Rheumatology & Immunology. Regional pain syndromes to be covered today. Some definitions. Tendinitis. Bursitis. History. History. Exam.
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1 Rheumatology & Immunology Some problems are difficult, but diagnosing and treating soft tissue syndromes are not! Soft tissue syndromes one of the most common reasons patients present to their doctor. Elinor Mody, MD No Disclosures Regional pain syndromes to be covered today Shoulder Elbow Wrist Hip Knee Ankle 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. Tendinitis Bursitis 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 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
2 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 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 Shoulder: Normal anatomy Shoulder: Normal anatomy Shoulder: Normal anatomy Shoulder: Subacromial approach
3 Shoulder: Posterior approach Shoulder: Normal arthrogram Shoulder: Chondrocalcinosis and AC osteophytes 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. Elbow Elbow: Lateral epicondylitis Lateral epicondylitis (actually an enthesitis) Olecranon bursitis Arthritis is uncommon
4 Elbow: Tennis elbow strap Elbow: Olecranon bursitis Elbow: Olecranon bursitis 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 Wrist Carpal tunnel syndrome Fracture: Colle s Arthritis: Crystal Median neuropathy: carpal tunnel syndrome dequervain s tenosynovitis 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
5 Wrist: rest Wrist: splint Wrist: Aspiration/Injection Hip Bursitis Tendinitis Groin pull Arthritis Referred from spine Hip: Bursitis Hip: Trochanteric bursitis
6 Hip: Trochanteric bursa injection 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! Knee: Normal Anatomy Knee: Normal Anatomy Knee: Chondrocalcinosis Knee: Osteoarthritis
7 Ankle Ankle: Normal 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 Ankle & Foot: Normal Ankle: Aspiration/Injection Summary Question 1 Soft tissue pain syndromes 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. 55 year old man with significant etoh use, hypertension and diabetes, with a decreased GFR presents with a swollen olecranon bursa. Aspiration is performed, and crystal exam of the fluid reveals sodium urate crystals.
8 Question 1 Question 2 Which of the following is appropriate at this point? a)cortisone injection b)nsaid therapy c)oral steroids 50 year old woman with a 1 week history of severe R shoulder pain. On exam, her shoulder moves normally, but due to level of pain, a cortisone injection is administered. She presents back one week later with no improvement, but extension of the pain down to her elbow. Question 2 What is the most likely diagnosis? a)recalcitrant adhesive capsulitis b)acute MI c)cervical radiculopathy
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