Soft Tissue Rheumatism

Prof. Dr. Şansın Tüzün

" Soft tissue Rheumatism" refers to aches or pains which arise from structures surrounding the joint such as tendons, muscles, bursae and ligaments.

This may be localized when pain is felt in one region or generalized when pain is felt either all over or in many parts of the body.

FIBROMYALGIA

Chronic musculoskeletal syndrome characterized by

diffuse pain and tender points

No evidence that synovitis or myositis are causes

Occurs in the context of unrevealing physical

examination, labaratory and radiologic examination

% 80-90 of patients are women, peak age is 30-50

years

Clinical Features

Generalized chronic musculoskeletal pain

Diffuse tenderness at discrete anatomic locations

termed tender points

Other features, diagnostic utility but not essential for

classification of fibromyalgia are; fatique, sleep

disturbances, headaches, irritable bowel syndrome,

paresthesias, Raynaud’s-like syndromes,

depression and anxiety

For classification criteria, patients must have

pain for at least 3 months involving the upper

and lower body, right and left sides, as well

as axial skeleton, and pain at least 11 of 18

tender points on digital examination

Classification Criteria

ChronicChronicFatigueFatigue

SyndromeSyndrome

FibromyalgiaFibromyalgia

Central Sensitization Syndromes

Irritable BowelIrritable BowelSyndromeSyndrome

Primary dysmenorrheaPrimary dysmenorrheaMigraineMigraine

Tension-typeTension-typeHeadacheHeadache

MPSMPS

Restless LegRestless LegSyndromeSyndrome

GulfGulf WarWarSyndromeSyndrome

OTHERSOTHERS

Central Sensitization

An exaggerated response of the central

nervous system to a peripheral stimulus

that is normally painful (hyperalgesia) or

non-nociceptive, such as touch

(allodynia)

Prolongedor

Persistence Pain

Central Sensitization

Hyperexcitability Hypersensitivity

CNS function is not fixed but is capableCNS function is not fixed but is capableof alterations depending on various peripheral and/orof alterations depending on various peripheral and/or

environmental factorsenvironmental factors

The ability of CNS to undergo these changes is called

““NEUROPLASTICITY”NEUROPLASTICITY”

“Common”s among CSSs

Gender (Female)

Family history

Chronic pain/fatigue

Abnormal neuroendocrine functions

Absence of pathological findings

FMS and MPS

Myofascial pain syndromes....... (20 - 30%) Fibromyalgia.............................. (3 - 5%)

Are they part of a continuum?

TrP PATHOGENESIS

TraumaTrauma StressStress

Muscle SpasmMuscle Spasm SympatheticSympathetic ActivationActivation

TRIGGER POINTTRIGGER POINT

MUSCLE SPASMMUSCLE SPASM(Taut Band)(Taut Band)

PainPain

Pain

CentralCentralSensitizationSensitization

EndocrineEndocrineDisordersDisorders

??

PAINPAINGENERATORGENERATOR

MPS & FMS

Trigger points Tender points

The most important criteria for

differential diagnosis

The presence of tender points (TeP) and widespread muscle pain in

FMS

compared with

Regional and characteristic referred pain patterns with discrete

muscular trigger points (TrP) and taut bands of skeletal muscle in

MPS

Myofascial Trigger Point Diagnosis

Palpable Taut Palpable Taut BandBand

Local TwitchLocal Twitch Response Response

Jump SignJump Sign

Referred painReferred pain

Fibromyalgia

Pain in 11 of 18 tender point sites on digital palpation

““tender does not meantender does not meanpainful”painful”

Fibromyalgia Tender Points

CHRONIC FATIGUE SYNDROME

CFS has recently emerged as a popular

diagnostic label for a centuries-old disorders

of fatigue and multiple somatic complaints.

“ Yuppie flue “

It shares many features with fibromyalgia

including the lack of objective physical or

laboratory abnormalities.

Syndrome Relationship with Fibromyalgia

Depression

Irritable bowel

Migraine

Chronic fatiqe Syndrome

Myofascial pain

25-60 % of FM cases

50-80 % of FM cases

50 % of FM cases

70 % of CFS cases meet FM

May be localized form of FM

Classify as CFS if;

Fatique persists or relapse for > 6 months

History, physical examination and appropriate

laboratory tests exclude any other cause for the

chronic fatique

Additionally;

Impaired memory of concentration, sore throat,

tender cervical or axillary lymph nodes,muscle

pain, multijoint pain, new headaches and

unrefreshing sleep

Treatment

Tricyclic antidepresants ( i.e. amitriptyline, desipramine

1-3h before bedtime)

Cardiovasculer fitness training

Biofeedback

Hypnotherapy

Cognitive behavioral therapy

Educating patient

MYOFASCIAL PAIN SYNDROMES

Presence of trigger points, which include a

localized area of deep muscle tenderness,

located in a taut band in the muscle, and

a characteristic reference zone of the

perceived pain that is aggravated by the

palpation of the trigger point

Comparison of FM and MFS

Variable Fibromyalgia Myofascial pain

Examination Tender points Trigger points

Location Generalized Regional

Response to local therapy

Not sustained Curative

Sex Females vs Males

9:1

F vs M

3:1

Systemic features

characteristic ?

Treatment

Physical therapy

"Stretch and spray" technique: This treatment

involves spraying the muscle and trigger

point with a coolant and then slowly

stretching the muscle.

Massage therapy

Trigger point injection

Entrapment Neuropathies Results from incresed pressure on a nerve as it passes through an

enclosed space Knowledge of anatomy is essential for understanding of the clinical

manifestations of these syndromes

Splinting, NSAIDs and local corticosteroid injections usually suffice when symptoms are mild and of short time.

Surgical procedures to decompress the nerve are indicated in more severe cases

Thoracic Outlet Syndrome

Results from compression of one or more of the neurovasculer elements that pass through the superior thoracic aperture

Anatomic abnormalities and trauma to the shoulder girdle region play a far more pivotal role

Potential narrowing areas

Between the scalenius anterior and scalenius medius

Costoclavicular space

Under the pectoralis minor tendon

Signs and Symptoms

Paresthesias

Pain, radiating to the neck, shoulder and arm

Motor weakness

Atrophy of thenar, hypotenar and intrinsic

muscles of the hand

Vasomotor disturbances

Diagnosis Neurologic examination Certain clinical stress

tests (Adson and hyperabduction maneuvers)

A radiograph of cervicothoracic region (cervical rib, elongated transverse process of C7)

Treatment

Exercise designed to improve posture by

strengthening muscles

Avoidance of hyperabduction

Surgical intervention if; muscle wasting,

paresthesias replaced by continous sensory

loss, incapacitating pain,worsening of

circulatory impairment

Cubital Tunnel Syndrome Compression neuropathy of

the ulnar nerve as it

transverses the elbow

Causes are; history of a

trauma, chronic pressure by

occupational stress or from

unusual elbow positioning

Arthritic conditions that results

in synovitis and osteophyte

production

Signs and symptoms Paresthesias in the distribution

of the ulnar nerve

Aggrevated by prolonged use of

the elbow in flexed position

(+) Tinel’s sign

Atrophy of intrinsic muscles and

weakness in grasp

Wasting of the hypothenar

muscles and slight clawing of

the 4th and 5th fingers

Weakness in adduction of the

5th finger

Cubital Tunnel Syndrome

Diagnosis

Physical examination

(Tinel’s sign,

Wartenberg’s sign i.e.)

Radiographs

Electrodiagnosis

Treatment

Avoidance of prolonged elbow flexion

Local steroid injection along the ulnar groove

Surgical procedures to decompress the nerve

Ulnar Tunnel Syndrome

Entrapment of the ulnar nerve in

Guyon’s canal at the wrist (os

hamatum-os pisiform)

Compression is due to ganglia

Causes are; RA, OA

Chronic trauma due to

occupations

Signs and Symptoms

Combined sensory and motor deficits

Hypoesthesia in the hypothenar region and 4th and 5th fingers

Weakness of the intrinsic muscles of the hand

Diagnosis

Pyhsical examination Electrodiagnosis is helpful in determining the site of

the entrapmant

Treatment Avoidance of trauma Physical therapy Surgical decompression

Carpal Tunnel Syndrome Most common entrapment

neuroropathy

Compression of the median

nerve at the wrist

Causes are; occupation,

crystal-induced rheumatic

disorders

Complication of connective

tissue disorders

Uremia, metabolic and

endocrine diseases, infections,

pregnancy

Signs and Semptoms

Sensory loss in the radial three

finger and one-half of the ring

finger

Burning, pins-and-needles

sensations, numbness in the

fingers

Pain may radiate to the

antecubital region or to the

lateral shoulder area

Awaken at night by abnormal

sensation

(+)Tinel’s sign

(+) Phalen’s sign

Thenar atrophy

Diagnosis

History and physical examination

Radiographs

Electrodiagnosis

Treatment Splints

Local corticosteroid injection

NSAIDs Physical therapy

Surgery ; patients with progressive increases in distal motor latency times

Tarsal tunnel syndrome

Entrapment neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel beneath the flexor retinaculum on the medial side of the ankle

Tarsal tunnel syndrome …Etiology

Fracture or dislocation involving the talus

calcaneus,or medial malleolus

Rheumatoid arthritis

Tumors

Pronation related to the loss of the plantar

arch

Tarsal tunnel syndrome….Presentation

Burning or aching foot pain usually around

the plantar surface, distal foot, toes

May radiate up to the calf

Worse at night, when standing

Feels better when barefoot

Tarsal tunnel syndrome….diagnosis

Tinel test

Nerve is tapped with a

finger or reflex

hammer at the flexor

retinaculum posterior

and inferior to the

medial malleolus

Tarsal tunnel syndrome… Management

Conservative NSAIDs Arch support Orthoses to correct pronation Proper shoes (1 inch heel and cushioned sole) Avoid flat slippers

If symptoms persistent Local injections Decompression surgery