Soft Tissue Disorders and Fibromyalgia

1. Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist

2. Introduction • Definitions • Approach to soft tissue disorders • Overview of some soft tissue conditions • Fibromyalgia

3. Definitions • WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?

4. Definitions • Ligament • connective tissue that connects bone to bone • Tendon • connective tissue that connects muscle to bone • Enthesis • the point at which a tendon inserts into bone • Bursa • a fluid filled sac located between a bone and tendon

5. CLUES IN SOFT TISSUE DISORDERS?

6. Approach to soft tissue disorders • anatomy of area and mechanism of injury/overuse (work history) • Differentiate from inflammatory/mechanical arthropathy • ? referred pain eg C5/6 Neck pain radiating to shoulder – ask about neurological symptoms

7. Approach to soft tissue disorders • May be associated with inflammatory arthritis • Bloods not helpful • Imaging - X-ray and ultrasound may play a role in certain soft-tissue disorders

8. JOINT vs PERIARTICULAR?

9. Is it an articular or extra-articular problem? • ARTICULAR PERI-ARTICULAR • pain all planes pain in plane of tendon • active = passive active > passive • capsular swelling/effusion linear swelling • joint line tenderness localised tenderness • diffuse erythema/heat localised erythema/heat

10. Features of flexor tenosynovitis ?

11. Flexor tenosynovitis • Inflammation of flexor tendon sheaths • Pain and stiffness in flexor finger/thumb • Reduced active flexion, crepitus, thickened tender tendon sheaths • May be associated with nodule – “trigger finger” • Can be associated with RA, Diabetes • Treatment – injection hydrocortisone, surgery

12. Features of De Quervains?

13. De Quervain’s (tenosynovitis) • Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons

14. De Quervain’s (tenosynovitis) • Pain, swelling radial wrist • Localised tenderness, crepitus, pain worse over radial styloid • Other test?

15. De Quervain’s (tenosynovitis) • Finkelstein • With the thumb flexed across the palm of the hand, ask the patient to move the wrist into flexion and ulnar deviation. • Positive if reproduces pain

16. De Quervain’s (tenosynovitis) • Management • Rest from precipitating activity • Splintage • Steroid injection • surgery

17. carpal tunnel syndrome?

18. Carpal tunnel syndrome • Compression of median nerve as it passes through carpal tunnel

19. Carpal tunnel syndrome - anatomy • Median nerve supplies: • Motor (beyond carpal tunnel in hand) • L lateral two lumbricals • O opponens pollicis • A abductor pollicis brevis • F flexor pollicis brevis • Sensory • Palmar surface thumb, lateral 2 ½ digits

20. Carpal tunnel syndrome • Clinical features • Numbness/parasthesia in median nerve distribution • Pain, can radiate up arm • Worse at night • ‘Hang hand over end of bed’ • Weakness of thumb (abduction) • Thenar wasting • Positive Tinel’s/Phalen’s

21. Carpal tunnel syndrome Phalen’s Tinel’s

22. Carpal tunnel syndrome • Common, F>M, elderly/middle aged • Mostly idiopathic • Associated with (particularly if bilateral): • Diabetes • Hypothyroidism • RA • Pregnancy • Acromegaly • Vasculitis • Trauma • Others (e.g. amyloid, sarcoid)

23. Carpal tunnel syndrome • Investigation • Nerve conduction studies show reduce nerve conduction velocities across wrist • Management • Avoidance of precipitating activity • Night time splints • Local steroid injection • Surgery – division of flexor retinaculum and decompression of carpal tunnel (80% success)

24. Features of epicondylitis ?

25. Tennis & Golfer’s Elbow • Both enthesopathies • Tennis elbow = lateral epicondylitis = inflammation common extensor origin • Golfer’s elbow = medial epicondylitis = inflammation common flexor origin • Tennis elbow more common than Golfer’s

26. Tennis & Golfer’s Elbow • Pain localised to specific area • Elbow flexion/extension does not cause pain • Pain upon: • resisted wrist extension (Tennis) • resisted wrist flexion (Golfer’s)

27. Tennis & Golfer’s Elbow • Management • Rest from precipitating activity • Elbow clasps • Local corticosteroid injection • Physiotherapy – ultrasound and acupuncture • Surgery (often ineffective)

28. Rotator cuff disease features?

29. Rotator Cuff – anatomy • A sheath of conjoint tendons to support glenohumeral joint, made up of: • S supraspinatus - abduction • I infraspinatus – external rotation • T teres minor – external rotation • S subscapularis – internal rotation

30. Rotator Cuff Syndrome • Spectrum from mild supraspinatus tendinitis to complete tendon rupture • Chronic impingement of cuff under acromial arch • Pain often over acromial area extending into deltoid

31. Rotator Cuff Syndrome • Painful mid arc • Impingement test – abducted, flexed and internally rotated • Supraspinatus stress

32. Rotator cuff investigation - ultrasound • Full thickness tear

33. Rotator Cuff Syndrome • Management • Rest, NSAIDs • Local steroid injection around tendon – subacromial space and PT • If chronic/rupture refer to Orthopaedics for surgical opinion

34. Acute calcific supraspinatus tendinitis • Calcium hydroxyapatite deposition near supraspinatus enthesis • Young adults, F>M, acute pain over several hours • Normally resolves over few days • Treatment • Minor – NSAID • Moderate – consider steroid injection • Severe – consider aspirating calcified material

35. Adhesive capsulitis (Frozen shoulder) • Progressive pain and stiffness • Global reduction in movement, but particularly external rotation • Three phases • Pain (3-5 months) • Adhesive phase (4-12 months) • Recovery phase (12-42 months)

36. Adhesive capsulitis (Frozen shoulder) • Associated with diabetes • Most patients recover by 30 months, but still have reduced movements • Management • Analgesia, NSAIDs, Physiotherapy, steroid injection • Surgical opinion in difficult cases (manipulation under anaesthesia)

37. ACJ disease features ?

38. Acromioclavicular OA • High arc pain • Local tenderness • Adduction painful • Impingement

39. Trochanteric bursitis features?

40. Trochanteric bursitis • Inflammation of the superficial and deep bursa that separates the gluteus muscles from the posterior and lateral side of the greater trochanter of the femur

41. Trochanteric bursitis • pain over lateral aspect of hip • may radiate down lateral thigh • Worse on walking or lying in bed at night • Localised tenderness upon pressure over greater trochanter

42. Trochanteric bursitis • Management • Rest • Analgesia • Steroid injection • Physio

43. Achilles pain • Inflammation - seronegatives (enthesis) • Degeneration (middle avascular portion of tendon) • Retrocalcaneal bursitis

44. Achilles tendonitis • Investigation - ultrasound • Management • Rest, NSAIDs, physiotherapy • Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear

45. Achilles rupture • Acute rupture – sudden calf pain as if being hit on back of leg • Palpable gap in tendon • Some but little plantarflexion • Squeeze calf whilst prone - no plantarflexion in affected leg (Simmond’s) • Management • Surgery to repair tendon • Conservative – below knee cast in ankle equinus 6 weeks

46. Fibromyalgia features ?

47. Fibromyalgia • “All over pain” • Fatigue • Sleep disturbance • Depression • Anxiety • Irritable bowel • Tender spots • Diagnosis of exclusion

48. Prevalence/Risk Factors • Common • Approx 2-5% depending upon definition • Female (F:M ratio between 3:1 and 7:1) • Middle age (typically 30-60)

49. Differential diagnosis • Other conditions can mimic fibromyalgia: • Systemic lupus erythematosus (SLE) • Hypothyroidism • Polymyalgia rheumatica • Malignancy • Myopathy • Metabolic bone disease

50. Management • Patient education • About condition • Reassure that no serious pathology • No harm in exercising • Cognitive behavioural therapy (CBT) • Low dose amitriptyline • Graded aerobic exercise regime