Soft Tissue Disorders and Fibromyalgia: Jaya Ravindran Consultant Rheumatologist

Soft Tissue Disorders and
Fibromyalgia
Jaya Ravindran
Consultant Rheumatologist
Introduction
 Definitions
 Approach to soft tissue disorders
 Overview of some soft tissue conditions:
 Flexor tenosynovitis
 De Quervain’s
 Carpal tunnel
 Golfer’s/Tennis elbow
 Rotator Cuff
 Trochanteric bursitis
 Achilles tendonitis
 Fibromyalgia
• WHAT ARE TENDONS, LIGAMENTS, ENTHESIS
AND BURSA?
Definitions
 Ligament
 A band of tough connective tissue that connects bone to bone
 Tendon
 a tough band of fibrous connective tissue that connects muscle to bone
 Enthesis
 the point at which a tendon inserts into bone, where the collagen fibres
are mineralised and integrated into bone tissue
 Bursa
 a fluid filled sac located between a bone and tendon which normally
serves to reduce friction between the two moving surfaces
• THOUGHT PROCESS/ISSUES IN SOFT TISSUE
DISORDERS?
Approach to soft tissue disorders
 History and examination paramount
 Differentiate from inflammatory/mechanical arthropathy
 Think about anatomy of area and mechanism of injury/overuse

to understand pathology
 Work history
 Precipitating activity
Approach to soft tissue disorders
 Could it be referred pain eg C5/6 Neck pain radiating
to shoulder – ask about neurological symptoms
 May be associated with inflammatory arthritis eg RA or

psoriatic arthritis or systemic illness
 Bloods not helpful in making diagnosis

 Imaging - X-ray and ultrasound may play a role in
certain soft-tissue disorders
• JOINT vs PERIARTICULAR?
Is it an articular or extra-articular
problem?
• ARTICULAR PERI-ARTICULAR
• pain all planes pain in plane of tendon

• active = passive active > passive
• capsular swelling/effusion linear swelling
• joint line tenderness localised tenderness
• diffuse erythema/heat localised erythema/heat
Management
 Rest
 Simple analgesia
 NSAIDs
 Local steroid injection
 Physiotherapy/Occupational therapy
 Surgery in certain cases e.g. carpal tunnel
• Features of flexor tenosynovitis ?
Flexor tenosynovitis
 Inflammation of flexor tendon sheaths
 Pain and stiffness in flexor finger/thumb, may
extend to wrist
 Reduced active flexion, crepitus, thickened
tender tendon sheaths
 May be associated with nodule – “trigger finger”
 Can be associated with RA, Diabetes
 Treatment – injection hydrocortisone, surgery
• Features of De Quervains?
De Quervain’s (tenosynovitis)
 Inflammation of tendon sheath containing
extensor pollicis brevis and abductor pollicis
longus tendons
 Pain, swelling radial wrist
 Localised tenderness, crepitus, pain worse over
radial styloid
 Finkelstein’s test
 Finkelstein
 With the thumb flexed across the palm of the hand, ask the
patient to move the wrist into flexion and ulnar deviation.
 Positive if reproduces pain
 Management
 Rest from precipitating activity
 Splintage
 Steroid injection
 surgery
• Features and causes of carpal
tunnel syndrome?
Carpal tunnel syndrome
 Compression of median nerve as it passes
through carpal tunnel
 Common, F>M, elderly/middle aged
 Mostly idiopathic
 Associated with (particularly if bilateral):
 Diabetes
 Hypothyroidism
 RA
 Pregnancy
 Acromegaly
 Vasculitis
 Trauma
 Others (e.g. amyloid, sarcoid)
Carpal tunnel syndrome -
anatomy
 Median nerve supplies:
 Motor (beyond carpal tunnel in hand)
 L lateral two lumbricals
 O opponens pollicis
 A abductor pollicis brevis
 F flexor pollicis brevis
 Sensory
 Palmar surface thumb, lateral 2 ½ digits
 Clinical features
 Numbness/parasthesia in median nerve distribution
 Pain, can radiate up arm
 Worse at night
 ‘Hang hand over end of bed’
 Weakness of thumb (abduction)
 Thenar wasting
 Positive Tinel’s/Phalen’s
Tinel’s Phalen’s
 Investigation
 Nerve conduction studies show reduce nerve conduction
velocities across wrist
 Management
 Avoidance of precipitating activity
 Night time splints
 Local steroid injection
 Surgery – division of flexor retinaculum and decompression
of carpal tunnel (80% success)
• Features of epicondylitis ?
Tennis & Golfer’s Elbow
 Both enthesopathies
 Tennis elbow = lateral epicondylitis = inflammation common extensor origin
 Golfer’s elbow = medial epicondylitis = inflammation common flexor origin
 Tennis elbow more common than Golfer’s
 Pain localised to specific area
 Elbow flexion/extension does not cause pain
 Pain upon:
 resisted wrist extension (Tennis)
 resisted wrist flexion (Golfer’s)
 Management
 Rest from precipitating activity
 Elbow clasps
 Local corticosteroid injection
 Physiotherapy – ultrasound and acupuncture
 Surgery (often ineffective)
• Rotator cuff disease features?
Rotator Cuff Pathology
 A range of various conditions, including:
 Supraspinatous tendinitis/rupture
 Rotator cuff tear
 Adhesive capsultitis (frozen shoulder)
 Acute calcific supraspinatous tendonitis
 Subacromial bursitis
 Acromioclavicular joint OA
 Overlap in clinical features but distinct entities
Rotator Cuff – anatomy
 A sheath of conjoint tendons to support

glenohumeral joint, made up of:
 S supraspinatous - abduction
 I infraspinatous – external rotation
 T teres minor – external rotation
 S subscapularis – internal rotation
Rotator Cuff Syndrome
 Spectrum from mild supraspinatus tendinitis to

complete tendon rupture
 Chronic impingement of cuff under acromial arch
 Pain often over acromial area extending into deltoid
 Painful mid arc
 Impingement test –
abducted, flexed and
internally rotated
 Supraspinatus stress
Rotator cuff investigation - ultrasound
• Full thickness tear

 Management
 Rest, NSAIDs
 Local steroid injection around tendon – subacromial
space and PT
 If chronic/rupture refer to Orthopaedics for surgical
opinion
Acute calcific supraspinatus
tendinitis
 Calcium hydroxyapatite deposition near supraspinatus
enthesis
 Young adults, F>M, acute pain

over several hours
 Normally resolves over few days
 Treatment
 Minor – NSAID
 Moderate – consider steroid injection
 Severe – consider aspirating calcified
material
Adhesive capsulitis (Frozen
shoulder)
 Progressive pain and stiffness
 Global reduction in movement, but particularly
external rotation
 Three phases
 Pain (3-5 months)
 Adhesive phase (4-12 months)
 Recovery phase (12-42 months)
Adhesive capsulitis (Frozen
shoulder)
 Associated with diabetes
 Most patients recover by 30 months, but still have
reduced movements
 Management
 Analgesia, NSAIDs, Physiotherapy, steroid injection
 Surgical opinion in difficult cases (manipulation under
anaesthesia)
• ACJ disease features ?
Acromioclavicular OA
• High arc pain
• Local tenderness
• Adduction painful
• Impingement
• Trochanteric bursitis features?
Trochanteric bursitis
 Inflammation of the superficial
and deep bursa that separates
the gluteus muscles from the
posterior and lateral side of the
greater trochanter of the femur
 Boring pain over lateral aspect of hip
 May radiate down lateral thigh
 Worse on walking or lying in bed at night
 Localised tenderness upon pressure over
greater trochanter
 Management
 Rest
 Analgesia
 Steroid injection
 Physio
Achilles tendonitis
 Inflammation of the achilles
tendon
 Sometimes at enthesis
 Sometimes in middle avascular
portion of tendon
 Can be seen with seronegatives
Achilles tendonitis
 Chronic tendonitis can lead to Achilles
tendon rupture
 Aetiology of tendonitis though to be
avascular degeneration of tendon
 Tenosynovitis does not lead to rupture
 Also can get acute traumatic rupture
 All have localised pain and swelling of
Achilles tendon, with difficulty walking
Achilles tendonitis
 Investigation - ultrasound
 Management
 Rest, NSAIDs, physiotherapy
 Local steroid injection under U/S guidance
into paratenon can help tenosynovitis – if no
evidence of tear
Achilles rupture
 Acute rupture – sudden calf pain as if being
hit on back of leg
 Palpable gap in tendon
 Some but little plantarflexion
 Squeeze calf whilst prone - no plantarflexion
in affected leg (Simmond’s)
 Management
 Surgery to repair tendon
 Conservative – below knee cast in ankle equinus 6
weeks
• Fibromyalgia features ?
Fibromyalgia
• “All over pain”
• Fatigue
• Sleep disturbance
• Depression
• Anxiety
• Irritable bowel
• Tender spots
• Diagnosis of exclusion
Prevalence/Risk Factors
 Common
 Approx 2-5% depending upon definition
 Female (F:M ratio between 3:1 and 7:1)
 Middle age (typically 30-60)
Differential diagnosis
 Other conditions can mimic fibromyalgia:

 Systemic lupus erythematosus (SLE)
 Hypothyroidism
 Polymyalgia rheumatica
 Malignancy
 Myopathy
 Metabolic bone disease
Management
 Patient education
 About condition
 Reassure that no serious pathology
 No harm in exercising
 Cognitive behavioural therapy (CBT)
 Low dose amitriptyline
 Graded aerobic exercise regime
THANK-YOU

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What are tendons, ligaments, enthesis and bursa and what are their functions?

What is the thought process in evaluating soft tissue disorders?

Soft Tissue Disorders and

 Differentiate from inflammatory/mechanical arthropathy

 Think about anatomy of area and mechanism of injury/overuse

 May be associated with inflammatory arthritis eg RA or

 Bloods not helpful in making diagnosis

• pain all planes pain in plane of tendon

 A sheath of conjoint tendons to support

 Spectrum from mild supraspinatus tendinitis to

• Full thickness tear

 Young adults, F>M, acute pain

 Other conditions can mimic fibromyalgia:

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