SOFT TISSUE RHEUMATISM Upper Exterimity Mohsen Akhiani M.D.

Soft Tissue Rheumatism shoulder Region Rotator Cuff Tendinitis Rotator Cuff Tear Bicipital tendinitis Adhesive Capsulitis

Soft Tissue Rheumatism Shoulder pain Periarthritis (80%) Glenohumeral joint (1%) Refferal pain (15%)

Soft Tissue Rheumatism Rotator Cuff Muscle

Soft Tissue Rheumatism Rotator Cuff Tendinitis Epidemiology: F>M, middle and old ages Most common cause of shoulder pain Etiology: overused, overhead activity, degeneration, osteophyte, athletic injury, inflammatory arthritis Clinical manifestation: painful arch (60-120), acute calcific (younger patients), chronic (middle or old age), night pain, pain and tenderness in abduction and internal rotation, impingement sign and test Treatment: rest, physical therapy, pendullar exercise, NSAIDs, steroid injection

Soft Tissue rheumatism Impingement Of Rotator Cuff

Soft Tissue Rheumatism Painful Arc

Soft Tissue Rheumatism Calcific Tendinitis

Soft Tissue Rheumatism Injection of Subacromion Bursa

Soft Tissue Rheumatism Rotator Cuff Tear Epidemiology: F>M, middle and old ages Etiology: trauma, fracture or dislocation of shoulder joint, degeneration, rotator cuff tendinitis Clinical manifestation: pain and weakness on abduction, drop arm sign Diagnosis: X-Ray, ultrasound, arthrography; MRI Treatment: acute tearing in young patients (surgery), steroid injection (after 6 weeks in acute form), physical therapy

Soft Tissue Rheumatism MRI Of Complete-Cuff Tear

Soft Tissue Rheumatism Shoulder Arthrogram (Rotator Cuff)

Soft Tissue Rheumatism Bicipital Tendon

Soft Tissue Rheumatism Bicipital Tendinitis Etiology: sport injury, special activity Clinical manifestation: acute or chronic pain on anterior of shoulder, tenderness on palpation of bicipital groove, associated with Rotator cuff tendinitis Diagnosis: yergason’s sign, speed test, pope eye sign (tendon rupture) Treatment: rest, physical therapy, NSAIDs, steroid injection, surgery

Soft Tissue Rheumatism Yergason’s Sign And Speed Test

Soft Tissue Rheumatism Adhesive Capsulitis (1) Epidemiology: age>40 years, F>M Etiology: any type of shoulder problem, immobility, diabetes, CVA, anti tuberculosis and convulsive drugs, any chronic disease Clinical manifestation: generalized pain and tenderness, sever loss of active and passive motion in all plane

Soft Tissue Rheumatism Adhesive Capsulitis (2) Diagnosis: underlying disease (FBS), X-Ray MRI, arthrography (loss of joint cavity space) Treatment: NSAIDs, steroid (local injection or systemic), physical therapy (pendulum exercise, wall climbing), manipulation under anesthesia in refractory cases

Soft Tissue Rheumatism Elbow Region Lateral epicondylitis Medial Epicondylitis Olecranon bursitis Ulnar nerve entrapment

Soft Tissue Rheumatism Lateral Epicondylitis Epidemiology: ages (35-50), F=M Etiology: inflammation of common extensor tendon, tennis player, gardening, Clinical manifestation: pain in lateral epicondyle, radiation to forearm, weakness on grasping, differentiation with radial nerve entrapment Diagnosis: pain on resisted wrist extension, X-Ray (calcification, exostosis) Treatment: NSAIDs, physical therapy, steroid injection, surgery (>6 months),

Soft Tissue Rheumatism Muscle Insertions Around The Elbow Joint

Soft Tissue Rheumatism Resisted Wrist Extension Test

Soft Tissue Rheumatism Medial Epicondylitis Epidemiology: ages: 30-50 years, M/F=2/1 Etiology: inflammation of common flexor tendon Clinical manifestation: local pain and tenderness radiation to forearm, weakness On grasping, pain on resisted wrist flexion, differentiation with ulnar nerve entrapment (50%), calcification in X-Ray (20%) Treatment: alteration of activities, NSAIDs, steroid injection, surgery (>6 months)

Soft Tissue Rheumatism Resisted Wrist Flexion Test

Soft Tissue Rheumatism Olecranon Bursitis Etiology: low grade chronic trauma (student, miner, hemodialysis), inflammatory arthritis, septic Clinical manifestation: pain and tenderness is minimal , clear or blood tinged fluid in aspiration Treatment: avoid special habit, fluid aspiration and steroid injection, antibiotic in septic bursitis, surgery in refractory cases

Soft Tissue Rheumatism Ulnar Nerve Entrapment Etiology: occupation, trauma, prolonged bed rest, fracture, inflammatory arthritis Clinical manifestation: numbness and paresthesi of little finger and adjacent side of fourth digits, tenderness of ulnar nerve groove, decreased sense and motor power of little finger, tinel’s sign Diagnosis: NCV Treatment: avoiding pressure on elbow and repetitive elbow flexion, surgery

Soft Tissue Rheumatism Ulnar Nerve Entrapment

Soft Tissue Rheumatism wrist And Hand Region Carpal tunnel syndrome De quervain’s tenosynovitis Trigger finger Ganglion Dupuytren’s contracture

Soft Tissue Rheumatism Anatomy Of Carpal Tunnel

Soft Tissue Rheumatism Carpal Tunnel Syndrome (1) Epidemiology: F/M=5/1, symptomatic CTS (3% F, 2% M), peak age (30-60) Etiology: Inflammatory disease (RA, SLE, PSS), crystal arthropathy, job trauma, local (osteophyte, tumors), metabolic (DM 6%, myxedema, acromegaly), infection (tuberculosis, fungal, rubella), pregnancy, idiopathic Clinical manifestation: nocturnal symptom (sensitivity 51-77%, specificity 27-68%), flick sign (sensitivity and specificity 90%)

Soft Tissue Rheumatism Sensory Supply To The Hand

Soft Tissue Rheumatism Carpal Tunnel Syndrome (2) loss of two point discrimination (highly specific, low sensitivity), weakness and atrophy in chronic cases, Phalen’s maneuver (40-80% sensitivity and specificity), Tinel’s sign (sensitivity 25-60%, specificity 68-87%), tourniquet test Diagnosis: physical examination, EMG-NCV Treatment: treating associated conditions, splinting, NSAID’s, steroid (local injection or systemic), diuretic,vitamin B6, surgery (sever symptom>1 year, atrophy

Soft Tissue Rheumatism Tinel’s Sign And Phalen’s Test

Soft Tissue Rheumatism Thenar Muscle Atrophy

Soft Tissue Rheumatism Carpal Tunnel Syndrome (Local Injection)

Soft Tissue Rheumatism De Quervain’s Tenosynovitis Epidemiology: age>40, F>M Etiology: repetitive activity with thumb pinching and moving wrist, inflammation of tendon sheath (abductor pollicis longus and extensor pollicis brevis) Clinical manifestation: pain and tenderness, swelling over the radial styloid, Finkelstein test Treatment: rest, physical therapy, NSAID’s, local steroid injection, surgery in refractory cases

Soft Tissue Rheumatism De Quervain’s Tenosynovitis

Soft Tissue Rheumatism Finkelstein Test

Soft Tissue Rheumatism Flexor Tendon Sheaths Of The Hand

Soft Tissue Rheumatism Dupuytren’s Contracture Epidemiology: F/M 1/5, white man Etiology: shortening and thickening of palmar fascia, hereditary, alcoholism, epilepsy, DM, any chronic disease Clinical manifestation: dimpling or puckering of skin palmar fascia, flexion contracture of one or more digits, in decreasing order (5th 3th, 2th fingers) Treatment: physical therapy, steroid injection, colchicin, vitamin E, surgery

Soft Tissue Rheumatism Dupuytren’s Contracture

Soft Tissue Rheumatism Volar Flexor Tenosynovitis (Trigger Fingers) Etiology: inflammation of tendon sheaths of flexor digitorum, trauma, inflammatory disease (RA, psoriatic arthritis, crystal arthropathy, overused, osteoarthritis Clinical manifestation: painful finger flexion (middle and index fingers), swelling, tenderness and nodule proximal to MCP joint in the volar side, treatment: rest, physical therapy, NSAID’s, steroid injection, surgery

Soft Tissue Rheumatism Ganglion Epidemiology: ages 20-40, F=M Etiology: cystic swelling arising from a joint or tendon sheath, trauma, prolonged wrist extension Clinical manifestation: swelling and discomfort on wrist extension Treatment: splint, rest, physical therapy, NSAID’s, steroid injection, surgery

Soft Tissue Syndrome Costochondritis-teitze’s syndrome Epidemiology: costochondritis (age >40, F>M), tietz’s syndrome (age <40, M=F) Pain and tenderness without swelling over more than one costochondral junction (costochondritis), with swelling in second and third costal cartilage (tietz’s syndrom) Etiology: trauma, sever cough, mechanical stress, spondyloarthropathy Differential diagnosis: cardiac pain, fibromyalgia Treatment: NSAID’s, steroid injection

SOFT TISSUE RHEUMATISM LOWER EXTREMITY Mohsen Akhiani M.D.

Soft Tissue Rheumatism Hip Region Trochantric bursitis Iliopsoas bursitis Ischial bursitis Meralgia paresthetica Piriformis syndrome

Soft Tissue Rheumatism The Bursa Of The Hip Joint

Soft Tissue Rheumatism Trochantric Bursitis Epidemiology: age 30-70, F>M Etiology: local trauma, osteoarthritis of hip and lumbar spine, scoliosis, leg-length discrepancy, inflammatory conditions Clinical manifestation: pain on moving and lying on the involved side, pain in external rotation and abduction against resistance, calcification in X-Ray Treatment: NSAID’s, strengthening of gluteus medius muscles, steroid injection

Soft Tissue Rheumatism Iliopsoas Bursitis Etiology: trauma, inflammatory conditions, septic, communication with hip joint (15%) Clinical manifestation: groin and anterior thigh pain, exacerbation of pain with hyperextension of hip, cystic mass (30%), femoral venous obstruction Diagnosis: X-Ray with contrast media, MRI Treatment: NSAID’s, physical therapy, steroid injection, surgery

Soft Tissue Rheumatism CT Scan Of Iliopsoas Bursitis

Soft Tissue Rheumatism Ischial Bursitis Etiology: trauma, prolonged sitting on hard surface, weaver’s bottom Clinical Manifestation: radiation of pain to back of the thigh, local tenderness Treatment: modified activity, cushion’s, NSAID’s, steroid injection with caution

Soft Tissue Rheumatism Meralgia Paresthetica Etiology: obesity, pregnancy, diabetes, direct trauma, compression from corset, leg-length discrepancy Clinical manifestation: hyperesthesia and numbness of anterolateral thigh,exacerbation of pain with ,extension and abduction of thigh, prolonged standing and walking, Decreased touch and pinprik sensation Diagnosis: NCV Treatment: weight loss, steroid injection (medial to anterior superior iliac spine

Soft Tissue Rheumatism Meralgia Paresthetica

Soft Tissue Rheumatism Piriformis Syndrome Etiology: trauma, abnormal piriformis muscle Clinical manifestation: F>M, pain over buttocks with radiation to down and back of thigh (similar to siatica), tenderness of piriformis muscle on rectal or vaginal examination, pain on internal rotation of hip against resistance Treatment: NSAID’s, local injection of lidocaine and steroid (carefully)

Soft Tissue Rheumatism Piriformis Syndrome

Soft Tissue Rheumatism knee Region Popliteal cyst Prepatellar and infrapatellar bursitis Anserine bursitis Patellar tendinitis Osgood-schalatter’s disease Pellegrini-stiedia syndrom

Soft Tissue Rheumatism Popliteal Cyst (Baker’s Cyst) Etiology: any knee disease with synovial effusion (mechanical and inflammatory), naturally occurring communication between knee joint and semimembranosus-gastrocnemius bursa (40%) Clinical manifestation: diffuse swelling and pain of calf, erythema and edema of ankle (ceresent sign), mimiking thrombophlebitis Diagnosis: ultrasound, arthrography, MRI Treatment: rest, aspiration and steroid injection, surgery

Soft Tissue Syndrome Prepatellar and Infrapatellar Bursitis Etiology: trauma, frequent kneeling (housemaid’s knee), inflammatory (gout, septic) Clinical manifestation: pain, tenderness, swelling, hotness and redness (septic) Treatment: aspiration and culture, steroid injection, modified activity

Soft Tissue Rheumatism Bursa Around The Knee Joint

Soft Tissue Rheumatism Anserine Bursitis Epidemiology: age 30-50, F>M Etiology: inflammation of pes anserinus (goose foot) include, tendons of gracilis, sartorius, semitendinosus,osteoarthritis of knee, obese and long leg Clinical manifestation: pain and tenderness over the medial aspect of the knee (2 inch below the joint margin Treatment: rest, stretching of adductor and quadriceps muscles, NSAID’s, steroid injection

Soft tissue Rheumatism Patellar Tendinitis (Jumper’s Knee) Etiology: repetitive running, jumping Clinical manifestation: local pain and tenderness Treatment: stretching and strengthening of quadriceps and hamstring muscles, knee bracing, rest, avid steroid injection, NSAID’s

Soft Tissue Rheumatism Osgood-Schlatter’s Disease Etiology: traction apophysitis of tibial tuberosity, overuse Clinical manifestation: age (10-14), localized pain, tenderness and swelling Diagnosis: characteristic fragmentation of tibial tubercle in lateral X-Ray Treatment: rest, remission with fusion of tibial tuberosity

Soft Tissue Rheumatism Osgood-Schlatter’s Disease

Soft Tissue Rheumatism Pellegrini-Stiedia Syndrome Etiology:trauma, calcification of medial collateral ligament Clinical manifestation:men,asymptomatic period, later symptom of medial knee pain and progressive restriction of knee movement Diagnosis: calcification in X-Ray Treatment: pain is self limited, improvement usually within several months

Soft Tissue Rheumatism Pellegrini-Stiedia Syndrome

Soft Tissue Rheumatism Ankle And Foot Region Retrocalcaneal bursitis Subcutaneous achilles bursitis Achilles tendinitis Achilles tendon rupture Plantar fasciitis Tarsal tunnel syndrome Halux valgus and bunion Morton’s neuroma Pes planus Pes cavus

Soft Tissue Rheumatism Retrocalcaneal Bursitis Etiology: inflammation of the bursa between the posterior surface of the achille tendon and the calcaneous, trauma, inflammatory arthritis (especially spondyloarthropathy) Clinical manifestation: pain on dorsiflexion, tenderness, local swelling and bulging Diagnosis: physical diagnosis, MRI, ultrasound Treatment: rest, splint, NSAID’s, steroid injection (attention to achille tendon)

Soft Tissue Rheumatism Bursa Around the Foot

Soft Tissue Rheumatism Subcutaneous Achilles Bursitis Etiology: pressure of shoes, bony exostoses; sondyloarthropathy Clinical manifestation: pain, swelling and redness Treatment: relief from shoe pressure, treatment of underlying disease

Soft Tissue Rheumatism Achilles tendinitis Etiology: trauma, athletic injury, fitting shoes, inflammatory conditions (especially spondyloarthropathy) Clinical manifestation: pain on dorsiflexion, swelling, crepitus on motion Diagnosis: MRI, ultrasound Treatment: rest, splint (slight plantar flexion), NSAID’s, steroid injection (risk of tendon rupture)

Soft Tissue Rheumatism Achilles Tendon Rupture Etiology: athletic trauma (jumping, falling), achilles tendinitis, steroid injection Clinical manifestation: sudden onset of pain during forced dorsiflexion, swelling and edema, audible snap Diagnosis: thompson test, MRI, ultrasound Treatment: immobilization (cast), surgery (young patient)

Soft Tissue Rheumatism Plantar Fascia

Soft Tissue Rheumatism Plantar Fasciitis Etiology: athletic over activity, prolonged walking, improper shoes, spondyloarthropathy Clinical manifestation: pain (morning upon arising, initial improvement, worsen later in the day), burning, aching, tenderness on palpation of medial calcaneal tubercle Diagnosis: rest, heel pad, NSAID’s, orthoses, steroid injection

Soft Tissue Rheumatism Plantar Fasciitis

Soft Tissue Rheumatism Tarsal Tunnel Syndrome Etiology: compression of posterior tibial nerve at or near flexor retinaculum, trauma, fracture, valgus deformity, hypermobility, inflammatory arthritis Clinical manifestation: numbness, burning pain, paresthesia of the toes and sole, nocturnal exacerbation Diagnosis: tinel’s sign, loss of pinprick, NCV Treatment: shoe correction, steroid injection, surgery

Soft Tissue Syndrome The Tarsal Tunnel

Soft Tissue Rheumatism Hallux Valgus-Bunion Etiology: deviation of the large toe, genetic tendency, improper shoes, inflammatory arthritis, osteoarthritis Clinical manifestation: deformity, local tenderness and redness (bunion), X-Ray (osteoarthritis of first MTP) Treatment: orthoses and bunion pads, NSAID’s, surgery

Soft Tissue Rheumatism Hallux Valgus Deformity And Bunion

Soft Tissue Rheumatism Morton’s Neuroma Epidemiology: middle ages, F>M Etiology: compression of interdigital nerve by transverse metatarsal ligament,synovial cyst or intermetatarsophalengial bursa Clinical manifestation: paresthesia and burning, aching pain in forth toe, tenderness by palpation between the third and fourth metatarsal heads Diagnosis: MRI, NCV study Treatment: metatarsal bar, steroid injection, surgery

Soft Tissue Rheumatism Morton’s Neuroma

Soft Tissue Rheumatism Pes Planus (Flat Foot) Etiology: loss of longitudinal arch on the medial side , prominence of the navicular and head of the talus, generalized hypermobility, inherited, rheumatoid arthritis Clinical manifestation: asymptomatic (often), fatigue of foot muscles and aching, intolerance to prolonged walking or standing Treatment: thomas heel, firm shoes, grasping exercises, shoe orthoses

Soft Tissue Rheumatism Pes Planus

Soft Tissue Rheumatism Pes Planus

Soft Tissue Rheumatism Pes cavus (Claw Foot) Etiology: high medical arch , high longitudinal arch, shortening of extensor ligaments, neurologic disorder, inherited Clinical manifestation: foot fatigue, pain, tenderness over the metatarsal heads, callus formation, dorsiflexion of PIP and plantar flexion of DIP, claw like toes Treatment: metatarsal pad and bar, stretching of the toe extensor, surgery

Soft Tissue Rheumatism Pes Cavus

Soft Tissue Rheumatism Pes Cavus

Soft Tissue Rheumatism Metatarsalgia Etiology: foot strain, high-heelded shoes, everted foot, trauma, sesamoiditis, hallux valgus, inflammatory arthritis, high longitudinal arch Clinical manifestation: pain on standing, tenderness on transverse arch, weakness of the intrinsic muscles Treatment: orthose, strengthening the intrinsic muscles, weight reduction, metatarsal pad or bar