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 • 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 • 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 • 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 extensor-supinator 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 • 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 spica-splint, 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 • 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 • 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 • 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 • 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 • 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.

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.

Regional Rheumatism