Pain Between Joints Flashcards
most common soft tissue rheumatic conditions
- generalized
- polymyalgia rheuamtica
- giant cell arteritis
- fibromyalgia - overuse syndromes
- golfer’s elbow
- tennis elbow
- rotator cuff tendonitis
symptoms and physical findings of polymyalgia rheumatica
symptoms: proximal muscle pain and stiffness
- adults over 50 years
- stiffness with rest (gelling up)
- unable to raise arms; stand up from seated position; arise from bed
- MAY BE THE PRESENTING FEATURE OF RA AND SOMETIMES ASSOCIATED WITH TEMPORAL ARTERITIS
proximal findings: muscle tenderness, but NO LOSS OF MUSCLE BULK, difficulty rising from seated position, pain when raising arms from the side, and reduced range of motion in the shoulder.
T/F people with polymyaglia rheumatia have elevated EMG and ESR
partially false. they have elevated ESR (above 40 mm/hr) but they have normal EMG and normal muscle enzymes
differential diagnosis of PMR
- giant cell arteritis
- viral arthritis
- RA
- OA
- Multiple myeloma
- fibromyalgia
- depression
- occult infection or malignancy
management of polymyalgia rheumatica
prednisone 30-40mg a day
- reduce the dose slowly when ESR is normal
- many patients will need a small dose of steroid for up to 18 months,
sometimes a patient who presents with polymyalgia rheumatica will also have underlying RA. when does the underlying RA present?
the RA may only present when steroids are discontinued. the prednisone reduction results in complaint of joint aches and pains, and there is swelling of PIP and MCPs
• Other symptoms include
– Stroke, peripheral neuropathy, confusion – Arm claudication
– Fatigue, scalp tenderness – Jaw claudication – Fever – Visual disturbance – blindness most severe
• Other less common presentations
– Stroke, peripheral neuropathy, confusion – Arm claudication
what would be going on?
giant cell arteritis / temporal arteritis.
- seen more in patients over 50 years
immediate test to run when suspecting GCA
ESR AND CRPP!!!
in cga, what would you see on a temporal artery biospy?
abnormal skip lesions with mononuclear cells and granulomatous inflammation.
physical exam findings of cga
esr elevation over 50.
occiptal artery may be tender
temporal artery is tender to touch or has DECREASED pulsation
this is temporal artery thickening in temporal arteritis (cga)
what is this pathology of?
temporal artery biopsy. can see the arterial wall has infiltrates of plasma cells and lymphocytes. indicates inflammatino. probably cga/tempoeral arteritis
treatment for cga
- prednisone is primary treatment
- occarional DMARDs may be used as a steroid sparing agient.
- biolgic therapy approved in certain patients (tocilizumab)
golfer’s elbow
an “overuse syndrome” characterized by pain over the medial epicondyle and gets worse with activity. results in tenderness on palpation over the medial epicondyle and decrerased strenghth.
criteria for fibromyalgia
Widespread Pain INdex >7 and SS scale score >5, OR WPI 3-6 AND SS SCALE >9.
- symptoms are present at similar levels for at least 3 months
- no other comorbitidies to explain symptoms
outline the mechanisms of FM
- central sensitization
- first, impulses from afferents depolarize dorsal horn neurons
- then extracellular Ca2+ and nitric oxide diffuse into neurons and cause exaggerated release of substance P and glutamate; this results in neural hyperexcitability
- pain signal is sent tot he brain from the dorsal horn.
- overall, after central sensitization has occurred; there is.a low threshold for afferents, which normall trnasmit “toucch” info– may produce spontanous and movement-induced pain (allodynia_–little additional nociceptive input is required to maintian the sensitized state. - temporal summation: patients with FM have abnormal win up. winup after-sensations are greater in magnitude, last longer, and are more frequentl painful in Fm subjects.
note:
tender points of fibrositis (FM)
clavicals, hips, knees, iliosacral, shoulders and occiptal bones
