R H E U M A T I S M D I S O R D E R S A N D A L L E R G I E S SOFT TISSUE RHEUMATISM AND JOINT INJECTION TECHNIQUES FOR FAMILY PHYSICIANS Dr Humeira Badsha Non-articular musculoskeletal pain can arise as iatrogenic infection or tendon rupture, are rare. a result of tendinitis, bursitis, nerve entrapment Surgery may be required for patients who refuse syndromes,myofascial pain and fibromyalgia. infiltrations or in whom infiltrations fail. It is important to differentiate soft-tissue rheumatism from other causes of pain arising from DE QUERVAIN‘S TENOSYNOVITIS the joint. The location of pain and inflammation, Clinical appearance and presence of pain only on active range of motion This condition is characterized by disabling pain may help to differentiate a soft-tissue problem from in the radial aspect of the wrist at the base of the a joint problem. X-rays may be helpful by revealing thumb. There is swelling and tenderness of the joint problems although it must be pointed out common sheath of the abductor pollicis longus that soft tissue problems can be the cause of pain and extensor pollicis brevis. De Quervain’s and disability even when there is an underlying tenosynovitis is particularly common in two joint pathology. settings: in mothers who repeatedly lift infants and young children and in people who use their hands TRIGGER FINGER in repetitive activities, such as knitting, sewing, and Clinical appearance gardening. A positive Finkelstein’s test is A trigger finger is the locking of one or several characteristic of the condition. The correct way to fingers in flexion. The patient may have to pull perform this test is to position the hand in the the finger to straighten it. The cause is cartilaginous following manner: In the painful hand, (a) the fully metaplasia at the first retaining pulley (at the flexed thumb rests on the palm (b) the fingers are palmar aspect of the metacarpophalangeal joint) curled over the thumb and (c) the wrist is very which normally becomes taut during finger flexion. gently deviated to the ulnar side. Acute pain along When 3 or more digits are affected, conditions the tendon is diagnostic of de Quervain’s such as diabetes and hypothyroidism should be tenosynovitis. Additional findings can include a considered. diffusely swollen and tender sheath or loculated tenosynovial effusions near the radial styloid. Treatment Spontaneous improvement occurs only in 20% of Treatment cases. If untreated, the process can lead to an Corticosteroid infiltrations are very effective in de inability to straighten the finger and permanent Quervain’s tenosynovitis, although the success rate contracture. Trigger finger is treated with is slightly less than in trigger finger. Surgery is corticosteroid infiltrations. With appropriate indicated in the event of treatment failures. treatment, including up to 3 infiltrations, the success rate is over 95%. Complications, including GANGLIA Clinical appearance HUMEIRA BADSHA, MBBS, FAMS, FACR Ganglia are ubiquitous uni- or multilocular cystic Consultant, Department of Rheumatology, Allergy & lesions that arise in paratendinous, pararticular, or Immunology, Tan Tock Seng Hospital intraosseous locations. Ganglia can be confidently T H E S I N G A P O R E F A M I L Y P H Y S I C I A N A P R - J U N 2 0 0 2 ; V O L 2 8 ( 2 ) : 1 9 SOFT TISSUE RHEUMATISM AND JOINT INJECTION TECHNIQUES FOR FAMILY PHYSICIANS diagnosed in most cases on the basis of location, distal to the epicondyle, plus pain reproduction typical increase in size and symptoms caused by by resisted dorsiflexion of the wrist. Passive elbow joint use, and palpatory findings (cystic). flexion and extension are normal. Medial Aspiration, which must be made with a large-bore epicondylitis (golfer’s elbow) represents the mirror needle, yields a thick jelly-like material. image of lateral epicondylitis. Echography, computer tomography (CT) and Treatment magnetic resonance imaging (MRI) facilitate the Tennis elbow resolves spontaneously with time diagnosis of ganglia that occur in deep and atypical and rest of the affected arm. Patients should be locations. given isometric and range of motion exercises An imaging procedure should be performed for the entire upper extremity, including the whenever there is doubt about the diagnosis. shoulder, elbow, wrist, and fingers. Exercises Because of its low cost and excellent resolution, should not create prolonged (more than two echography is a useful imaging procedure to hours) post-exercise pain. In tennis players, investigate soft tissue lesions. alteration of technique and revision of Treatment equipment may be essential for good long-term Surprisingly, little research has been done on results. Medical therapy includes topical and ganglia. There are no published controlled trials systemic analgesics. Nonsteroidal anti- comparing different forms of treatment. inflammatory drugs (NSAIDs) can be used Aspiration followed by injection of a long-acting often, just prior to the offending exercise. corticosteroid is an appropriate treatment. Corticosteroid infiltrations are frequently used Technical details can be found in the in tennis elbow, and at least 50% of patients accompanying article. Surgery is generally find immediate relief. However, recurrence is required for lesions greater than 3 cm in seen in 30% of these patients. About 10% of diameter, for anterior wrist ganglia, and for patients have chronic symptoms despite medical intraosseous ganglia, as well as in cases where treatment, and repeated corticosteroid injections there is nerve compression. have been implicated in chronicity. Therefore, more than one injection is ill advised. TENNIS ELBOW SHOULDER PAIN Clinical appearance Particular emphasis should be placed on Tennis elbow, or lateral epicondylitis , is common determining whether paresthesias are present. in middle-aged people, most of whom are not The common shoulder pain syndromes include tennis players. Tennis elbow results from overuse rotator cuff tendinitis, subacromial of the extensor carpi radialis brevis, a muscle that impingement, frozen shoulder and acromial- spans the lateral epicondyle, and the base of the claricular joint disease. third metacarpal, a wrist dorsiflexor. The diagnosis is suggested by the lateral location of the pain, Rotator cuff tendinitis which characteristically affects the soft tissues just Inflammation of the common tendon of the T H E S I N G A P O R E F A M I L Y P H Y S I C I A N A P R - J U N 2 0 0 2 ; V O L 2 8 ( 2 ) : 2 0 SOFT TISSUE RHEUMATISM AND JOINT INJECTION TECHNIQUES FOR FAMILY PHYSICIANS subscapularis, supraspinatus, infraspinatus, and Differential diagnosis teres minor may result from microcrystalline The single feature that best assists in the diagnosis deposits (apatites), overuse, impingement on the of shoulder pain is its location. The pain may be tendon from above or below, or degenerative located at the top, side, front, back, or axillary sides changes that occur with aging. Specific shoulder of the joint. Lateral pain is characteristic of rotator motions are painful, particularly abduction when cuff or glenohumeral disease. Superior pain suggest combined with rotations. Range of passive motion acromial-claricular or sternoclavicular conditions. is typically normal. Calcific rotator cuff tendinitis Anterior pain may be caused by bicipital tendinitis occurs when a pre-existing calcium deposit and early frozen shoulder. Posterior pain can be undergoes resorption, resulting in acute caused by tears in labrum glenoidale and inflammation, extreme pain and loss of shoulder suprascapular neuropathy, and axillary pain of motion. various neural causes. An important maneuver in Subacromial impingement The rotator cuff tendon, which courses through a narrow space between the acromion and the proximal humerus, may be impinged upon from above or below. Increased tendon bulk acts as a tight-fitting wedge between the two bony boundaries. Impingement symptoms are largely due to the tendinitis. In some cases, there are also symptoms related to the condition that causes the impingement, such as tenderness at an osteoarthritic acromial-claricular joint. Frozen shoulder It is important to remember that acromial- claricular frozen shoulder may occur in diabetic fibrosis, paraneoplastic syndrome and occasionally Figure 1: The arc of elevation maneuver. Because the in scleroderma. Frozen shoulder should be greater tuberosity of the humerus has to clear under the distinguished from synovitis such as that seen in acromion/coracoacromial ligament during abduction, rheumatoid arthritis and ankylosing spondylitis, patients with subacromial impingement hurt during arc A. reduced motion caused by inactivity, rotator cuff Once the greater tuberosity has cleared, pain ceases in arc B. A similar phenomenon occurs as the arm is brought tendinitis, and posttraumatic and postsurgical down: no pain in arc B, pain in arc A, then no pain in full capsular retraction with limited joint motion. dependency. Because the acromioclavicular (AC) joint has Because the joint capsule encircles the joint, passive its greatest motion in terminal elevation, patients with AC and active shoulder motions are equally lost in all arthritis hurt in arc B. Finally, when the AC joint causes impingement, e.g., in osteoarthritis, there will be pain in directions. arc A from impingement, plus pain in arc B from stress on the diseased joint. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N A P R - J U N 2 0 0 2 ; V O L 2 8 ( 2 ) : 2 1 SOFT TISSUE RHEUMATISM AND JOINT INJECTION TECHNIQUES FOR FAMILY PHYSICIANS establishing the presence of rotator cuff tendinitis hip joint! To the presenting compliant “My hip and acromial-claricular joint arthropathy is the arc hurts,” ask “Where in the hip?” The patient may of elevation test (Figure 1). point to the anterior, the lateral, or the posterior aspect of the joint.