Soft Tissue Rheumatism. Elinor Mody, MD Chief, Division of Rheumatology Reliant Medical Group
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1 Soft Tissue Rheumatism Elinor Mody, MD Chief, Division of Rheumatology Reliant Medical Group
2 Some problems are difficult, but diagnosing and treating most causes of joint pain are not!
3 Common areas of pain Shoulder Elbow Wrist Hip Knee Ankle
4 Some definitions Tendon: The collagenous portion of a muscle at the origin and insertion. Enthesis: The attachment of a tendon to bone. Bursa: Two membranes and the lubricated space between, that allows near-frictionless motion of soft tissue over bone. Ligament: Collagenous tissue connecting two bony structures. Fascia: A layer or sheet of fibrous tissue that separates or covers various soft tissues or organs.
5 Tendinitis History Pain with active motion Weakness May elicit an overuse history Exam Little discomfort with passive ROM Isometric contraction is always tender. Palpable tendons usually tender
6 Bursitis History Pain with active motion Weakness not prominent May elicit an overuse history Exam Passive ROM more uncomfortable than tendinitis Isometric contraction is tender Palpable bursae tender
7 Arthritis History Pain with active motion Weakness only related to pain AM stiffness Exam Passive ROM as uncomfortable as AROM Isometrics not tender (the joint isn t moving) Crepitus in OA Joint aspirate often inflammatory
8 Shoulder: Common causes of shoulder pain Tendinitis: Rotator cuff (+/- Ca 2+ ), biceps Bursitis: Subacromial and subdeltoid bursae Adhesive capsulitis Arthritis: Glenohumeral, AC Neuropathy: Cervical, notalgia Dislocation/trauma: GH, AC separation, Fx Other: Cellulitis, pneumonia, cardiac
9 Shoulder: Normal anatomy
10 Shoulder: Normal anatomy
11 Shoulder: Normal anatomy
12 Empty Can Test» Tests Supraspinatus» Arm abducted 90 degrees in pronation» Downward pressure applied
13 Napoleon Test» Tests subscapularis» Press belly with elbow at 90 degrees» Pain or inability to perform suggests subscapularis tendonitis/derangement
14 External Rotation Lag» Tests Infraspinatus» Hold arm in external rotation with elbow at 90 degrees» Inability to maintain suggests infraspinatus tendonitis/derangement
15 Hawkins- Kennedy» Tests for subacromial impingement» Hold arm at 90 degrees flexion, with elbow at 90 degrees.» Forcibly internally rotate shoulder» Pain with this maneuver suggests impingement
16 Shoulder: Subacromial approach
17 Shoulder: Posterior approach
18 Shoulder: Normal arthrogram
19 Shoulder: Chondrocalcinosis and AC osteophytes
20 Other therapies Physical therapy Systemic Steroids or NSAIDs Disease-specific therapy, e.g. colchicine for crystal disease MR imaging indicated primarily to guide surgery. Not needed for diagnosis or treatment.
21 Elbow Lateral epicondylitis (actually an enthesitis) Olecranon bursitis Arthritis is uncommon
22 Elbow: Lateral epicondylitis
23 Elbow: Tennis elbow strap
24 Elbow: Olecranon bursitis
25 Elbow: Olecranon bursitis
26 Other therapies Physical therapy Steroids or NSAIDs Disease-specific therapy, e.g. colchicine for crystal disease, antibiotics for infection, etc. Steroid injection of olecranon bursa should be avoided, due to risk of infection
27 Wrist Fracture: Colle s Arthritis: Crystal Median neuropathy: carpal tunnel syndrome dequervain s tenosynovitis
28 Carpal tunnel syndrome Often overweight, middle-aged patient May have history of overuse/misuse Night pain, numbness in median distribution Tinel s & Phalen s signs EMG/NCS only necessary prior to surgery Therapeutic options include splint, rest, steroid injection, surgery
29 Wrist: rest
30 Wrist: splint
31 Wrist: Aspiration/Injection
32 Hip Bursitis Tendinitis Groin pull Arthritis Referred from spine
33 Hip: Bursitis
34 Hip: Trochanteric bursitis
35 Hip: Trochanteric bursa injection
36 Knee Trauma: meniscal or ligamentous tear, Fx Arthritis: Inflammatory and OA Bursitis: Pre-patellar, pes anserine, etc. The knee is the first joint we ve discussed today where routine plain films are often helpful!
37 Knee: Normal Anatomy
38 Knee: Normal Anatomy
39 Knee: Chondrocalcinosis
40 Knee: Osteoarthritis
41 Ankle Sprain = traumatic ligamentous tear Fracture Arthritis OA is uncommon in the ankle Crystal arthritis is common Tendinitis Peroneus longus et brevus Tibialis posterior/fhl Tibialis anterior Neuropathy, e.g. Tarsal tunnel syndrome
42 Ankle: Normal
43 Ankle & Foot: Normal
44 Ankle: Aspiration/Injection
45 Summary Joint, tendon, and bursal pain are among the most common reasons patients seek medical attention. A diagnosis is frequently evident after a proper history and exam. Usually, a film or other test is NOT required for accurate diagnosis and treatment. Embrace the principle of local therapy for a local problem.
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