Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist

Soft Tissue Disorders Soft Tissue Disorders and Fibromyalgia and Fibromyalgia

Jaya Ravindran Consultant Rheumatologist

Introduction Introduction

DefinitionsDefinitions Approach to soft tissue disorders Approach to soft tissue disorders Overview of Overview of somesome soft tissue conditions: soft tissue conditions:

Flexor tenosynovitisFlexor tenosynovitis De Quervain’s De Quervain’s Carpal tunnelCarpal tunnel Golfer’s/Tennis elbowGolfer’s/Tennis elbow Rotator CuffRotator Cuff Trochanteric bursitis Trochanteric bursitis Achilles tendonitis Achilles tendonitis

Fibromyalgia Fibromyalgia

• WHAT ARE TENDONS, LIGAMENTS, WHAT ARE TENDONS, LIGAMENTS, ENTHESIS AND BURSA?ENTHESIS AND BURSA?

Definitions Definitions

LigamentLigament A band of tough connective tissue that connects bone to boneA band of tough connective tissue that connects bone to bone

TendonTendon a tough band of fibrous connective tissue that connects muscle a tough band of fibrous connective tissue that connects muscle

to boneto bone Enthesis Enthesis

the point at which a tendon inserts into bone, where the the point at which a tendon inserts into bone, where the collagen fibres are mineralised and integrated into bone tissuecollagen fibres are mineralised and integrated into bone tissue

Bursa Bursa a fluid filled sac located between a bone and tendon which a fluid filled sac located between a bone and tendon which

normally serves to reduce friction between the two moving normally serves to reduce friction between the two moving surfacessurfaces

• THOUGHT PROCESS/ISSUES IN SOFT THOUGHT PROCESS/ISSUES IN SOFT TISSUE DISORDERS? TISSUE DISORDERS?

Approach to soft tissue Approach to soft tissue disordersdisorders History and examination paramountHistory and examination paramount

Differentiate from inflammatory/mechanical arthropathyDifferentiate from inflammatory/mechanical arthropathy

Think about anatomy of area and mechanism of Think about anatomy of area and mechanism of injury/overuse to understand pathologyinjury/overuse to understand pathology

Work historyWork history

Precipitating activityPrecipitating activity

Approach to soft tissue Approach to soft tissue disordersdisorders Could it be referred pain eg C5/6 Neck pain Could it be referred pain eg C5/6 Neck pain

radiating to shoulder – ask about neurological radiating to shoulder – ask about neurological symptomssymptoms

May be associated with inflammatory arthritis eg RA May be associated with inflammatory arthritis eg RA or psoriatic arthritis or systemic illnessor psoriatic arthritis or systemic illness

Bloods not helpful in making diagnosisBloods not helpful in making diagnosis

Imaging - X-ray and ultrasound may play a role in Imaging - X-ray and ultrasound may play a role in certain soft-tissue disorderscertain soft-tissue disorders

• JOINT vs PERIARTICULAR?JOINT vs PERIARTICULAR?

Is it an articular or extra-articular Is it an articular or extra-articular problem?problem?

• ARTICULARARTICULAR PERI-ARTICULARPERI-ARTICULAR

• pain all planespain all planes pain in plane of tendonpain in plane of tendon

• active = passiveactive = passive active > passiveactive > passive

• capsular swelling/effusion capsular swelling/effusion linear swellinglinear swelling

• joint line tenderness joint line tenderness localised tendernesslocalised tenderness

• diffuse erythema/heatdiffuse erythema/heat localised erythema/heatlocalised erythema/heat

ManagementManagement

RestRest Simple analgesiaSimple analgesia NSAIDsNSAIDs Local steroid injectionLocal steroid injection Physiotherapy/Occupational therapy Physiotherapy/Occupational therapy Surgery in certain cases e.g. carpal tunnelSurgery in certain cases e.g. carpal tunnel

•Features of flexor tenosynovitis ?Features of flexor tenosynovitis ?

Flexor tenosynovitis Flexor tenosynovitis

Inflammation of flexor tendon sheathsInflammation of flexor tendon sheaths Pain and stiffness in flexor finger/thumb, may Pain and stiffness in flexor finger/thumb, may

extend to wristextend to wrist Reduced active flexion, crepitus, thickened Reduced active flexion, crepitus, thickened

tender tendon sheathstender tendon sheaths May be associated with nodule – “trigger May be associated with nodule – “trigger

finger”finger” Can be associated with RA, DiabetesCan be associated with RA, Diabetes Treatment – injection hydrocortisone, surgery Treatment – injection hydrocortisone, surgery

•Features of De Quervains?Features of De Quervains?

De Quervain’s (tenosynovitis) De Quervain’s (tenosynovitis) Inflammation of tendon sheath containing Inflammation of tendon sheath containing

extensor pollicis brevis and abductor extensor pollicis brevis and abductor pollicis longus tendonspollicis longus tendons

De Quervain’s (tenosynovitis) De Quervain’s (tenosynovitis) Pain, swelling radial wristPain, swelling radial wrist Localised tenderness, crepitus, pain worse Localised tenderness, crepitus, pain worse

over radial styloidover radial styloid Finkelstein’s testFinkelstein’s test

De Quervain’s (tenosynovitis) De Quervain’s (tenosynovitis) Finkelstein Finkelstein

With the thumb flexed across the palm of the hand, ask the With the thumb flexed across the palm of the hand, ask the patient to move the wrist into flexion and ulnar deviation.patient to move the wrist into flexion and ulnar deviation.

Positive if reproduces pain Positive if reproduces pain

De Quervain’s (tenosynovitis) De Quervain’s (tenosynovitis) ManagementManagement

Rest from precipitating activityRest from precipitating activity SplintageSplintage Steroid injectionSteroid injection surgery surgery

•Features and causes of carpal Features and causes of carpal tunnel syndrome?tunnel syndrome?

Carpal tunnel syndrome Carpal tunnel syndrome

Compression of median nerve as it passes Compression of median nerve as it passes through carpal tunnel through carpal tunnel

Carpal tunnel syndrome Carpal tunnel syndrome

Common, F>M, elderly/middle agedCommon, F>M, elderly/middle aged Mostly idiopathicMostly idiopathic Associated with (particularly if bilateral):Associated with (particularly if bilateral):

DiabetesDiabetes HypothyroidismHypothyroidism RARA PregnancyPregnancy AcromegalyAcromegaly VasculitisVasculitis TraumaTrauma Others (e.g. amyloid, sarcoid)Others (e.g. amyloid, sarcoid)

Carpal tunnel syndrome - Carpal tunnel syndrome - anatomy anatomy Median nerve supplies:Median nerve supplies:

Motor (beyond carpal tunnel in hand)Motor (beyond carpal tunnel in hand) L L lateral two lumbricals lateral two lumbricals OO opponens pollicisopponens pollicis A A abductor pollicis brevis abductor pollicis brevis F F flexor pollicis brevisflexor pollicis brevis

SensorySensory Palmar surface thumb, lateral 2 ½ digitsPalmar surface thumb, lateral 2 ½ digits

Carpal tunnel syndromeCarpal tunnel syndrome

Clinical features Clinical features Numbness/parasthesia in median nerve distributionNumbness/parasthesia in median nerve distribution Pain, can radiate up armPain, can radiate up arm Worse at nightWorse at night ‘‘Hang hand over end of bed’Hang hand over end of bed’ Weakness of thumb (abduction)Weakness of thumb (abduction) Thenar wastingThenar wasting Positive Tinel’s/Phalen’s Positive Tinel’s/Phalen’s


Tinel’s Phalen’s


InvestigationInvestigation Nerve conduction studies show reduce nerve Nerve conduction studies show reduce nerve

conduction velocities across wristconduction velocities across wrist

ManagementManagement Avoidance of precipitating activityAvoidance of precipitating activity Night time splints Night time splints Local steroid injectionLocal steroid injection Surgery – division of flexor retinaculum and Surgery – division of flexor retinaculum and

decompression of carpal tunnel (80% success)decompression of carpal tunnel (80% success)

•Features of epicondylitis ?Features of epicondylitis ?

Tennis & Golfer’s ElbowTennis & Golfer’s Elbow

Both enthesopathiesBoth enthesopathies Tennis elbow = lateral epicondylitis = inflammation common extensor Tennis elbow = lateral epicondylitis = inflammation common extensor

originorigin Golfer’s elbow = medial epicondylitis = inflammation common flexor origin Golfer’s elbow = medial epicondylitis = inflammation common flexor origin Tennis elbow more common than Golfer’s Tennis elbow more common than Golfer’s


Pain localised to specific areaPain localised to specific area Elbow flexion/extension does not cause painElbow flexion/extension does not cause pain Pain upon:Pain upon:

resisted wrist extension (Tennis)resisted wrist extension (Tennis) resisted wrist flexion (Golfer’s) resisted wrist flexion (Golfer’s)


ManagementManagement Rest from precipitating activityRest from precipitating activity Elbow claspsElbow clasps Local corticosteroid injectionLocal corticosteroid injection Physiotherapy – ultrasound and acupuncturePhysiotherapy – ultrasound and acupuncture Surgery (often ineffective) Surgery (often ineffective)

•Rotator cuff disease features?Rotator cuff disease features?

Rotator Cuff PathologyRotator Cuff Pathology

A range of various conditions, including: A range of various conditions, including: Supraspinatous tendinitis/ruptureSupraspinatous tendinitis/rupture Rotator cuff tearRotator cuff tear Adhesive capsultitis (frozen shoulder)Adhesive capsultitis (frozen shoulder) Acute calcific supraspinatous tendonitisAcute calcific supraspinatous tendonitis Subacromial bursitisSubacromial bursitis Acromioclavicular joint OA Acromioclavicular joint OA

Overlap in clinical features but distinct entities Overlap in clinical features but distinct entities

Rotator Cuff – anatomy Rotator Cuff – anatomy

A sheath of conjoint tendons to support A sheath of conjoint tendons to support glenohumeral joint, made up of: glenohumeral joint, made up of: S S supraspinatous - abductionsupraspinatous - abduction II infraspinatous – external rotationinfraspinatous – external rotation T T teres minor – external rotationteres minor – external rotation S S subscapularis – internal rotationsubscapularis – internal rotation

Rotator Cuff SyndromeRotator Cuff Syndrome

Spectrum from mild supraspinatus tendinitis Spectrum from mild supraspinatus tendinitis to complete tendon ruptureto complete tendon rupture

Chronic impingement of cuff under acromial Chronic impingement of cuff under acromial archarch

Pain often over acromial area extending into Pain often over acromial area extending into deltoiddeltoid

Rotator Cuff SyndromeRotator Cuff Syndrome Painful mid arc Painful mid arc Impingement test – Impingement test –

abducted, flexed and abducted, flexed and internally rotated internally rotated

Supraspinatus stressSupraspinatus stress

Rotator cuff investigation - Rotator cuff investigation - ultrasoundultrasound

• Full thickness tearFull thickness tear

Rotator Cuff SyndromeRotator Cuff Syndrome

ManagementManagement Rest, NSAIDsRest, NSAIDs Local steroid injection around tendon – Local steroid injection around tendon –

subacromial space and PTsubacromial space and PT If chronic/rupture refer to Orthopaedics for If chronic/rupture refer to Orthopaedics for

surgical opinion surgical opinion

Acute calcific supraspinatus Acute calcific supraspinatus tendinitistendinitis

Young adults, F>M, acute pain Young adults, F>M, acute pain over several hoursover several hours

Normally resolves over few days Normally resolves over few days TreatmentTreatment

Minor – NSAIDMinor – NSAID Moderate – consider steroid Moderate – consider steroid

injectioninjection Severe – consider aspirating Severe – consider aspirating

calcified material calcified material

Calcium hydroxyapatite deposition near Calcium hydroxyapatite deposition near supraspinatus enthesis supraspinatus enthesis

Adhesive capsulitis (Frozen Adhesive capsulitis (Frozen shoulder)shoulder)

Progressive pain and stiffnessProgressive pain and stiffness Global reduction in movement, but Global reduction in movement, but

particularly external rotationparticularly external rotation Three phasesThree phases

Pain (3-5 months)Pain (3-5 months) Adhesive phase (4-12 months)Adhesive phase (4-12 months) Recovery phase (12-42 months)Recovery phase (12-42 months)

Adhesive capsulitis (Frozen Adhesive capsulitis (Frozen shoulder)shoulder)

Associated with diabetesAssociated with diabetes Most patients recover by 30 months, but still Most patients recover by 30 months, but still

have reduced movements have reduced movements ManagementManagement

Analgesia, NSAIDs, Physiotherapy, steroid injectionAnalgesia, NSAIDs, Physiotherapy, steroid injection Surgical opinion in difficult cases (manipulation Surgical opinion in difficult cases (manipulation

under anaesthesia)under anaesthesia)

•ACJ disease features ?ACJ disease features ?

Acromioclavicular OAAcromioclavicular OA

• High arc painHigh arc pain

• Local tendernessLocal tenderness

• Adduction painfulAdduction painful

• Impingement Impingement

•Trochanteric bursitis features?Trochanteric bursitis features?

Trochanteric bursitis Trochanteric bursitis

Inflammation of the Inflammation of the superficial and deep bursa superficial and deep bursa that separates the gluteus that separates the gluteus muscles from the posterior muscles from the posterior and lateral side of the and lateral side of the greater trochanter of the greater trochanter of the femurfemur


Boring pain over lateral aspect of hipBoring pain over lateral aspect of hip May radiate down lateral thighMay radiate down lateral thigh Worse on walking or lying in bed at nightWorse on walking or lying in bed at night Localised tenderness upon pressure over Localised tenderness upon pressure over

greater trochanter greater trochanter


ManagementManagement RestRest AnalgesiaAnalgesia Steroid injection Steroid injection Physio Physio

Achilles tendonitis Achilles tendonitis

Inflammation of the achilles Inflammation of the achilles tendontendon

Sometimes at enthesisSometimes at enthesis Sometimes in middle Sometimes in middle

avascular portion of tendonavascular portion of tendon Can be seen with Can be seen with

seronegativesseronegatives


Chronic tendonitis can lead to Achilles Chronic tendonitis can lead to Achilles tendon rupturetendon rupture

Aetiology of tendonitis though to be Aetiology of tendonitis though to be avascular degeneration of tendon avascular degeneration of tendon

Tenosynovitis does not lead to ruptureTenosynovitis does not lead to rupture Also can get acute traumatic rupture Also can get acute traumatic rupture All have localised pain and swelling of All have localised pain and swelling of

Achilles tendon, with difficulty walkingAchilles tendon, with difficulty walking


Investigation - ultrasoundInvestigation - ultrasound ManagementManagement

Rest, NSAIDs, physiotherapyRest, NSAIDs, physiotherapy Local steroid injection under U/S Local steroid injection under U/S

guidance into paratenon can help guidance into paratenon can help tenosynovitis – if no evidence of tear tenosynovitis – if no evidence of tear

Achilles rupture Achilles rupture

Acute rupture – sudden calf pain as if Acute rupture – sudden calf pain as if being hit on back of legbeing hit on back of leg

Palpable gap in tendon Palpable gap in tendon Some but little plantarflexion Some but little plantarflexion Squeeze calf whilst prone - no Squeeze calf whilst prone - no

plantarflexion in affected leg plantarflexion in affected leg (Simmond’s)(Simmond’s)

Management Management Surgery to repair tendonSurgery to repair tendon Conservative – below knee cast in ankle Conservative – below knee cast in ankle

equinus 6 weeks equinus 6 weeks

•Fibromyalgia features ?Fibromyalgia features ?

Fibromyalgia Fibromyalgia

• ““All over pain”All over pain”

• FatigueFatigue

• Sleep disturbanceSleep disturbance

• DepressionDepression

• AnxietyAnxiety

• Irritable bowelIrritable bowel

• Tender spotsTender spots

• Diagnosis of exclusionDiagnosis of exclusion

Prevalence/Risk FactorsPrevalence/Risk Factors

CommonCommon Approx 2-5% depending upon definitionApprox 2-5% depending upon definition Female (F:M ratio between 3:1 and 7:1)Female (F:M ratio between 3:1 and 7:1) Middle age (typically 30-60)Middle age (typically 30-60)

Differential diagnosisDifferential diagnosis

Other conditions can mimic fibromyalgia:Other conditions can mimic fibromyalgia: Systemic lupus erythematosus (SLE)Systemic lupus erythematosus (SLE) HypothyroidismHypothyroidism Polymyalgia rheumaticaPolymyalgia rheumatica Malignancy Malignancy Myopathy Myopathy Metabolic bone diseaseMetabolic bone disease

ManagementManagement

Patient educationPatient education About conditionAbout condition Reassure that no serious pathologyReassure that no serious pathology No harm in exercising No harm in exercising

Cognitive behavioural therapy (CBT)Cognitive behavioural therapy (CBT) Low dose amitriptyline Low dose amitriptyline Graded aerobic exercise regime Graded aerobic exercise regime

THANK-YOU THANK-YOU

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Soft Tissue Disorders and Fibromyalgia Jaya Ravindran Consultant Rheumatologist