Regional Periarticular Pain

REGIONAL PERIARTICULAR PAIN

DR SAMI SALMAN, FRCP, MRCP, DMR, CES, MB,ChB
PROFESSOR OF MEDICINE & RHEUMATOLOGY

Objectives

By the end of this lecture, the student will be able to:
Describe briefly the pathophysiology of Regional Periacticular painful conditions.
List the common causes, clinical features and how to diagnose the common Painful periarticular conditions.
Have a good idea as to how each condition can be managed.
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SINGLE REGIONAL PAIN

Over-usage strain or injury affecting a periarticular structure
The pain is non-progressive and reproduced by just one or a few movements
Localised periarticular tenderness
Pain may be reproduced by resisted active movement
Predisposing factors include increasing age, obesity, generalised hypermobility, occupational and recreational usage.



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Rotator cuff lesion

Pain reproduced by resisted active movement
Abduction-supraspinatus
External rotation-infraspinatus, teres minor
Internal rotation-subscapularis

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Subacromial bursitis

No pain on resisted active abduction (cf. supraspinatus lesion-the other cause of a painful middle arc)

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Bicipital (long head) tendinitis

Tenderness over bicipital groove
Pain reproduced by resisted active wrist supination or elbow flexion

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Adhesive capsulitis ('frozen shoulder')

Glenohumeral restriction
Early phase; marked anterior joint/capsular tenderness
Late phase; painless restriction of all movements.

Common in diabetics, rotator cuff lesion, local trauma, myocardial infarction or hemiplegia.
Treatment in the early stage is with analgesics, intra- and extracapsular corticosteroid injection and regular 'pendulum' exercises
Slow but complete recovery, the complete cycle sometimes taking as long as 2 years.
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'Tennis elbow'
Lateral epicondyle pain radiating to extensor forearm
Tender over epicondyle
Pain reproduced by resisted active wrist extension

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'Golfer's elbow'

Medial epicondyle pain radiating to flexor forearm
Tender over medial epicondyle
Pain reproduced by resisted active wrist flexion

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Olecranon bursitis

Olecranon pain
Fluctuant tender swelling over olecranon
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Hand and wrist pain

median nerve compression (carpal tunnel syndrome)
Tinel sign and Phalen sign
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Trigger finger

Stenosing tenosynovitis in the flexor tendon sheath, with intermittent locking of the finger in flexion.
A local corticosteroid injection often relieves the problem
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De Quervain's tenosynovitis

Inflamed tendon sheaths of abductor pollicis longus and extensor pollicis brevis
Pain over the radial aspect of the wrist.
Tenderness (with or without warmth, linear swelling and fine crepitus)
Pain on forced ulnar deviation of the wrist with the thumb held in the patient's palm (Finkelstein's sign).
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Dupuytren's contracture

Fibrosis and contracture of the superficial palmar fascia.
Inability to extend the fingers fully
Puckering of the skin and palpable nodules.
The ring and little fingers first and worst affected.
Painless

Age-related, bilateral, predominates in men, and is often familial with a dominant inheritance.
Alcohol misuse, chronic vibration injury.
Slowly progressive and fasciotomy is seldom necessary.
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Trochanteric bursitis
Older, especially obese, women,
Occurring either in isolation or secondary to an abnormal gait, e.g. in hip or knee OA.
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Gluteal enthesopathy

Upper lateral thigh, worse on lying on that side at night
Tenderness over greater trochanter
Pain reproduced by resisted active hip abduction

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Adductor tendinitis

Upper inner thighUsually sports-related
Tender over adductor origin/tendon/muscle
Pain reproduced by resisted active hip adduction

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Ischiogluteal bursitis

Buttock, worse on sitting

Tender over ischial prominence

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Iliopectineal bursitis

Anterior groin
Tender (± fluctuant swelling) lateral to femoral pulse

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A common problem, especially in adolescent girls.

There is evidence of fibrillation of the retro-patellar cartilage
Usually self-limiting and treatment should be conservative.

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Chondromalacia patellae

Pre-patellar bursitis

Anterior patella pain
Tender fluctuant swelling in front of patella

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Superficial and deep infrapatellar bursitis

Anterior knee, inferior to patella
Tender fluctuant swelling in front of (superficial) or behind (deep) patella tendon


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Anserine bursitis

Upper medial tibia
Tenderness (± warmth, swelling) over upper medial tibia

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Popliteal ('Baker's) cyst

Popliteal fossa pain
Tender swelling of popliteal fossa, usually reducible by massage with knee in mid-flexion


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Patella tendon enthesopathy(Osgood-Schlatter disease)

Anterior upper tibiaMainly energetic adolescents
Tenderness and firm swelling of tibial tuberclePain on resisted active knee extension

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Anterior tibial compartment syndrome

Severe pain in the front of the lower leg, aggravated by exercise and relieved by rest.
Symptoms result from fascial compression of the muscles in the anterior tibial compartment and may be associated with foot drop.
Treatment is urgent surgical decompression.


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Pes planus

Often congenital
Acquired causes: trauma, hypermobility, RA and neuropathic.
Treatment; medial arch supports in well-fitting shoes and/or intrinsic muscle-strengthening exercises
Rigid orthotics for hyperpronated feet when the foot is not rigid from fusion of the tarsal bones (tarsal coalition).
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Pes cavus ('claw foot')
High medial arch, secondary clawing of toes and metatarsal callosities.
Rarely, it associates with neurological disorders such as Friedreich's ataxia, spina bifida or poliomyelitis.
Pain is often helped by medial arch supports and metatarsal insoles, and fasciotomy or osteotomy is rarely indicated.

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Plantar fasciitis

Pain under heel, worse on standing and walking
Tender under distal calcaneus/ plantar fascia insertion site

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Achilles tendinitis

Localised pain to tendon
Tender on squeezing tendon, ± swelling of tendon
Pain reproduced by standing on toes or resisted plantar flexion

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Retro-Achilles bursitis

Posterior heel pain
Tenderness and soft swelling posterior to tendon

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Hallux valgus

Deformity with secondary bursitis (bunions) and OA of the first MTP
It predominates in women as a consequence of wearing narrow high-heeled shoes.
Severe restriction of first MTP joint extension (hallux rigidus), usually due to OA, may cause marked pain
Conservative treatment and appropriate footwear usually suffice, although surgery is required for a minority.
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MULTIPLE REGIONAL PAIN

Fibromyalgia
Seronegative spondarthritis
Generalised hypermobility
Endocrine disease; Hyperparathyroidism, hypothyroidism and Addison's disease
Parkinsonism
Polymyalgia rheumatica and polymyositis
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Messages to take home
Listen to the patients… 80% of diagnoses can be made on listening.
Don’t dictate symptoms or signs to the patients.
Know the prognosis!
Never lie at the patients!
Assurance can be the only treatment needed.
Beware of MRI reports!
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Thank you for listening
DR SAMI SALMAN, FRCP, MRCP, DMR, CES, MB,ChB
PROFESSOR OF MEDICINE & RHEUMATOLOGY

Email: ssshihab2@gmail.com

Personal Website: http://www.samisalman.comyr.com

Arab rheumatologists listing: http://www.romatezmeyat.com