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Regional Rheumatism

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Title: Regional Rheumatism


1
Regional Rheumatism
  • Andres Quiceno, MD
  • Rheumatology Division PHD
  • Clinical Assistant Professor of Medicine UTSW

2
Regional Rheumatism
  • These conditions are among the most poorly taught
    subjects in medical school.
  • Even in the orthopedic and rheumatology programs.
  • These ailments are extremely common in medical
    practice.
  • The medical conditions included here are
    tenosynovitis, bursitis, fasciitis, enthesopathy
    and compression neuropathy.

3
Regional Rheumatism
  • Approximately 33 of United States adults have a
    musculoskeletal complaint.
  • In patients over 65, musculoskeletal symptoms are
    the most common complaint reported and the most
    common cause of functional limitation.
  • Musculoskeletal and rheumatological conditions
    are frequently chronic and have a significant
    social and economical cost.

4
Regional Rheumatism
  • IMPINGEMENT SYNDROME
  • Chronic shoulder pain is the most common upper
    extremity problem in recreational, competitive
    and elite athletes.
  • This problem is more common in throwing athletes,
    racquet sports, volleyball, gymnasts and
    swimmers.
  • This kind of athletes need full, unrestricted
    upper extremity function to perform in their
    sport.
  • Even mild degree of pain and dysfunction can
    result in complete disability for their
    respective sports.

5
Regional Rheumatism
  • The glenohumeral joint represents the
    articulation of the humerus and glenoid fossa.
  • It is the most mobile joint in the body.
  • The joint is stabilized by multiple ligaments and
    muscles including the rotator cuff.
  • The rotator cuff comprises four muscles and their
    tendons the subscapularis, the supraspinatus,
    the infraspinatus and the teres minor.
  • The most commonly affected tendon is the
    supraspinatus.

6
Regional Rheumatism
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Regional Rheumatism
8
Regional Rheumatism
  • Problems of the rotator cuff involve many tendon
    abnormalities.
  • The most common cause full-thickness rotator cuff
    tears are chronic and most likely represent the
    final pathway of chronic subacromial pathology.
  • Other conditions in the spectrum of this syndrome
    includes rotator cuff tendinitis, subacromial
    bursitis and partial rotator cuff tears.

9
Regional Rheumatism
  • The earliest stage of rotator cuff pathology is
    rotator cuff tendinitis, this is a condition of
    athletes in their 20s and 30s.
  • There are many hypothesis for this tendinopathy.
  • These includes mechanical impingement of the
    coracoacromial arch onto the supraspinatus tendon
    with the arm abducted or forward-flexed position.
  • This position is part of the throwing motion in
    overhead throwers such us baseball pitchers and
    quarterbacks.

10
Regional Rheumatism
  • Impingement also affects the subacromial bursa.
  • Weakness or imbalance in the rotator cuff is
    associated with increase risk of subacromial
    pathology.
  • Clinical Manifestations
  • A relative gradual onset of symptoms associated
    with activity and that increase with overhead
    activities.
  • Pain can be diffuse and difficult to localize.
  • Often they refer the pain to the deltoid muscle
    area.

11
Regional Rheumatism
  • Patients with acromioclavicular pathology usually
    are able to point directly to this joint.
  • Limitation in the passive range of motion suggest
    adhesive capsulitis.
  • Patients with rotator cuff impingement avoid
    abduction
  • Abduction is more painful between 70 and 120
    degrees.
  • Imaging
  • Plain radiographs are usually no needed.
  • MRI can reveal many details of this pathology.

12
Regional Rheumatism
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Regional Rheumatism
  • Treatment
  • Activity modification or even completely avoiding
    the impingement position.
  • A physical therapy program that focuses in
    flexibility and strength of the rotator cuff is
    recommended.
  • NSAID are often used but is not clear if they are
    effective.
  • Conservative approach is keep for 2 to 3 months.
  • Other options include subacromial corticosteroid
    injection.
  • If no improvement in 4 to 6 months of
    conservative therapy consider surgery.
  • Arthroscopic treatment has similar results to
    open surgery with less complications.
  • Success rate is between 70 to 80.

14
Regional Rheumatism
15
Regional Rheumatism
  • Elbow Region
  • The elbow is formed by three articulations the
    humerus with the radius, the humerus with the
    ulna and the radius with the ulna.
  • The ulnar nerve passes medial to the olecranon
    process and behind the medial epicondyle in the
    cubital tunnel.
  • Lateral epicondyle is the site of origin of the
    wrist extensor-supinator muscle group.
  • The medial epicondyle is the site of origin of
    the wrist flexor-pronator.
  • Pathology includes chronic degenerative changes
    of the tendons.

16
Regional Rheumatism
  • Lateral epicondylitis or tennis elbow, is a
    syndrome of pain in the wrist extensor muscles.
  • Clinically the patient presents with discomfort
    if the lateral elbow.
  • Point of tenderness is at the epicondyle or
    slightly distal, pain at resisted wrist extension
    is suggestive of the diagnosis.
  • Risk factors include high hand force with
    repetitive use, repetitive rotation of the
    forearm and forceful gripping with wrist
    extension.

17
Regional Rheumatism
18
Regional Rheumatism
  • Treatment
  • This disorder may be slow to improve.
  • Initial therapy includes rest, splinting, ice and
    heat application.
  • Anti-inflammatories or pain medications could be
    helpful.
  • Steroid injection is consider when conservative
    treatment fails.
  • Injections are relatively safe and give relief
    for two to six weeks.
  • Steroid injection is not recommended in medial
    epicondylitis.

19
Regional Rheumatism
  • Olecranon Bursitis
  • Commonly occurs after repetitive trauma to the
    elbow.
  • Other etiologies include rheumatoid arthritis
    and crystalloid arthritis.
  • Aspiration of the bursa can be performed to
    relief discomfort.
  • If symptoms recur Steroid injection can be done.
  • This bursa is a common site of infection
    frequently caused by Staphylococcus aureus.

20
Regional Rheumatism
  • DE Quervain's Disease
  • This is the name given to the tenosynovitis to
    the extensor tendons of the thumb.
  • The most clinical manifestation is pain over the
    styloid process.
  • Swelling and warmth over the radial wrist is
    common.
  • A positive Finkelstein test is the classic
    diagnostic maneuver.
  • Differential diagnosis include osteoarthritis and
    Ulnar nerve compression at the wrist.

21
Regional Rheumatism
  • Risk factors include assembly line work, small
    goods manufacturing, meat and poultry processing,
    textile production and computer use.
  • Treatment includes rest with a thumb in a
    spica-splint, NSDAIDS and physical therapy.
  • Steroid injection is an option after conservative
    treatment.
  • If symptoms persist changes in the work place
    could be necessary.

22
Regional Rheumatism
23
Regional Rheumatism
24
Regional Rheumatism
  • Trigger Finger
  • Trigger finger is caused by swelling of the
    flexor tendon or narrowing of the tendon pulley
    superficial to the MCP joint.
  • Trigger finger manifests with pain or crepitus in
    the flexor sheath and impaired finger flexion
    with triggering or locking.
  • Pain over the MCP joint is a classic feature.
  • Risk factors include pressure over hard objects,
    such us tool handles and repeated movements.
  • Often is seen middle age women and can be
    associated with endocrinologic or rheumatoid
    diseases.

25
Regional Rheumatism
26
Regional Rheumatism
  • Hip pain involves a wide differential diagnosis.
  • The anatomy of this region is complex.
  • The hip is ball-and-socket joint.
  • The bone structures that conform this area
    include acetabulum, femoral head, ischium, ilium
    and pubis.
  • A large number of muscles enable the hip to move
    in a wide range of motion.
  • Flexion is performed by the iliopsoas and
    quadriceps, extension by the hamstring.
  • The nerves that more commonly cause pain are the
    Sciatic and the femoral cutaneus.

27
Regional Rheumatism
  • The age of the patient suggest different
    diagnostic possibilities.
  • Younger patients are more prone to apophyseal
    injuries.
  • Avulsion fractures are more common in skeletally
    immature patients.
  • Bursitis and muscle strains are more common in
    skeletally mature patients and DJD is more common
    in older adults.

28
Regional Rheumatism
  • Physical examination is similar for all groups of
    age.
  • Observation includes determining whether the
    affected leg can bear weight. Observe the patient
    posture and evaluate height symmetry of the iliac
    crests.
  • Palpation can help localize vague complains to an
    specific structure.
  • Range of motion is dependent of patients age,
    with range decreasing with age.
  • Some specific tests such us the Trendelenburgs
    and Obers are helpful to diagnose specific
    pathologies.

29
Regional Rheumatism
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Regional Rheumatism
31
Regional Rheumatism
  • Radiology is not as helpful as is in ankle or
    knee pain.
  • Radiographs anteroposterior and frog leg lateral
    hip are recommended in all acutely injured
    patients, patients with marked reduced range of
    motion, point tenderness at the site of muscular
    insertion and inability to bear weight.
  • Plain films are helpful in the diagnosis of
    slipped capital femoral epiphysis,
    Legg-Calve-Perthes, dysplasia and apophyseal
    injuries.

32
Regional Rheumatism
  • Ultrasound is limited in the evaluation of the
    adult hip, but can be helpful in the evaluation
    of the intraarticular effusions and soft tissue
    swelling.
  • In pediatric patients could be helpful in the
    diagnosis of hip subluxation.
  • CT scan provides an excellent detail of the
    osseus structures, can define fractures and
    intraarticular loose bodies.
  • Bone scan is sensitive for stress fractures but
    lacks specificity.
  • MRI is helpful defining soft tissue inflammation,
    synovitis, neoplasm, infection and stress
    fractures.

33
Regional Rheumatism
  • Age-Specific Hip Problems
  • Prepubescent
  • Transient synovitis is the most common cause of
    hip pain in children.
  • Legg-Calve-Perthes is an inflammatory disease of
    the femoral head, with a male-female ratio of 5
    to 1, peak incidence is between four to eight
    year old.

34
Regional Rheumatism
  • Adolescence
  • Slipped femoral epiphysis is another age specific
    entity. It is most common in kids 11 to 14 year
    old. Obesity and male sex increase the risk.
  • This disease increase the risk of avascular
    necrosis of the femoral head or ostearthritis in
    the adults.
  • This entity requires early referral to and
    orthopedic surgeon because this disease benefits
    from surgical pinning of the slipped bone.

35
Regional Rheumatism
  • Young Adult
  • Young adults have the longest list of possible
    diagnoses. Because the practice of high intensity
    sports, avulsion fractures, femoral neck stress
    fractures, iliotibial band syndrome are more
    common in this group of age.
  • The most critical diagnosis to make early is
    stress fracture.
  • Females are in higher risk such us endurance
    athletes.
  • This fractures can progress to unstable fractures
    and increase the risk for avascular necrosis.

36
Regional Rheumatism
  • Older Adult
  • The most common cause of pain is DJD.
  • Other causes is trochanteric bursitis.

37
Regional Rheumatism
  • Patellar tendinopathy
  • The quadriceps tendon connects the rectus
    femoris, the vastus intermedius and the vastus
    lateralis to the patella.
  • The tendon inserts in the proximal pole of the
    patella and continues distally as the Galea
    aponeurotica to merge with the patella tendon.
  • The tendon of the inferior pole of the patella to
    the tibial tuberosity is a 30 thinner than the
    quadriceps tendon and is most susceptible to
    overuse injury.

38
Regional Rheumatism
39
Regional Rheumatism
  • The pathophysiology of patellar tendinopathy
    shows mucoid degeneration of the tendon.
  • At light microscopy the tendon show abnormal
    collagen, tenocytes and abnormal blood vessels
    ingrowth.
  • A major feature is the absence of inflammation,
    for this reason some authors call this finding as
    tendinosis instead of tendinitis.
  • This suggest that this condition is more a
    degenerative condition.

40
Regional Rheumatism
  • Patellar tendinoapthy is more often located in
    the lower pole of the patella.
  • The cause is repeated overloads on the extensor
    mechanism.
  • It is more common in that requires maximal
    muscle-tendon unit exertion such us jumping.
  • Pain is elicited by activity, pain when sitting
    for long periods and going up and down stairs.
  • The most common physical finding is tenderness
    and in chronic cases swelling.
  • MRI and US are the modalities of choice to
    evaluate patellar disorders.

41
Regional Rheumatism
  • Conservative management includes correction of
    the predisposing factors, stretching and
    strengthening, physical therapy, NSDAID and
    steroid injection.
  • Surgery is indicated in patients that not improve
    after three to six months of conservative
    therapy.
  • Iliotibial band
  • Iliotibial band friction syndrome results of
    excessive friction between the band and lateral
    femoral condyle.

42
Regional Rheumatism
  • The iliotibial band originates proximally from
    the confluence of the fascia from the tensor
    fascia lata, the gluteus maximus and gluteus
    medius.
  • At the knee the iliotibial band attaches to the
    patella, crosses the knee and attach in the
    Gerdys tubercle and lateral to the tibial
    tubercle.
  • The pathogenesis of this condition is attributed
    to the friction of the deep layer of the band and
    the lateral femoral epicondyle.
  • Clinically presents with pain or burning over the
    lateral aspect of the knee.

43
Regional Rheumatism
  • Activities such as distance running or running
    downhill aggravate the symptoms.
  • Physical examination reveals tenderness over the
    lateral femoral epicondyle, greater with knee at
    30 degrees of flexion.
  • Obers test indicates tightness of iliotibial
    band.
  • In ITB syndrome, there should be no knee
    effusion, instability or positive McMurray test.
  • MRI confirms the diagnosis in patients considered
    for surgery.
  • Majority of the patients improve with
    conservative management, if symptoms persist for
    more than six months, surgery should be
    considered.

44
Regional Rheumatism
45
Regional Rheumatism
  • Conditions of the Achilles tendon
  • The Achilles tendon is the largest tendon in the
    body.
  • Its limited blood supply and the combination of
    forces which is subjected increase the risk of
    injury.
  • Achilles tendinosis occurs in 10 of the runners,
    but is also common in dancers, gymnasts and
    tennis players.

46
Regional Rheumatism
  • Injury typically occurs in active persons.
  • The typical symptoms is pain or tenderness
    proximal or at the insertion of the calcaneus.
  • Peritendinitis, inflammation of the tendon
    sheath, causes localized tenderness and burning
    about 2 to 6 cm above the tendon insertion.
  • At exam the patient should lying prone, feet
    hanging out of the examination table.
  • Palpation often elicits pain.
  • Thompson test the physician squeezed the calf and
    watches for plantar flexion.

47
Regional Rheumatism
  • In patient with tendinosis the treatment should
    be conservative using ice, rest and NSAIDS.
  • Control of the biomechanical factors and a slow
    gentle warm-up before exercise and icing after
    exercise help patients that want to continue
    athletic training.
  • In patients with Achilles tendon rupture, the
    treatment is controversial.
  • The main treatment is surgery plus immobilization
    or immobilization alone.
  • The trend in younger patients is surgery and
    immobilization in the elderly patient.

48
Regional Rheumatism
49
References
  • Tallia, Alfred and Dennis Cardone. Diagnostic
    and Therapeutic Injection of the Shoulder Region.
    American Family Physician. Volume 67, Number 6,
    March 15, 2003
  • Almekinders, Louis. Impingement Syndrome.
    Clinics is Sport Medicine. Volume 20, Number 3,
    July 2001.
  • Cardone, Dennis and Alfred Tallia. Diagnostic and
    Therapeutic Injection of the Elbow Region.
    American Family Physician. Volume 66, Number 11,
    December 1, 2002.

50
References
  • Mani, Lisa and Fredric Gerr. Work Related Upper
    Extremity Musculoskeletal Disorders. Primary
    Care Clinics in Office Practice. Volume 27,
    Number 4, December 2000.
  • Adkins, Samuel and Richard Figler. American
    Family Physician. Volume 61, Number 7, April 1,
    2000.
  • Scopp, Jason and Claude Moorman. The Assessment
    of Athletic Hip Injury. Clinics in Sports
    Medicine. Volume 20, Number 4, October 2001.

51
References
  • Cardone, Dennis and Alfred Tallia. Diagnostic
    and Therapeutic Injection of the Hip and Knee.
  • American Family Physician. Volume 67, Number 10,
    May 15, 2000.
  • Mazzone, Michael and Timothy MC Cue. Common
    Conditions of the Achilles Tendon. American
    Family Physician. Volume 65, Number 9, May 1,
    2002.
  • Canoso, Juan. Regional Rheumatic Diseases.
    Rheumatology in Primary Care. W.B Saunders
    Company, 1997.

52
References
  • Cush, John and Arthur Kavanaugh. Rheumatology
    Diagnosis and Therapeutics. Lippincott Williams
    Wilkins, 2000.
  • Canoso, Juan and Simon Carette. Rheumatology
    Second Edition. Mosby, 1998.
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