Soft Tissue Rheumatism

1. Soft Tissue Rheumatism Prof. Dr. Şansın Tüzün

2. " 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.

3. 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

4. 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

5. Classification Criteria • 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

6. Central Sensitization Syndromes Fibromyalgia Chronic Fatigue Syndrome MPS Irritable Bowel Syndrome GulfWar Syndrome Tension-type Headache Migraine Primary dysmenorrhea Restless Leg Syndrome OTHERS

8. Central Sensitization An exaggerated response of the central nervoussystem to a peripheral stimulus that is normally painful (hyperalgesia) or non-nociceptive, such as touch (allodynia)

9. Central Sensitization Hyperexcitability Hypersensitivity Prolonged or Persistence Pain

10. The ability ofCNS to undergo these changes is called “NEUROPLASTICITY” CNS function is not fixed but is capable of alterations depending on various peripheral and/or environmental factors

11. “Common”s among CSSs • Gender (Female) • Family history • Chronic pain/fatigue • Abnormal neuroendocrine functions • Absence ofpathological findings

12. FMS and MPS • Myofascial pain syndromes....... (20 - 30%) • Fibromyalgia.............................. (3 - 5%) Are they part of a continuum?

13. TrPPATHOGENESIS Trauma Stress Central Sensitization Pain MUSCLE SPASM (Taut Band) Endocrine Disorders ? Pain TRIGGER POINT Sympathetic Activation Muscle Spasm

14. MPS & FMS Trigger points Tender points PAIN GENERATOR

15. 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

16. Myofascial Trigger Point Diagnosis • Palpable Taut Band • Local Twitch Response • Jump Sign • Referred pain

17. Fibromyalgia Pain in 11 of 18 tender point sites on digital palpation “tender does not mean painful”

18. Fibromyalgia Tender Points

19. 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.

21. 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

22. Additionally; • Impaired memory of concentration, sore throat, tender cervical or axillary lymph nodes,muscle pain, multijoint pain, new headaches and unrefreshing sleep

23. Treatment • Tricyclic antidepresants ( i.e. amitriptyline, desipramine 1-3h before bedtime) • Cardiovasculer fitness training • Biofeedback • Hypnotherapy • Cognitive behavioral therapy • Educating patient

24. 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

25. Comparison of FM and MFS

26. 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

27. 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

28. 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

29. Potential narrowing areas • Between the scalenius anterior and scalenius medius • Costoclavicular space • Under the pectoralis minor tendon

30. 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

31. Diagnosis • Neurologic examination • Certain clinical stress tests (Adson and hyperabduction maneuvers) • A radiograph of cervicothoracic region (cervical rib, elongated transverse process of C7)

34. 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

35. 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

36. 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

37. Cubital Tunnel Syndrome

38. Diagnosis • Physical examination (Tinel’s sign, Wartenberg’s sign i.e.) • Radiographs • Electrodiagnosis

39. Treatment • Avoidance of prolonged elbow flexion • Local steroid injection along the ulnar groove • Surgical procedures to decompress the nerve

40. 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

42. 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

43. Diagnosis • Pyhsical examination • Electrodiagnosis is helpful in determining the site of the entrapmant Treatment • Avoidance of trauma • Physical therapy • Surgical decompression

44. 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

45. 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

46. (+)Tinel’s sign • (+) Phalen’s sign • Thenar atrophy

47. Diagnosis • History and physical examination • Radiographs • Electrodiagnosis

48. Treatment • Splints • Local corticosteroid injection • NSAIDs • Physical therapy • Surgery ; patients with progressive increases in distal motor latency times

50. 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