Regional Pain syndromes and psychology Flashcards
Wrist tendon problems (6)
Flexor tenosynovitis Trigger finger/thumb
De Quervains tenosynovitis Dorsal Tenosynovitis
Tendon ganglion Dupuytren’s contracture
Flexor tenosynovitis
Tendon sheath inflammation causing stiffness or pain
–> leads to thickening of the the tendon sheaths in the palm
Trigger finger/thumb
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)
De Quervains tenosynovitis
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
Dorsal Tenosynositis
Extensor tendon sheath inflammation – similar to Flexor tenosynovitis
Tendon ganglion
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)
Dupuytren’s contracture
Painless thickening of the palmar aponeurosis – can be caused by a number of conditions
Pulling one or more fingers into flexion
Nodal osteoarthritis
Rare before the age of 45yrs – OA of the 1st CMC joint (‘square hand’) and heberden’s and Bouchard’s nodes
Carpal tunnel syndrome (7)
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
Raynaud’s phenomenon
Vasospastic digital arteries – can be primary or secondary
Very common in young women
Mechanical neck pain
Acute spasms of neck muscles are common – link to bad posture – degenerative changes are only painful when very severe
Whiplash
Front, side or rear collisions in an RTA – develops hours/days after the injury
Investigations are normal but significant ROM
Neck pain
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)
Shoulder pain
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)
Conditions which refer to the shoulder
Cervical spondylosis (30-50yrs) or lung tumours, subphrenic abscesses or peritonitis
Articular lesions of the shoulder
Glenohumeral instability (under 30yrs) Inflammatory arthritis (30yrs plus) Glenohumeral OA or polymyalgia (over 50yrs)
Soft tissue disorders of the shoulder
Rotator cuff tendinitis (under 30yrs)
Capsulitis & calcific rotator cuff tendinitis (30-50yrs)
Rotator cuff tears (over 50yrs)
Rotator cuff diseases
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
Frozen shoulder (adhesive capsulitis)
Initially pain which resolves leaving global movement restriction – usually resolves within 1-2yrs
Shoulder impingement
Humeral head impinges on ACJ due to loss of supraspinatus or ACJ osteophytes
Management of shoulder injuries (5)
MRI if needed
Analgesia, physiotherapy
Steroid injections and surgery if unresolved
Elbow pain
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
Diabetic stiff hand
Stiff painful hand in diabetic patient
Positive prayer sign
Chronic pain syndromes
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)
Chronic widespread pain (fibromyalgia)
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
Clinical Features of Chronic widespread pain (fibromyalgia)
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
Cause of Chronic widespread pain (fibromyalgia)
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
Treatment of Chronic widespread pain (fibromyalgia)
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
Medication for Chronic widespread pain (fibromyalgia)
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
Injections for Chronic widespread pain (fibromyalgia)
Trigger point injections of LAs, corticosteroids or acupunture can be useful but oral corticosteroids are not helpful
Chronic fatigue syndrome (Myalgic Encephalomyelitis)
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
Tempromandibular pain dysfunction syndrome
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
Chronic regional pain syndrome type 1 (reflex sympathetic dystrophy or Sudek’s Atrophy)
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
Chronic (or work related) upper-limb pain syndrome (AKA RSI)
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
Treatment of Chronic regional pain syndrome type 1
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
Treatment of Chronic (or work related) upper-limb pain syndrome (AKA RSI)
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
Management of Trigger finger
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.
Myofascial pain syndrome (CMP)
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
