Sensory loss in the radial three
finger and one-half of the ring
finger
Burning, pins-and-needles
sensations, numbness in the
fingers
Pain may radiate to the
antecubital region or to the
lateral shoulder area
Awaken at night by abnormal
sensation
(+)Tinel’s sign
(+) Phalen’s sign
Thenar atrophy
Diagnosis
History and physical examination
Radiographs
Electrodiagnosis
Treatment Splints
Local corticosteroid injection
NSAIDs Physical therapy
Surgery ; patients with progressive increases in distal motor latency times
Tarsal tunnel syndrome
Entrapment neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel beneath the flexor retinaculum on the medial side of the ankle
Tarsal tunnel syndrome …Etiology
Fracture or dislocation involving the talus
calcaneus,or medial malleolus
Rheumatoid arthritis
Tumors
Pronation related to the loss of the plantar
arch
Tarsal tunnel syndrome….Presentation
Burning or aching foot pain usually around
the plantar surface, distal foot, toes
May radiate up to the calf
Worse at night, when standing
Feels better when barefoot
Tarsal tunnel syndrome….diagnosis
Tinel test
Nerve is tapped with a
finger or reflex
hammer at the flexor
retinaculum posterior
and inferior to the
medial malleolus
Tarsal tunnel syndrome… Management
Conservative NSAIDs Arch support Orthoses to correct pronation Proper shoes (1 inch heel and cushioned sole) Avoid flat slippers
If symptoms persistent Local injections Decompression surgery