Nonaricular Rheumatism Flashcards
Non-articular Conditions
-very common
-related to mild and repetitive trauma (overuse)
-often idiopathic
-tenderness and pain is often localized and pin-point, and not found around joint spaces
-pain often increases with certain motions but not full range of motion
Provocaive test are postitive (active/passive)
-may occure in systemic diseases or infectious diseases
-lack specific diagnositc laboratory tests
Shoulder Pain
-knowing anatomy lets make diagnosis from exam
-H&P guides for treatment
-DDX should include common (tendon) or distant anatomic sites arising by referred pain-mediated pathways
-
Bicipital Tendonitis
“nonarticular disorders”
- anterior shoulder pain (diffuse) from irritation of the long head of the bicepts tendon
- palpation of bicipital tendon elicits pain but compare slides
- Yergason’s sign, speed’s test - prolonged cases with full tendon rupture can occur producing “Popeye’s sign”
Yergason’s sign
supination of forearm against resistance
for bicipital tendonitis
Adhesive Capsulitis
(frozen shoulder)
- most often idiopathic but may also be secondary to other shoulder and upper extremity pathology
- seen with prolonged immobilization of arm
- seen often in association with diabetes
- physical shows severe loss of active and passive ROM in all places
Olecranon Bursitis
“nonarticular disorder”
- “golf ball on the elbow”
- often septic (infective), with a definite site/portal of entry of microorganisms although may be secondary to crystalline, gout or trauma
- note that the olecranon bursa does not normally communicate with the true elbow joint
Lateral Epicondylitis
“tennis elbow”
-degenration of the common extensor tendon, particularly the extensor carpi radialis brevis
Inflammation vs. small tendon tear
-overuse injury (rarely from tennis)
involves entheses
Lateral Epicondylitis Physical Exam
- localized tenderness over a slightly anterior to lateral epicondyle
- provocative maneuvers are forced forearm supination and resisted wrist extension
Medial epicondylitis
“golfer’s elbow”
- mainly involves flexor carpi radialis
- less common than tennis elbow
- rarely from golf
- nonarticular
Medial epicondylitis Physical Exam
-localized tenderness over or slightly anterior to medial epicondyle
-provocative maneuvers
forced forearm pronation and resisted wrist flexion
Ulnar Nerve Entrapment
nonarticular
- entrapment at elbow produces aching on medial side of elbow, numbness and paresthesia of the little finger and adjacent side of fourth digit
- many causes
- EMG can diagnose
Flexor Tenosynovitis
nonarticular of hand&wrist
- inflammation of tendon sheaths of flexor digitorum superficials and profundus
- pain in the palm of hand mainly with finger flexion
- tendon over volar tendon sheath and may have associated nodule which causes “trigger finger”
de Quervain’s Tenosynocitis
nonarticular
- inflammation of the sheaths of the extensor pollicis brevis and abductor pollicis brevis tendons
- presents as wrist pain, positive “Finklestein test” on clinical exam
- common in women, repetitive hand activities
Ganglion
- nonarticular
- cystic swelling arising from a joint or tendon sheath that occurs most commonly over the dorsum of the wrist
- is lined with synovium and does have fluid
- unknown cause but trauma implicated
Carpal Tunnel Syndrome
- most commonly diagnosed, isolated phenomenon
- 3:1 women, 50% between 40-60 years old
- median nerve compression
- postiive Tinel & Phalen’s tests
- Thenar muscle atrophy
Volar Flexor Tenodynovitis
-pain in the palm on finger flexion, occasionally “triggering”
Rotator Cuff Syndromes
- acute/chronic tendonitis, varried presentations and causes
- rotator cuff tear (partial and complete)
Subdeltoid Burstits/Calcific tendonitis
-secondary to recurrent episodes of tendonitis
Rotator Cuff Tendons
- Supraspinatue - abduction
- Infraspinatus - external rotation
- Subdeltoid - internal rotation
- Teres minor - external rotation
Functions of Rotator Cuff
- provides internal and external rotation of shoulder
- fixes humeral head in the glenoid fossa during adbuction to counteract the pull of the deltoid
Rotator Cuff Tendinitis
“nonarticular”
- impingement syndrome
- most common cause of “shoulder paint”
- tendinitis is the primary cause of the pain, but secondary involvement of subacromial bursa may occure
- acute or chronic
Acute Rotator Cuff Tendinitis
- more common in young patients
- more likely with calcific deposit at the supraspinotous tendon insertion
Physical Exam of Rotator Cuff Tendinitis
- Key is pain within rotator cuff active abduction esp between 60 and 120 deg
- pain increased with active abduction against resistance
- impingement sign positive
- less pain on passive rather than active ROM
Rotator Cuff Tear
- 50% recall trauma
- remainder due to gradual degeneration of muscle causing complete tear
- MRI best to diagnose
Complete Rotator Cuff Tear
-positive drop-arm test with inability to actively maintain 90 deg of passive shoulder abduction
Partial Rotator Cuff Tear
weakness, pain, loss of abduction
Cervical Radiculopathy
- manifest with shoulder pain, the area of referred pain has dermatomal pattern consistent with the distribution of dermatomal nerve roots
- pain can be differentiated from shoulder pain by: history, physical, EMG, cervical radiographs, myelography or MRI
Brachial Neuritis
-painful condition of shoulder associated with limitation of motion after which pain subsides leaving weakness of shoulder muscles including deltoid, supraspinatus, infraspinatis, biceps and triceps and can also have an associated paralysis of the diaphragm; cause is unclear but thought to be associated with viral or post viral syndromes and has developed after a previous vaccination.
Nerve Entrapment Syndromes
-referred pain to the shoulder; distant compression neuropathies such as carpal tunnel (median nerve) and cubital tunnel (ulnar nerve) may manifest with concomitant and separate shoulder impingement with rotator cuff disease; associated numbness and paresthesias with mapping of the dermatomal distribution and with peripheral neuropathy often direct the examiner to the appropriate diagnosis; in quadrilateral space syndrome, the axillary nerve is compressed and typically occurs when the arm is held in abduction and external rotation with subsequent tightening of fibrous bands across the nerve and is most commonly seen in the dominant shoulder of young athletic individuals such as pitchers, swimmers and tennis players who function with excessive overhead activity; suprascapular nerve entrapment syndrome can be caused by a traction lesion resulting from repetitive overhead activities, a compression lesion, or both to the nerve, caused by tethering of the nerve at the suprascapular notch by the suprascapular ligament, or the spinoglenoid notch by the transverse ligament.
Reflex Sympathetic Dystrophy (RSD) [New Name=COMPLEX REGIONAL PAIN SYNDROME]
poorly understood and frequently overlooked condition (also known as causalgia, shoulder-hand syndrome and Sudeck’s atrophy) that is generally associated with minor trauma and is to be differentiated from causalgia which involves trauma to major nerve roots; RSD has 3 phases: Phase 1 is characterized by sympathetic overflow with diffuse swelling, pain, increased vascularity and radiographic evidence of demineralization. Phase 2 is characterized by atrophy and the extremity may be cold and shiny with atrophy of skin and muscles. Phase 3 refers to progression of trophic changes with irreversible flexion contractures, a pale, cold and painful extremity.
Neoplasms
primary or metastatic may cause shoulder pain by direct invasion of musculoskeletal system or by compression with referred pain; In younger individuals consider chondroblastoma (proximal humeral epiphysis) osteogenic sarcoma (metaphysics); For older individuals consider metastatic lesions and myeloma; pancoast syndrome or apical lung tumor may manifest as shoulder or cervical radiculitis.
Dialysis Shoulder Arthropathy
is seen in some long-term hemodialysis patients and consists of shoulder pain, weakness, loss of motion, and functional limitation. Cause is unknown but may improve with correction of underlying metabolic disorder such as osteomalacia and secondary hyperparathyroidism.
Osteonecrosis
to necrosis of the humeral head seen in association with a variety of conditions with symptoms due to synovitis and joint incongruity resulting from resorption, repair and remodeling; most common cause is avascularity resulting from a fracture through the anatomic neck of the humerus secondary to condition such as long-term steroid use, SLE, hemaglobinopathies, pancreatitis and hyperbarism.
Carpal Tunnel Syndrome Presentation
- nocturnal paresthesias associated with intermittent pain or paresthesia during the day
- weakness, clumsiness of hand
- complain of forearm/elbow/shoulder pain that is aggravated with activity
What are ganglia?
mucin-filled cysts arising form joint capsules or tendon sheaths
-use steroid injection or surgery
Why is tendinitis of extensor pollicis longus tendon dangerous?
-because of risk of tendon rupture
How do you treat painful osteoarthritis involving carpometacarpal joint of the thumb?
splinting
Trigger Fingers
- thickening of the A1 retinacular pully in the palm
- treated by steroids and splinting
Systemic Conditions of Carpal Tunnel Syndrome
-heart failure, multiple myeloma, TB, pregnancy, diabetes, obesity, rheumatoid arthritis, gout
Treatment of Carpal Tunnel Syndrome
- night splints initially
- steroid injection in tunnel
- surgical release (sensory loss)
Trochanteric Bursitis
Hip
- lateral thigh pain ending at the knee
- often reported as “hip pain”
- various secondary causes
Meralgia Paresthetica
Hip
- lateral femoral cutaneous nerve (L2-L3) entrapment, causing diffuse lateral thigh pain described as burning or numbness
- most common sites: inguinal lig., psoas insertion
- EMG for diagnosis*
Common causes of Meralgia Paresthetica
- pregnancy
- obesity
- diabetes
Popiteal Cysts
“bakers cyst” knee
- common
- 40% communicate with knee joint
- presents with cystic swelling/discomfort behind knee
- best seen from behind
- may rupture
Anserine bursitis
pes anserinus = goose’s foot
knee
prepatellar bursitis
“housemaid’s/tile layers/penitent’s knee”
- manifests as swelling superficial to kneecap
- multiple etiologies, but consider sepsis
- Rubor, Calor, Dolor over patella and tissue
- lack of joint involvement evident from nontender suprapatellar pouch and popliteal area
- don’t tap a normal knee through cellulitis
Patellar tendonitis
“jumpers knee”
-patellofemoral pain syndrome (formerly chondromalacia patellae)
Achilles Tendinitis
nonarticular
- inflammation of tendon
- may associated with systemic inflammatory disorders, trauma, etc.
- pain/swelling/tenderness over Achilles tendon at its attachment
- may also rupture (Thompson’s sign)
Treatment of Achilles Tendinitis
rest, shoe modification, a heel raise to reduce tendon stretching, NSAIDs, physiotherapy and splinting if needed
Achilles bursitis
is associated with posterior heel pain made worse by passive dorsiflexion of the ankle; bursal distention produces a tendon swelling behind the ankle with bulging on both sides of the tendon; may occur with Achilles tendinitis; treatment is similar as for Achilles tendinitis.
Plantar fasciitis
most common cause of heel pain and results from repetitive microtrauma causing tearing and stretching of the fibers of the plantar fascia and its narrow proximal calcaneal attachment
- Pain on the undersurface of the heel on weight bearing is the principal complaint
- Localized tenderness, without swelling is present over the anteromedial portion of the plantar surface of the calcaneus
- Passive dorsiflexion of the toes often accentuates the discomfort
- Commonly seen in obese middle-aged and elderly patients as a result of repetitive trauma from athletic activities
- worse in morning
Flat feet (pes planus)
- flattening of the longitudinal arch on medial side is often asymptomatic
- may result in muscle fatigue with aching and intolerance due to long hours of standing or walking
- hereditary
- watch for rupture of posterior tibialis tendon
- calcaneus is everted and out-toeing is seen on ambulation
Cavus feet (pes cavus
unusually high arch and is usually hereditary but can follow poliomyelitis, Friedreich’s ataxia or spina bifida; it is usually asymptomatic but can cause foot fatigue and discomfort particularly in runners; shoe modification to accommodate the high instep and claw toes, metatarsal pads with cushioned high arch supports and stretching exercises of the toe extensors are usually helpful
Metatarsalgia
is pain and tenderness in and about the metatarsal heads or MTP joints and may be limited to a single joint or generalized across the ball of the foot; pain in the forefoot on standing and walking and tenderness on palpation of the metatarsal heads and sometimes in MTP joints are the main clinical findings; this condition frequently follows years of disuse and weakness of the intrinsic muscles due to chronic foot strain from improper footwear with the toes cramped into tight or pointed shoes, but can be associated with a variety of other foot conditions
Sesamoiditis
results from damage to the articular surfaces between the sesamoids and the first metatarsal head resulting in chondromalacia or osteoarthritis; the area becomes painful, inflamed and is referred to as sesamoiditis; treatment consists of shifting the weight elsewhere by means of a soft metatarsal support, rest, activity modification and NSAIDs; in patients with severe disability, sesamoidectomy may be required
Treatment of Flat feet (pes planus
If symptomatic, a soft orthotic polyethylene-foam-lined arch support often produces symptomatic relief
Morton’s Neuroma
- entrapment neuropathy of interdigital plantar nerves occures most commonly in the web space b/w 3 & 4th toes
- chronic irritation lead to neuroma
- patients complain of aching/burning pain-radiates from web space distally to toes
- worsen: jogging/standing/hard surfaces, tight fitted or high heal shoes
- more in women
Morton’s Neuroma Treatment
padding of metatarsal area, loose fitting shoes, steroid injection
-surgery (removal)
Hammertoe
- flexion of PIP joint and tip of toe points downward
- most common second toe
Bunionette
-prominence of metatarsal head
Management of Hammertoe & Bunionette
- avoid aggravating activities
- active/passive stretching
- immobilization (splint)
- application of heat/cold
- anti-inflammatory meds (NSAIDS/steroids)
- steroid injection
- topical capasaicin cream
- surgery
Fibromyalgia
- widespread pain > 3 months (bilateral, upper, lower)
- non-restorative sleep
- tender points
Associated Syndromes of Fibromyalgia
Neuro: arthralgias, burning/paresthesias (extremeties), migraine
GI: IBS
Cardio: costochonditis
depression, anxiety, medication sensitivities
Fibromyalgia Management
exercise improve sleep behavioral/psychological therapy anagesics tricyclic/tetracyclic antidepressants ***NSAIDS, Analgesics not effective***
