بنام خداوند بخشنده و مهربان

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4. Classification : Tendinitis & Bursitis Myofascial pain syndrome Structural disorders Entrapment disorders Generalized pain disorders

5. Topographic Classification: Upper limb : Shoulder Elbow Hand Lower limb: Hip Knee Foot

6. Epidemiology (USA): Musculoskeletal disorders : 15-20% Osteoarthritis : 5% LBP & Chronic neck pain : 5% Periarthritis : 3-5% RA : 1% FMS : 1% others

7. Epidemiology (Iran): Musculoskeletal disorders : 31.4% Periarthritis : 5.5% Shoulder : 44% Trigger finger : 17% Tennis elbow : 12% Talalgia : 11% Ankle bursitis : 11% Ganglion :10% DeQuervain’s t. :7% Trochanteric bursitis : 5% Nerve entrapment : 1.3% CTS : 94% Others : 9%

8. Etiology : Trauma Overuse syndrome Systemic disorders

9. 4 Joints Glenohumeral J. Capsule Rotator cuff Deltoid muscle Coracoacromial arch Subacromial bursa Movement Anatomy :

10. Periarthritis : 80% The most common periarthritis 20% of periarthritis(USA) 44% of periarthritis(Iran) Reffered pain : 15% Articular pain : 5% Arthritis Osteoarthritis Shoulder pain :

11. Rotator cuff tendinitis : 70% Supraspinatus t. Infraspinatus t. Calcific tendinitis RC tear : 1-2% Biceps tendinitis Biceps tendon tear Subacromial bursitis Adhesive capsulitis : 10% Others

12. Middle & old age F > M Impingement Etiology : Exercise : 1/3 Overuse : 1/3 Idiopathic : 1/3 Falling : rare

13. Clinical features : Shoulder pain Subacromial tenderness (SAS) Painful arc pain in external rotation : infraspinatus Paraclinic : NL Complications : Frozen shoulder RC tearing Cuff arthropathy

14. Resting : (No PPLRO) Pulling Pushing Lifting Reaching Overhead positioning NSAIDs &/or Steroids SAS injection Absolute resting : 3 days Relative resting : 1 month Exercise ; > 75% response => daily activity < 50% response => repeat injection Treatment :

15. Acute tear : young Chronic tear : old age Often > 50 y/o Falling < 30 y/o Clinical feature : Pseudoparalysis Drop off sign Unable to abduction Lidocaine injection test

16. Milwaukee shoulder syndrome : HA arthropathy with: RC tear GH arthritis with effusion Humeroacromial pseudoarticulation

17. X-Ray : Plain-PA : SAS < 1 cm Dynamic-PA : SAS < 6 mm Arthrography Ultrasound MRI : Choice for complete tear MRA : Choice for partial tear

18. Diagnosis : at least 2 of below abduction or ext. rotation < 50% or (+)Lidocaine injection test Age > 62 y/o Out stretch hand falling or direct trauma Hx. Of recurrent RC tendinitis SAS < 1 cm in X-Ray Documentation of Dx.:MRI,MRA

19. Medical : Rest,NSAIDs,Steroids for 6 weeks If no response : SAS injection Surgical : Severe tear in young Mild to moderate tear in young: If no response to 6 weeks of medical. Tear with intractable pain in old RC tear + Biceps tear Treatment :

20. Young or adult male Anterior shoulder & arm pain Anterior tender point Yergason’s maneuver Speed’s maneuver Treatment : Rest, NSAIDs, Physiotherapy, Laser therapy, Injection

21. Young or adult male Severe exercise or lifting Sudden onset pain + snap sound “Popeye sign” Treatment : Active youngs : Surgery Old : Conservative

22. F/M # 1/1 50 - 60 y/o HA deposition Clinical feature: Asymptomatic Salam attack X-Ray Treatment : NSAIDs(full dose) Steroids(MDS) Injection ?

23. Adhesive capsulitis Frozen shoulder Hand shoulder syndrome

24. Primary : Without underlying disease Secondary : RC tendinitis &/or SA bursitis Diabetes mellitus MI , CVA , Prolong immobility Pancost’s tumor Cervicobrachial neuralgia Etiology :

25. Inflammatory phase : Acute severe global shoulder pain No LOM Transitional phase : Subacute moderate global pain Mild to moderate LOM Adhesion(Frozen) phase : Severe global LOM Pain with aggressive Ph. Ex. Clinical features :

26. FBS CBC, ESR, CRP Wrigth & C.W., PPD Ca/P Al.Ph., X-Ray : R/O Arthritis & arthrosis Early : NL Late : Patchy osteoporosis Arthrography Paraclinics :

27. NSAIDs Steroids PO IM IA ROM Exercise : Flexion Abduction Mixed posterior movement Treatment :

28. Lateral epicondylitis (Tennis elbow) Medial epicondylitis (Golfer’s elbow) Olecranon bursitis Ulnar nerve entrapment

29. Lateral elbow pain Common insertion of extensors Causes : Wrist extension & supination Common : (>90%) Carrying suitcase or briefcase Using screwdriver Uncommon : (<10%) Tennis playing

30. Clinical features: Lat. Epicondyle tender point Mill’s test Middle finger test Treatment : Resting NSAIDs/Steroids Local steroid injection

31. Medial elbow pain Less common than tennis elbow Common insertion of flexors Causes : Wrist flexion & pronation Overuse Golf

32. Clinical features: Medial elbow tender point Pain on resisted wrist flexion & pronation with elbow extended Ulnar neuritis : 25-50% Treatment

33. Primary: Chronic low-grade trauma Leaning on the elbow Laying carpet Secondary : Gout &CPPD RA & SpA & SLE Septic Hemorrhagic Diagnosis & Treatment : Aspiration=> R/O septic Drainage & Steroid injection

34. Numbness & paresthesia of little & ring finger Medial elbow pain Hand clumsiness Elevating the hand by resting the forearm on the head for 1 minute => paresthesia Tinel’s sign Ulnar Nerve Entrapment

35. Ganglion De Quervain’s tenosynovitis Carpal tunnel syndrome Guyon’s canal syndrome Dupuytren’s contracture Tenosynovitis of the wrist Pronator teres syndrome: writer’s cramp Anterior interosseous nerve syndrome: O Radial nerve palsy : Saturday night palsy Cheiralgia paresthetica

36. 20-40 y/o F/M >1 Dorsum of wrist : most common site Synovial cyst Treatment: Local injection of steroid Surgical resection

37. Stenosing tenosynovitis of Abductor pollicis longus Extensor pollicis brevis Female >40 y/o :90% Radial tender cord Finkelstein test Treatment

38. Median nerve entrapment The most common entrapment The most common hand paresthesia 30-60 y/o , F / M = 5 / 1 Pathogenesis Causes : Idiopathic Secodary

39. Median n. paresthesia : 100% Nocturnal paresthesia : 71% Ascending pain : 38% Tinel’s sign : 55% Phalen test : 53% sensory defect : Thenar atrophy Tenar weakness Clinical features :

40. Prayer sign Compression test Cuff sign Paraclinics: NCV: Others: CBC , FBS ,...

41. Symptoms: Paresthesia Hypesthesia Burning pain Signs : Tinel’s sign Phalen’s sign Sensory defect NCV one symptom + one sign Diagnosis :

42. Splinting NSAIDs/Steroids Local steroid injection Surgery Treatment :

43. Ulnar nerve entrapment GCS <<< CTS Ulnar nerve branches ; Superficial(sensory) Deep(motor) Clinical pictures : Only sensory Only motor Both Treatment

44. Volar flexor stenosing tenosynovitis Clinical features: Triggering finger Locking finger Tender nodule Middle & index finger Causes : Overuse RA, PsA, … Treatment

45. Fibromyalgia syndrome White Female:70-90% Age at onset ; 35-40 Generalized pain Tender points : 11 of 18 Control points sleep disturbance Lab : NL Treatment : Myofascial pain syndrome : Localized pain Trigger points

46. Thickening & shortening of palmar fascia Initial fascial nodules Skin fixation to fascia Dimpling or puckering Finger flessum :4 > 5 > 3 > 2 Contraction of proliferative myofibroblast M/F = 5/1, whites, Europe Associations: Diabetes m., Alcoholism, Epilepsy

47. Articular : Arthralgias Reiter’s syndrome Psoriatic arthritis Undifferentiated SpA AIDS-associated arthritis Painful articular syndrome

48. Muscular : Myalgias Polymyositis Dermatomyositis Myopathies HIV wasting AZT-induced

49. Sjogren’s-like syndrome Vasculitis Infections: Septic arthritis Osteomyelitis Pyomyositis

50. Miscellaneous: Periarthritis: Tendinitis Bursitis CTS Adhesive capsulitis Dupuytren’s C. Fibromyalgia Avascular necrosis Hypertrophic osteoarthropathy

51. Cellular: CD4 independent CD8 dependent Autoantibodies (?) : ANA RF aCL Pathogenesis :

52. Systemic lupus erythematosus Rheumatoid arthritis Primary Ankylosing spondylitis (?) Negative associations :

53. Before , Synchronized , After AIDS Differences: Conjunctivitis : rare Axial : unusual NSAIDs + Sulfasalazine + IAS With caution; Steroids , Immunosuppressive Reiter’s syndrome:

54. Poor prognostic Herald: Life-threatening infections Psoriaform Attention : Severe unexplainable flare up of psoriasis Psoriasis unresponsive to treatment Psoriatic arthritis :

55. AIDS associated arthritis Extreme disability & pain in knee & ankle Noninflammatory synovial fluid lasting 1-6 weeks Rest + NSAIDs + Physiotherapy Painful articular syndrome Knee, Shoulder, Elbow Lasting 2-24 hours Transient bone ischemia

56. DILS : Diffuse infiltrative lymphocytic syndrome Differences with sjogren Extraglandular : common Infiltrative lymphocyte : CD8 Autoantibodies : rare Sex ratio : male dominant Sjogren’s-like syndrome:

57. Lag period : six months Pathology: “Ragged red fibers” Remission after Zidovudin reduction or D/C Zidovudin-induced myopathy:

58. Polyarteritis Churg-Strauss Hypersensitivity vasculitis Henoch-Schonlein purpura CNS vasculitis Lymphomatoid granulomatosis Vasculitis :

59. Definition ; Attack Interval Including : Intermittent hydrarthrosis Palindromic Rheumatism Familial mediterranean fever Others Periodic Arthritis :

60. Knee effusion Female Lab : NL Assurance & observation Intermittent Hydrarthrosis :

61. Athritis of 1-3 joints Erythematous Durationof 1-3 days Asymptomatic interval period Course : Palindromic ; 50% RA :30-40% SLE , Gout : low percent Remission ; 10% Treatment Palindromic Rheumatism:

62. M/F=3/2 Age of onset : 5-15 y/o Race Sephardic jews :50% Armenian :20% Turk or Arab: 20% Etiopathogenesis Familial mediterranean fever(FMF)

63. Attacks of: Fever : 100% Abdominal pain : 95% Arthralgia : 75% Chest pain : 65% Skin lesions Musculoskeletal Familial mediterranean fever(FMF)

64. Lab data: Complications: Drug addiction Depression Amyloidosis Course & prognosis Diagnosis Treatment : Dramatic response to Colchicine Familial mediterranean fever(FMF)