Regional Rheumatic Pain Syndromes

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Rheumatic Pain Syndromes

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  • 1. Regional Rheumatic PainSyndromesDiana Girnita, MD PhDUC Rheumatology Fellow

2. RRPS include disorders involving muscles Tendons Entheses Joints Cartilage ligaments fascia bone nerve. 3. Causative factors Injury Overuse Atrophy due to aging Inflammation processes Tendinitis/ tendinosis/ tendinopathy-mostlydegenerative changes and few inflammatory cells Tenosynovitis- inflammatory response oftenosynovium 4. Concepts of management Drug therapy NSAIDS Analgesics: tylenol, tramadol, propoxyphen TCA- amytriptiline in chronic pain/ neurogenic/myofascial Intralesions injections with lidocaine, steroids(needle parallel with tendon fibers) Physical therapy 5. Disorders of Shoulder Region 6. Rotator cuff tendinitis (RCT) orimpingement sdr Most common causeof shoulder pain Acute/ chronic May + calcificdeposits in the tendon Pain with activeABDUCTION between60-120degrees/lowering thearm 7. Chronic RCT Ache in the shoulder over the lateral deltoid Pain with abduction and internal rotation Difficulties dressing Night pain Less pain with passive abduction Pain with abduction against resistance 8. Impingement test Inject 2-5 ml 2% lidocaine in the subacromialbursa- pain relief on abduction = test positiv 9. RCT Causes: Overuse/ overhead activity Aging/ decline in use Osteophytes in the acromioclavicular joint RA TX: rest, hot packs, cold, NSAIDs, CS injectionsin the subacromial bursa 10. Rotator Cuff Tear Most common trauma with ruptured cuff (falls, FX) Classification Small 5cm Shoulder pain, weakness on abduction, and loss ofmotion severe pain and mild weakness to no painand marked weakness. A positive drop-arm sign with inability to activelymaintain 90 of passive shoulder abduction (massivetears) MRI /abnormal arthrogram for diagnosis TX: rest, PT, NSAIDs surgery 11. Bicipital tendinitis& Rupture ofproximal Bicipital Tendon Pain in the anterior region ofshoulder Acute/Chronic. Tenderness over the bicipitalgrove Supination of the forearmagainst resistance Shoulder flexion againstresistance Tx: rest, hot packs, US, NSAIDs,CS injection Full rupture of the long head oftendon bulbous enlargement of 12. Adhesive Capsulitis/ FrozenShoulder/ Pericapsulitis generalized pain and tenderness with severe lossof active and passive motion in all planes. RareM; due to lordosis which exposes coccyx totrauma 49. DISORDERS OF THE KNEEREGION 50. Popliteal Cyst (Bakers cyst) Patient standing, examined from behing Associated with any disease having synovialeffusion: OA, RA A syndrome mimicking thrombophlebitis mayoccur with rupture Dg: US Tx: CS injection/ surgery 51. Anserine Bursitis overweight, middle-aged to elderlyF w/ big legs and OA of the knees pain and tenderness over themedial aspect of the knee about 2below the joint margin. Pain is worse by climbing stairs. TX: rest, stretching of the adductorand quadriceps muscles, and CSinj 52. Prepatellar Bursitis Swelling superficial to knee cap housemaid knee Consider septic prepatellar bursitis(trauma, knee abrassion) 53. Medial Plica Syndrome Patella pain may be the predominant complaint,and snapping or clicking of the knee, a sense ofinstability, and possible pseudolocking of the knee 54. Popliteal Tendinitis Pain posterolateral of the knee secondary totendinitis of the popliteal tendons (hamstrings andpopliteus) Knee flexed at 90 degrees, tender to palpation Pain with running downhill Tx: rest, conservative 55. PellegriniStieda Syndrome calcification of the medial collateral ligament ofthe knee. 56. Patellar tendinitis jumpers knee athletes engaging in repetitive running, jumping,or kicking activities. Pain and tenderness are present over the patellartendon Dg: US Tx:rest, NSAIDS,CS injection 57. Rupture of Quadriceps TendonandPatellar Tendon sudden violent contractions of the quadricepsmuscle when the knee is flexed. trauma from sports, systemic diseases (CKD,RA, hyperPTH, gout, SLE on steroids sudden sharp pain and cannot extend the leg Rx: high riding patella Tx:surgery 58. Peroneal Nerve Palsy/ FOOTDROP painless foot drop with a steppage gait Sensation decreased Causes: Direct trauma, fracture of the lowerportion of the femur or upper portion of the tibia,compression of the nerve over the head of thefibula 59. Patellofemoral Pain Syndrome pain and crepitus in the patellar region Stiffness occurs after prolonged sitting and isalleviated by activity; overactivity involving kneeflexion, particularly under loaded conditions suchas stair climbing pain occurs when the patella is compressedagainst the femoral condyle or when the patella isdisplaced laterally. Tx: analgesics, NSAIDs, ice, rest, isometricstrengtheningexercises for the quadriceps 60. DISORDERS OF THE ANKLEANDFOOT REGION 61. Achilles Tendinitis/ tendonrupture Causes: trauma, athletic overactivity, improperlyfitting shoes with a stiff heel counter, inflammatorydx (AS, reactive arthritis, gout, RA, CPPD; FK use Pain, swelling, and tenderness occur over theAchilles tendon Rupture: occurs with a sudden onset of painduring forced dorsiflexion Subcutaneous Achilles BursitisA subcutaneous bursa superficial to theAchilles due to shoes pressure 62. Retrocalcaneal Bursitis Pain at the back of the heel, tenderness of thearea anterior to the Achilles tendon, and pain ondorsiflexion. Local swelling is present, with bulging on themedial and lateral aspects of the tendon Dg: MRI/ US 63. Plantar Fasciitis Pain in the plantar area of the heel arising and is mostsevere for the first few steps. After an initial improvement, the pain may worsenlater in the day, especially after prolonged standing orwalking. The pain is burning, aching, and occasionallylancinating. Palpation typically reveals tenderness anteromedially Tx: NSAIDs, use of heel pad or heel cup orthoses,arch support, and stretching of the heel cord andplantar fascia 64. Posterior Tibial Tendinitis/rupture Pain and tenderness just posterior to the medialmalleolus occur in posterior tibial tendinitis. Cause: trauma, excessive pronation, RA, orspondyloarthropathy. pain is present on resisted inversion or passiveeversion. 65. Peroneal Tendon Dislocationand Peroneal Tendinitis Ankle sprain dorsiflexion with eversion severe pain and tenderness of the tendon areathat lies over the lateral malleolus 66. Hallux Valgus 67. Bunionette prominence of the 5th MT head from the overlyingbursa and a localized callus 68. Hammer Toe2nd toe PIP joint is flexed andthe tip of the toepoints downward. 69. Metatarsalgia Pain arising from the metatarsal heads Pain on standing and tenderness on palpation ofthe metatarsal heads are present. Calluses over the metatarsal heads are usuallyseen. 70. Pes Planus/ Pes Cavus 71. Mortons Neuroma Middle-aged women entrapment neuropathy of theinterdigital nerve occurring mostoften between the 3rd and 4thtoes. Paresthesia and a burning,aching pain in the 4th toe worsewith walking on hard surfacesor wearing tight shoes or highheels Tx: metatarsal bar or a local CSinto the web space or surgicalexcision of the neurom 72. Tarsal Tunnel Syndrome posterior tibial nerve is compressedat or near the flexor retinaculum the nerve divides into the medialplantar, lateral plantar, and posteriorcalcaneal branches. The flexor retinaculum is locatedposterior and inferior to the medialmalleolus. Numbness, burning pain, andparesthesias of the toes and soleextend proximally to the medialmalleolus. relief by leg, foot, and anklemovements. 73. DISORDERS OF THE ANTERIORCHEST WALL 74. Tietzes syndrome : gradual or abrupt withswelling usually occurring in the second or thirdcostal cartilage. Pain, which ranges from mild tosevere, may radiate to the shoulder and beaggravated by coughing, sneezing, inspiration, orby movements affecting the chest wall.Tenderness with palpation, and approximately80% of patients have a single site. Costochondritis is more common; pain andtenderness of the chest wall, without swelling.Tenderness is present over more than onecostochondral junction, and palpation shouldduplicate pain Xiphoid cartilage syndrome orxiphoidalgia/xiphodynia, is pain over the xiphoidarea and tenderness on palpation. Pain may beintermittent and brought on by overeating andvarious twisting movements. 75. FINALLY DONE!!!Reference:Primer on the Rheumatic diseases13th edition&Google images