Regional Rheumatism

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Regional Rheumatism

• Andres Quiceno, MD
• Rheumatology Division PHD
• Clinical Assistant Professor of Medicine UTSW

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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.

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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.

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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.

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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.

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Regional Rheumatism
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Regional Rheumatism
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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.

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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.

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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.

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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.

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Regional Rheumatism
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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.

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Regional Rheumatism
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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.

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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.

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Regional Rheumatism
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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.

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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.

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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.

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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.

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Regional Rheumatism
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Regional Rheumatism
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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.

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Regional Rheumatism
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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.

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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.

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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 patients age,
  with range decreasing with age.
• Some specific tests such us the Trendelenburgs
  and Obers are helpful to diagnose specific
  pathologies.

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Regional Rheumatism
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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.

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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.

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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.

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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.

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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.

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Regional Rheumatism

• Older Adult
• The most common cause of pain is DJD.
• Other causes is trochanteric bursitis.

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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.

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Regional Rheumatism
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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.

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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.

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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.

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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
  Gerdys 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.

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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.
• Obers 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.

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Regional Rheumatism
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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.

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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.

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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.

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Regional Rheumatism
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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.

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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.

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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.

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References

• Cush, John and Arthur Kavanaugh. Rheumatology
  Diagnosis and Therapeutics. Lippincott Williams
  Wilkins, 2000.
• Canoso, Juan and Simon Carette. Rheumatology
  Second Edition. Mosby, 1998.