Other Miscellaneous Joint Diseases

Ankylosing spondylitis

AS Prevalence 0.1-0.2% M>F Late teens to age 40 More common in whites than in nonwhites HLA-B27 positivity Chronic progressive disease and develop disability due to spinal inflammation leading to fusion, often with thoracic kyphosis or erosive disease Worse during first 10 years Begins at sacroiliac joints

Symptoms Morning stiffness and fatigue Fever and weight loss Radiation of pain into both buttocks Criteria for diagnosis: Morning stiffness that lasts more than 30 minutes Improvement of back pain with exercise but not rest Nocturnal back pain during second half of the night only Alternating buttock pain Achilles tendonitis, Plantar fascitis

Signs: Stooped posture and a stiff back Loss of lumbar lordosis – straight back Schober test confirms-marking a 10-cm length of the lumbar spine (with patient in the erect position), starting at the fifth lumbar spinous process. Instruct the patient to maximally flex his or her spine. Remeasure the distance between the marks. Normal flexion increases the distance by at least 5 cm. Loss of chest expansion (<3-cm difference between minimum and maximum chest diameter) late stage of disease Eyes can be involved Aortic valvular leak can happen

Tests

Therapy NSAIDs TNF alpha Steroids Methotrexate Monitor with ESR, CRP

Physical therapy Exercise program and postural training Spinal extension and deep-breathing exercises Maintaining an erect posture during daily activities Sleeping on a firm mattress with a thin pillow also tend to reduce the tendency toward thoracic kyphosis. Water therapy and swimming

Myofascial Pain Syndrome

?Myofascial trigger points (MTrPs). 200 paired muscles Any one of these muscles can develop myofascial trigger points (MTrPs).  MTrPs are hyperirritable tender spots in palpable tense bands of skeletal muscle that refer pain and motor dysfunction, often to another location.

Major clinical components: The TrP The taut band The local twitch response

Latent TrPs Cause motor dysfunction: Stiffness, Restricted range of motion without pain

Active TrPs Most common: postural muscles- of the neck, shoulder, and pelvic girdles and the masticatory muscles Others: upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum muscles

Features of myofascial pain: Results in palpable nodules and the taut bands associated with TrPs. TrP triggers: Acute overload, overwork fatigue, direct impact trauma, and radiculopathy Patients with active MTrPs usually complain of poorly localized, regional, aching pain in subcutaneous tissues, including muscles and joints. They rarely complain of sharp, clearly localized cutaneous-type pain.

Disturbances of autonomic functions - abnormal sweating, persistent lacrimation, persistent runny nose, excessive salivation, and pilomotor activities Proprioceptive disturbances- imbalance, dizziness, tinnitus, and distorted perception of the weight of lifted objects

Loss of motor functions: Spasm of other muscles, weakness of the involved muscle function, loss of coordination by the involved muscle, and decreased work tolerance of the involved muscle.

Taut band By gently rubbing across the direction of the muscle fibers in a superficial muscle, the examiner can feel a nodule at the MTrP and a ropelike induration that extends from this nodule to the attachment of the taut muscle fibers at each end of the muscle The taut band can be snapped or rolled under the finger in accessible muscles. With effective inactivation of the TrP, this palpable sign becomes less tense and often (but not always) disappears, sometimes immediately

Tender nodule Palpation along the taut band reveals a nodule exhibiting a highly localized and exquisitely tender spot that is characteristic of a MTrP.

Local twitch response: Snapping palpation of the TrP frequently evokes a transient twitch response of the taut band fibers. Twitch responses can be elicited both from active and latent TrPs.

Diferential Diagnosis Feature Myofascial Pain (TrPs) Fibromyalgia Female-to-male ratio 1:1 4-9:1 Pain Local or regional Widespread, general Tenderness Focal Widespread Muscle Feels tense (taut bands) Feels soft and doughy Motion Restricted range of motion Hypermobility Examination Examine for TrPs Examine for tender points FeatureMyofascial Pain (TrPs)FibromyalgiaFemale-to-male ratio1:14-9:1PainLocal or regionalWidespread, generalTendernessFocalWidespreadMuscleFeels tense (taut bands)Feels soft and doughyMotionRestricted range of motionHypermobilityExaminationExamine for TrPsExamine for tender points

REACTIVE ARHTRITIS Triad of- Nongonococcal urethritis, Conjunctivitis, and Arthritis Preceded by bloody dysentery

Associated with: Gastrointestinal infections- Shigella Salmonella and Campylobacter species and Genitourinary infections (especially with Chlamydia trachomatis). Usually develops 2-6 weeks after infection

Prognosis: A self-limited course, with resolution of symptoms by 3-12 months Has a high tendency to recur HLA-B27 positivity M:F 9:1 Age: 20-40 years

Symptoms/Signs: Malaise, fever, prostatitis, epidydimitis Low-back pain, heel pain Achilles or plantar fascia inflammation Small joints of the hands and feet – sausage shaped digits Palm and soles skin exfloiation and pustules Penile foreskin inflammation Symptomatic treatment

TM joint disease

TMJ function: Movements- side to side, up and down, as well as protrusion and retrusion. This allows movements needed for speaking, chewing, and making facial expressions.

Causes for TMJ disease: Rheumatoid arthritis, osteoarthritis Other causes- hypermobile TMJs, nocturnal jaw clenching, nocturnal bruxism, jaw clenching due to psychosocial stresses, and local trauma Trigeminal neuralgia of mandibular division Incidence: 10 million people have TMJ F:M ratio is roughly 4:1 Common in adults aged 20-40 years

Symptoms Muscles of mastication: dull ache, unilateral Pain radiates to the ear and jaw and is worsened with chewing When opening the mouth locking of the jaw Ear clicking or popping Headache and/or neck ache A bite that feels uncomfortable Neck, shoulder, and back pain Bruxism, teeth clenching

Signs Limitation of jaw opening (normal range is at least 40 mm as measured from lower to upper anterior teeth) Palpable spasm of facial muscles (masseter and internal pterygoid muscles) Unilateral facial swelling Clicking or popping in the TMJ Tenderness to palpation of the TMJ via the external auditory meatus (the tips of the fingers placed behind the tragi at each external acoustic meatus and pulled forward while the patient opens the jaw) Crepitus over joint (in advanced disease) Lateral deviation of mandible

Tests Non specific Treatment: Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs) Muscle relaxants - Benzodiazepines Moist heat and massage of masticatory muscles