AS, CTS, etc Flashcards
What conditions are in the spondyloarthropathy category?
Ankylosing spondylitis, psoriatic arthropathy, reactive arthropathy, Reiter Syndrome, Intestinal Arthopathy, Ulcerative Colitis, Crohns Disease, and juvenile ankylosing spondylitis
What relates the spondylarthopathies together?
They are a family of related disorders linked by common pathology. Chronic inflammation involving sacroiliac joints, axial skeleton, and peripheral joints to a lesser degree.
What is ankylosing spondylitis? What is its etiology?
Inflammed spine growing together. It is considered to be prototypical spondylarthropathy (SpA), etiology is unknown but is associated with a genetic predisposition associated with HLA-B27. 90% of patients with AS have a + HLA-B27
What is the antigen associated with AS?
HLA-B27
How is AS characterized?
It is symmetric sacroiliitis and progressive inflammatory arthritis, involved tendons and insertions, not the bone
What is the CP of AS?
Aching low back pain around SI joint area, persistent morning back stiffness for more than one hour. Pain can awaken them in the morning.
Stiffness exacerbated by inactivity and improves with moderate activity.
Can be a/w Achilles tendon, plantar fascia, and costosternal junctions
What way does AS progress?
Proximally
What constitutional symptoms may occur during an acute exacerbation? What age range is this more common in?
Low grade fever, fatigue, weight loss, anorexia, night sweats; more common in adolescents than adults
What are some extra-articular manifestations of AS involving the eyes?
acute anterior uveitis (iritis) is the MOST FREQUENT, present in 25% of AS patients. Unilateral circumcorneal flush is also present and resolves after 2-3 months
What are some extra-articular symptoms of AS?
Cardiac (AV block or aortic regurgitation during diastole),
Pulmonary fibrosis (rare)
Neurologic (cauda equina syndrome secondary to fxs)
TMJ dysfunction and fibromyalgia
What are PE exam findings in AS?
Limited spinal motion (always)
Tenderness over SI joint +/- muscle spasm
loss of lumbar lordosis
accentuation of thoracic kyphosis and cervical forward flexion
tenderness and swelling of affected joints
What is the Shober Test of AS?
Mark 10 cm above and 5 cm below intersection of iliac crests and spine. Patient should then flex forward as much as possible and the total distance should be measured (>20cm is normal, less is abnormal)
What are lab studies for AS?
There is no specific test for AS, CBC may show N/N anemia consistent with anemia of chronic disease
ESR and/or CRP is elevated in 75% (sensitive not specific)
alkaline phosphatase is elevated in 50% due to ossification
What does a positive HLA-B27 antigen represent in AS?
HLA-B27 is present in people without AS too, so a negative result is more useful in excluding diagnosis than a positive result in confirming diagnosis
What does a radiograph reveal in AS?
lumbar spine x-rays reveal blurring of coritcal margins of SI joints, followed by erosions, sclerosis, and pseudo-widening of joint space
Vertebral body squaring along with ossification of annular fibrosis leads to fusion of vertebral bodies and bamboo spine
What is the first line treatment of AS?
NSAIDs (indomethacin most effective, may consider Celebrex)
Rheumatology referral if NSAIDs and conservative therapy are ineffective
Intra-articular steroids should only be used every 3-4 months
What will a rheumatologist do to treat AS?
Tumor necrosis factor alpha antagonists (etanercept, infliximab, adalimumab);
Sulfasalazine for peripheral arthritis;
Other: methotrexate, azathioprine
What are other treatment options for AS?
Anti-depressents, hypnotics, ophthalmology referral for iritis and uveitis
Surgery for severe arthritis
What are some supportive measures for AS?
Daily exercise (essential), stretching and strengthening exercises, individualized PT training, exercise programs, swimming, water therapy, and postural training
What is the most common entrapment neuropathy? What is it also considered?
Carpal Tunnel Syndrome; it is considered cumulative trauma disorder, largely an occupational problem
What is the narrowest part of the carpal tunnel? What are the tendons in the CT?
at the level of the hook of the hamate; flexor digitorum superficialis and profundus, flexor pollicis longus tendon, median nerve and synovial sheaths
What are other potential causes of CTS?
fracture callus, osteophytes, anomalous muscle bodies, tumors, hypertrophic synovium, and infection; connective tissue disorders (lupus, gout, scleroderma, polymyalgia rheumatica)
What are causes of acute CTS? What are the symptoms of acute CTS?
distal radial fractures, carpal dislocations, called carpal canal compartment syndrome; swelling, pain, and paresthesias. Swelling and pain are unique
What is the pathophysiology behind CTS?
compression impedes the venous return of the nerve, impairs circulation. Causes demyelination of the nerve, followed by decreased axonal function.
What is the main classic complaint of chronic CTS?
burning pain, numbness, and tingling in the areas of the hand supplied by the median nerve (pain is only early on), motor and sensory disruption cause clumsiness and weakness
When are the symptoms of CTS worse?
At night, may awaken patient from sleep. Usually occurs 2-3 hours after falling asleep
What other disease must you ask about if you have a complaint of chronic CTS?
Personal or family history of arthritis
What are the two provocative tests for CTS?
Phalen’s and Tinel’s
Atrophy of which muscle is seen as a late finding in the thenar eminence?
abductor pollicis brevis
What diagnostic studies are helpful in confirming CTS?
Wrist x-rays, nerve conduction velocity (NCV), electromyogram (EMG) into abductor pollicis brevis m.
When is a wrist x-ray for CTS not recommended?
If trauma or rheumatic disease is suspected
What will the findings of an EMG be if it is positive for CTS?
Denervated muscle spontaneously fires during relaxation and produces fibrillation
How do you treat acute CTS?
With immediate decompression
How do you treat chronic CTS?
NSAIDs, corticosteroid injections, splinting hand in a neutral position, PT or OT (conservative treatment effective in about 2/3 of patients with mild to moderate compression)
What are some important notes to make about surgery for CTS?
Pregnancy should proceed to term, unrealistic expectations can influence surgical outcome
What is important to remember for a patient after having a CTS release?
Early hand therapy
Inflammation of the what two muscles are a/w DeQuervain Tenosynovitis?
extensor pollicis brevis and abductor pollicis longus
Where is pain reported with DeQuervain tenosynovitis? What type of pain is it described as?
Pain at the dorsolateral aspect of the wrist with referred pain to the thumb and lateral forearm; either sharp or aching
What is the cause of DeQT?
Overuse or repetitive gripping leads to irritation of tendons and sheaths leads to a stenosing tenosynovitis
What reductions in ROM can we see with DeQT?
Weakness of thumb extension or abduction of the thumb leads to decreased ability to grip
What test is used to diagnose DeQT? What is the result of a positive test?
Finklestein Test; pain in the tendons of the thumb. Compare with the unaffected hand
What two diagnoses have to be r/o in order to diagnose DeQuervain Tenosynovitis?
Median or radial nerve pathology and cervical radiculopathy
What are conservative treatments for DeQT?
Rest and ice, NSAIDs, local steroid injection, PT and/or OT, surgical decompression if refractory
What is the name of the splint used for DeQuervain Tenosynovitis?
Thumb spica cast
What is plantar fasciitis?
The plantar fascia extends from the calcaneus to the proximal phalanges of each toe in gait, inflammation of the fascia is common due to strain and employment issues (standing on hard floors)
Pain is MOST COMMON on the plantar aspect of the heel
What is the pain like in plantar fasciitis?
It may be unilateral or bilateral. Bilateral may be an early symptom of other inflammatory disorders, such as AS, RA, or gout (+/- heel spur)
What is the clinical presentation for plantar fasciitis?
Heel pain directly beneath the calcaneus or in area of medial arch. Pain is usually worse in the morning, after weight-bearing activities, or when getting up after periods of inactivity, “first step pain”
What movements make the pain of plantar fasciitis worse?
direct pressure or by maneuvers that place the fascia under a strain (dorsiflexing the toes and ankle)
What may be comorbid in a physical exam for PF?
pes planus, Achilles tendonitis, bony deformities, r/o S1 radiculopathy SLR and Achilles tendon reflex
How is a diagnosis for plantar fasciitis usually made?
With history and physical
What is the primary pharmocologic treatment for plantar fasciitis (after nonpharm tx)
NSAIDs (usually taken PRN or for preventative measures in some cases), injection of steroid/anesthetic mixture (marcaine, lidocaine, kenalog), not more than 3 in one year
