Regional Pain syndromes and psychology

Question 1

Wrist tendon problems (6)

Answer 1

Flexor tenosynovitis Trigger finger/thumb
De Quervains tenosynovitis Dorsal Tenosynovitis
Tendon ganglion Dupuytren’s contracture

Question 2

Flexor tenosynovitis

Answer 2

Tendon sheath inflammation causing stiffness or pain

–> leads to thickening of the the tendon sheaths in the palm

Question 3

Trigger finger/thumb

Answer 3

Can occur spontaneously or be linked to RA or diabetes (F>M)
Palpable nodule which moves with flexor tendon
Will present with local pain or ‘triggering’ - snapping or locking of the digit (most commonly thumb, middle or ring finger)

Question 4

De Quervains tenosynovitis

Answer 4

Pain around the radial styloid related to overuse – local swelling and tenderness of the abductor pollicis longus & extensor pollicis brevis – more common in women – treat with activity alterations, splinting and steroid injections

Question 5

Dorsal Tenosynositis

Answer 5

Extensor tendon sheath inflammation – similar to Flexor tenosynovitis

Question 6

Tendon ganglion

Answer 6

A bulge, tear or cyst in the synovial joint or tendon lining - often asymptomatic and often resolve spontaneously. Most common on the dorsum of the hand, (1:3/M:F)

Question 7

Dupuytren’s contracture

Answer 7

Painless thickening of the palmar aponeurosis – can be caused by a number of conditions
Pulling one or more fingers into flexion

Question 8

Nodal osteoarthritis

Answer 8

Rare before the age of 45yrs – OA of the 1st CMC joint (‘square hand’) and heberden’s and Bouchard’s nodes

Question 9

Carpal tunnel syndrome (7)

Answer 9

Commonest cause of nocturnal hand pain – pain, swelling, paraesthesia, dysaethesia & weakness in the median nerve distribution (thenar wasting)
Causes: Flexor tenosynovitis, RA, oedema, pregnancy
Commonest in middle aged women
treat –> surgery, splinting, steroid injections
Positive Tinels, phalen’s and reverse phalen’s signs

Question 10

Raynaud’s phenomenon

Answer 10

Vasospastic digital arteries – can be primary or secondary

Very common in young women

Question 11

Mechanical neck pain

Answer 11

Acute spasms of neck muscles are common – link to bad posture – degenerative changes are only painful when very severe

Question 12

Whiplash

Answer 12

Front, side or rear collisions in an RTA – develops hours/days after the injury
Investigations are normal but significant ROM

Question 13

Neck pain

Answer 13

Common and usually mechanical –
Inflammatory –cervical spondylosis - osteophytes can cause root pressure and myelopathy
Traumatic (whiplash, occupational, assault)
Rare - infection, tumours, referred pain (heart disease)

Question 14

Shoulder pain

Answer 14

Usually soft tissue (capsulitis, rotator cuff) not articular

Can be referred, commonly from the neck or rarely from chest/abdomen (shoulder tip pain from peritonitis)

Question 15

Conditions which refer to the shoulder

Answer 15

Cervical spondylosis (30-50yrs) or lung tumours, subphrenic abscesses or peritonitis

Question 16

Articular lesions of the shoulder

Answer 16

Glenohumeral instability (under 30yrs)
Inflammatory arthritis (30yrs plus)
Glenohumeral OA or polymyalgia (over 50yrs)

Question 17

Soft tissue disorders of the shoulder

Answer 17

Rotator cuff tendinitis (under 30yrs)
Capsulitis & calcific rotator cuff tendinitis (30-50yrs)
Rotator cuff tears (over 50yrs)

Question 18

Rotator cuff diseases

Answer 18

Tendinitis – painful arc of abduction, passive movement is full and pain free
Calcific tendinitis – detectable calcification of usually the supraspinatus tendon
Tears – Occur spontaneously in elderly or traumatically in young, associated with immediate loss of active abduction

Question 19

Frozen shoulder (adhesive capsulitis)

Answer 19

Initially pain which resolves leaving global movement restriction – usually resolves within 1-2yrs

Question 20

Shoulder impingement

Answer 20

Humeral head impinges on ACJ due to loss of supraspinatus or ACJ osteophytes

Question 21

Management of shoulder injuries (5)

Answer 21

MRI if needed
Analgesia, physiotherapy
Steroid injections and surgery if unresolved

Question 22

Elbow pain

Answer 22

Can be referred from the shoulder or neck
Can be affected by arthritidies but rarely
Common disorders are Lateral and medial epicondylitis and olecranon bursitis

Question 23

Diabetic stiff hand

Answer 23

Stiff painful hand in diabetic patient

Positive prayer sign

Question 24

Chronic pain syndromes

Answer 24

Chronic widespread pain (CWP or fibromyalgia)
Chronic fatigue syndrome (CFS or ME)
TMJ dysfunction syndrome
Chronic regional pain syndrome type 1(sympathetic reflex dystrophy) Chronic (or work related) upper-limb pain syndrome (RSI)

Question 25

Chronic widespread pain (fibromyalgia)

Answer 25

A diagnosis of exclusion when there is >3months pain above and below the waist –> Diagnosed by tender trigger points –> effects middle aged people (F>M) who often still work (1-11% incidence)
Impacts sleep and interpersonal relations

Question 26

Clinical Features of Chronic widespread pain (fibromyalgia)

Answer 26

Widespread, unremitting and acting discomfort –> very commonly co-exists with IBS, CFS, tension headaches, PMS, anxiety and depression –> tests will be normal and this may further frustrate the patient

Question 27

Cause of Chronic widespread pain (fibromyalgia)

Answer 27

Certainly there is a psychological element and the beliefs and coping strategies the pt develops to deal with their pain are important –> can be considered a pain amplification syndrome due to changes in the descending inhibitory pathways in spinal cord
Should be considered within a biopsychosocial model

Question 28

Treatment of Chronic widespread pain (fibromyalgia)

Answer 28

Sympathetic and supportive approach must be taken –>pts should be reassured the pain often improves.
Graded aerobic exercise regimen is safe and effective
Psychological help is often useful but the use of addictive anxiolytics should be avoided

Question 29

Medication for Chronic widespread pain (fibromyalgia)

Answer 29

NSAIDs can help but should only be used intermittently
Gabapentin and preglabalin useful but risk of drowiness
Low-doses of sedatives antidepressants (amitriptyline or dosulepin) are helpful if taken before bed (sedating and increase descending inhibition) but explanation should focus on analgesic rather than antidepressant properties

Question 30

Injections for Chronic widespread pain (fibromyalgia)

Answer 30

Trigger point injections of LAs, corticosteroids or acupunture can be useful but oral corticosteroids are not helpful

Question 31

Chronic fatigue syndrome (Myalgic Encephalomyelitis)

Answer 31

Incidence of 0.5% in UK -> mostly in women 20-50yrs
More common in ethnic minorities
Principle symptom is Chronic fatigue worsened by minimal exertion –>additionally there is often sleep disturbance, poor concentration & muscular pain/stiffness
Emotional symptoms are common as well

Question 32

Tempromandibular pain dysfunction syndrome

Answer 32

A disorder of the TMJ associated with bite abnormalities and nocturnal tooth grinding –> occurs mainly in anxious people –> presents as pain in one or both TMJ
In a small number dental bite correction is helpful but most benefit more from low dose tricyclic medication

Question 33

Chronic regional pain syndrome type 1 (reflex sympathetic dystrophy or Sudek’s Atrophy)

Answer 33

Sympathetic dysfunction after trauma –> starts with pain, swelling and increased temp (no sweating)-> dystrophic stage with articular symptoms and cold skin –> late phase involves pain, atrophy and contracture
Diagnosis is clinical and by 3-stage bone uptake scan

Question 34

Chronic (or work related) upper-limb pain syndrome (AKA RSI)

Answer 34

Pain in a part of or all of the arm – often begins with a specific distribution and can then develop into chronic, generalised limb pain –> occurs in office workers or musicans particularly

Question 35

Treatment of Chronic regional pain syndrome type 1

Answer 35

NSAIDs and corticosteroids can be used in the early stages
Physiotherapy can also be useful
Persistant sympathetic pain can be treated with stellate ganglion or sympathetic chain block

Question 36

Treatment of Chronic (or work related) upper-limb pain syndrome (AKA RSI)

Answer 36

NSAIDs and physiotherapy in the acute stage is useful –> amitrptyline or gabapentin is helpful in some patients
Time off work with gradual return and a review of screen, keyboard and chairs is important

Question 37

Management of Trigger finger

Answer 37

Steroid injections are sucessful in the majority of patients - a splint may be applied afterwards
Surgery should be reserved for those who haven’t responded to steroid injections.

Question 38

Myofascial pain syndrome (CMP)

Answer 38

Chronic pain from multiple trigger points and fascial constrictions - classically focal point/muscle hardening, referred pain and limited RoM, differs from fibromyalgia in having distinct, localised areas of pain. Treatment is as with other pain syndromes, Trigger point injections or by the wise-anderson protocol