1. Upper Limb Periarthritis
Iraj Salehi-Abari MD.,
Internist
Rheumatologist
Salehi I. M.D.

2. Classification : Tendinitis & Bursitis Myofascial pain syndrome
Periarthritis
Classification :
Tendinitis & Bursitis
Myofascial pain syndrome
Structural disorders
Entrapment disorders
Generalized pain disorders
Salehi I. M.D.

3. Topographic Classification:
Periarthritis
Topographic Classification:
Upper limb :
Shoulder
Elbow
Hand
Lower limb:
Hip
Knee
Foot
Salehi I. M.D.

4. Epidemiology (USA): Musculoskeletal disorders : 15-20%
Periarthritis
Epidemiology (USA):
Musculoskeletal disorders : 15-20%
Osteoarthritis : 5%
LBP & Chronic neck pain : 5%
Periarthritis : 3-5%
RA : 1%
FMS : 1%
others
Salehi I. M.D.

5. Epidemiology (Iran): Musculoskeletal disorders : 31.4%
Periarthritis
Epidemiology (Iran):
Musculoskeletal disorders : 31.4%
Periarthritis : 5.5%
Shoulder : 44%
Trigger finger : 17%
Tennis elbow : 12%
Talalgia : 11%
Ankle bursitis : 11%
Ganglion :10%
DeQuervain’s t. :7%
Trochanteric bursitis : 5%
Nerve entrapment : 1.3%
CTS : 94%
Others : 9%
Salehi I. M.D.

6. Etiology : Trauma Overuse syndrome Systemic disorders Periarthritis
Salehi I. M.D.

7. Anatomy : 4 Joints Glenohumeral J. Capsule Rotator cuff Deltoid muscle
Periarthritis
Shoulder
Anatomy :
4 Joints
Glenohumeral J.
Capsule
Rotator cuff
Deltoid muscle
Coracoacromial arch
Subacromial bursa
Movement
Salehi I. M.D.

8. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

9. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

10. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

11. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

12. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

13. Periarthritis
Shoulder
Anatomy :
Salehi I. M.D.

14. Shoulder pain : Periarthritis : 80% Reffered pain : 15%
The most common periarthritis
20% of periarthritis(USA)
44% of periarthritis(Iran)
Reffered pain : 15%
Articular pain : 5%
Arthritis
Osteoarthritis
Salehi I. M.D.

15. Rotator cuff tendinitis : 70%
Periarthritis
Shoulder-Periarthritis
Rotator cuff tendinitis : 70%
Supraspinatus t.
Infraspinatus t.
Calcific tendinitis
RC tear : 1-2%
Biceps tendinitis
Biceps tendon tear
Subacromial bursitis
Adhesive capsulitis : 10%
Others
Salehi I. M.D.

16. Middle & old age F > M Impingement Etiology : Exercise : 1/3
Periarthritis
Shoulder-RC tendinitis
Middle & old age
F > M
Impingement
Etiology :
Exercise : 1/3
Overuse : 1/3
Idiopathic : 1/3
Falling : rare
Salehi I. M.D.

17. Clinical features : Paraclinic : NL Complications : Shoulder pain
Periarthritis
Shoulder-RC tendinitis
Clinical features :
Shoulder pain
Subacromial tenderness (SAS)
Painful arc
pain in external rotation :
infraspinatus
Paraclinic : NL
Complications :
Frozen shoulder
RC tearing
Cuff arthropathy
Salehi I. M.D.

18. Treatment : Resting : (No PPLRO) NSAIDs &/or Steroids SAS injection
Periarthritis
Shoulder-RC tendinitis
Treatment :
Resting : (No PPLRO)
Pulling
Pushing
Lifting
Reaching
Overhead positioning
NSAIDs &/or Steroids
SAS injection
Absolute resting : 3 days
Relative resting : 1 month
Exercise ;
> 75% response => daily activity
< 50% response => repeat injection
Salehi I. M.D.

19. Lidocaine injection test
Periarthritis
Shoulder-RC tear
Acute tear : young
Chronic tear : old age
Often > 50 y/o
Falling < 30 y/o
Clinical feature :
Pseudoparalysis
Drop off sign
Unable to abduction
Lidocaine injection test
Salehi I. M.D.

20. Milwaukee shoulder syndrome :
Periarthritis
Shoulder-RC tear
Milwaukee shoulder syndrome :
HA arthropathy with:
RC tear
GH arthritis with effusion
Humeroacromial pseudoarticulation
Salehi I. M.D.

21. MRI : Choice for complete tear MRA : Choice for partial tear
Periarthritis
Shoulder-RC tear
X-Ray :
Plain-PA : SAS < 1 cm
Dynamic-PA : SAS < 6 mm
Arthrography
Ultrasound
MRI : Choice for complete tear
MRA : Choice for partial tear
Salehi I. M.D.

22. Diagnosis : at least 2 of below
Periarthritis
Shoulder-RC tear
Diagnosis : at least 2 of below
abduction or ext. rotation < 50% or (+)Lidocaine injection test
Age > 62 y/o
Out stretch hand falling or direct trauma
Hx. Of recurrent RC tendinitis
SAS < 1 cm in X-Ray
Documentation of Dx.:MRI,MRA
Salehi I. M.D.

23. Treatment : Medical : Surgical : Rest,NSAIDs,Steroids for 6 weeks
Periarthritis
Shoulder-RC tear
Treatment :
Medical :
Rest,NSAIDs,Steroids for 6 weeks
If no response : SAS injection
Surgical :
Severe tear in young
Mild to moderate tear in young:
If no response to 6 weeks of medical.
Tear with intractable pain in old
RC tear + Biceps tear
Salehi I. M.D.

24. Anterior shoulder & arm pain Anterior tender point Yergason’s maneuver
Periarthritis
Shoulder-Biceps tendinitis
Young or adult male
Anterior shoulder & arm pain
Anterior tender point
Yergason’s maneuver
Speed’s maneuver
Treatment :
Rest, NSAIDs, Physiotherapy, Laser therapy, Injection
Salehi I. M.D.

25. Severe exercise or lifting Sudden onset pain + snap sound
Periarthritis
Shoulder-Biceps rupture
Young or adult male
Severe exercise or lifting
Sudden onset pain + snap sound
“Popeye sign”
Treatment :
Active youngs : Surgery
Old : Conservative
Salehi I. M.D.

26. F/M # 1/1 50 - 60 y/o HA deposition Clinical feature: X-Ray
Periarthritis
Shoulder-Calcific tendinitis
F/M # 1/1
y/o
HA deposition
Clinical feature:
Asymptomatic
Salam attack
X-Ray
Treatment :
NSAIDs(full dose)
Steroids(MDS)
Injection ?
Salehi I. M.D.

27. Hand shoulder syndrome
Periarthritis
Shoulder capsulitis
Adhesive capsulitis
Frozen shoulder
Hand shoulder syndrome
Salehi I. M.D.

28. Etiology : Primary : Secondary : Periarthritis Shoulder capsulitis
Without underlying disease
Secondary :
RC tendinitis &/or SA bursitis
Diabetes mellitus
MI , CVA , Prolong immobility
Pancost’s tumor
Cervicobrachial neuralgia
Salehi I. M.D.

29. Clinical features : Inflammatory phase : Transitional phase :
Periarthritis
Shoulder capsulitis
Clinical features :
Inflammatory phase :
Acute severe global shoulder pain
No LOM
Transitional phase :
Subacute moderate global pain
Mild to moderate LOM
Adhesion(Frozen) phase :
Severe global LOM
Pain with aggressive Ph. Ex.
Salehi I. M.D.

30. Paraclinics : FBS CBC, ESR, CRP Wrigth & C.W., PPD Ca/P Al.Ph.,
Periarthritis
Shoulder capsulitis
Paraclinics :
FBS
CBC, ESR, CRP
Wrigth & C.W., PPD
Ca/P Al.Ph.,
X-Ray :
R/O Arthritis & arthrosis
Early : NL
Late : Patchy osteoporosis
Arthrography
Salehi I. M.D.

31. Diagnostic criteria: Global shoulder stiffness + Pain
Periarthritis
Shoulder capsulitis
Diagnostic criteria:
Global shoulder stiffness + Pain
Limited ROM of 50%
Nl X-Rays of shoulder
Salehi I. M.D.

32. Treatment : NSAIDs Steroids ROM Exercise : Periarthritis
Shoulder capsulitis
Treatment :
NSAIDs
Steroids PO IM IA
ROM Exercise :
Flexion
Abduction
Mixed posterior movement
Salehi I. M.D.

33. Lateral epicondylitis (Tennis elbow)
Periarthritis
Elbow
Lateral epicondylitis (Tennis elbow)
Medial epicondylitis (Golfer’s elbow)
Olecranon bursitis
Ulnar nerve entrapment
Salehi I. M.D.

34. Common insertion of extensors Causes : Wrist extension & supination
Periarthritis
Tennis elbow
Lateral elbow pain
Common insertion of extensors
Causes : Wrist extension & supination
Common : (>90%)
Carrying suitcase or briefcase
Using screwdriver
Uncommon : (<10%)
Tennis playing
Salehi I. M.D.

35. Clinical features: Treatment : Lat. Epicondyle tender point
Periarthritis
Tennis elbow
Clinical features:
Lat. Epicondyle tender point
Mill’s test
Middle finger test
Treatment :
Resting
NSAIDs/Steroids
Local steroid injection
Salehi I. M.D.

36. Less common than tennis elbow Common insertion of flexors Causes :
Periarthritis
Golfer’s elbow
Medial elbow pain
Less common than tennis elbow
Common insertion of flexors
Causes :
Wrist flexion & pronation
Overuse
Golf
Salehi I. M.D.

37. Clinical features: Treatment Medial elbow tender point
Periarthritis
Golfer’s elbow
Clinical features:
Medial elbow tender point
Pain on resisted wrist flexion & pronation with elbow extended
Ulnar neuritis : 25-50%
Treatment
Salehi I. M.D.

38. Primary: Chronic low-grade trauma
Periarthritis
Olecranon bursitis
Primary: Chronic low-grade trauma
Leaning on the elbow
Laying carpet
Secondary :
Gout &CPPD
RA & SpA & SLE
Septic
Hemorrhagic
Diagnosis & Treatment :
Aspiration=> R/O septic
Drainage & Steroid injection
Salehi I. M.D.

39. Ulnar Nerve Entrapment
Periarthritis
Elbow
Ulnar Nerve Entrapment
Numbness & paresthesia of little & ring finger
Medial elbow pain
Hand clumsiness
Elevating the hand by resting the forearm on the head for 1 minute => paresthesia
Tinel’s sign
Salehi I. M.D.

40. De Quervain’s tenosynovitis Carpal tunnel syndrome
Periarthritis
Hand
Ganglion
De Quervain’s tenosynovitis
Carpal tunnel syndrome
Guyon’s canal syndrome
Dupuytren’s contracture
Tenosynovitis of the wrist
Pronator teres syndrome: writer’s cramp
Anterior interosseous nerve syndrome: O
Radial nerve palsy : Saturday night palsy
Cheiralgia paresthetica
Salehi I. M.D.

41. Dorsum of wrist : most common site Synovial cyst Treatment:
Periarthritis
Ganglion
20-40 y/o
F/M >1
Dorsum of wrist : most common site
Synovial cyst
Treatment:
Local injection of steroid
Surgical resection
Salehi I. M.D.

42. Female >40 y/o :90% Radial tender cord Finkelstein test Treatment
Periarthritis
De Quervain’s t.
Stenosing tenosynovitis of
Abductor pollicis longus
Extensor pollicis brevis
Female >40 y/o :90%
Radial tender cord
Finkelstein test
Treatment
Salehi I. M.D.

43. Median nerve entrapment The most common entrapment
Periarthritis
Carpal tunnel syndrome
Median nerve entrapment
The most common entrapment
The most common hand paresthesia
30-60 y/o , F / M = 5 / 1
Pathogenesis
Causes :
Idiopathic
Secodary
Salehi I. M.D.

44. Clinical features : Median n. paresthesia : 100%
Periarthritis
Carpal tunnel syndrome
Clinical features :
Median n. paresthesia : 100%
Nocturnal paresthesia : 71%
Ascending pain : 38%
Tinel’s sign : 55%
Phalen test : 53%
sensory defect :
Thenar atrophy
Tenar weakness
Salehi I. M.D.

45. Prayer sign Compression test Cuff sign Paraclinics: NCV:
Periarthritis
Carpal tunnel syndrome
Prayer sign
Compression test
Cuff sign
Paraclinics:
NCV:
Others: CBC , FBS ,...
Salehi I. M.D.

46. Diagnosis : Symptoms: Signs : one symptom + one sign Tinel’s sign
Periarthritis
Carpal tunnel syndrome
Diagnosis :
Symptoms:
Paresthesia
Hypesthesia
Burning pain
Signs :
Tinel’s sign
Phalen’s sign
Sensory defect
NCV
one symptom + one sign
Salehi I. M.D.

47. Local steroid injection Surgery
Periarthritis
Carpal tunnel syndrome
Treatment :
Splinting
NSAIDs/Steroids
Local steroid injection
Surgery
Salehi I. M.D.

48. Ulnar nerve entrapment GCS <<< CTS Ulnar nerve branches ;
Periarthritis
Guyon’s canal syndrome
Ulnar nerve entrapment
GCS <<< CTS
Ulnar nerve branches ;
Superficial(sensory)
Deep(motor)
Clinical pictures :
Only sensory
Only motor
Both
Treatment
Salehi I. M.D.

49. Volar flexor stenosing tenosynovitis Clinical features:
Periarthritis
Trigger finger
Volar flexor stenosing tenosynovitis
Clinical features:
Triggering finger
Locking finger
Tender nodule
Middle & index finger
Causes :
Overuse
RA, PsA, …
Treatment
Salehi I. M.D.

50. Thickening & shortening of palmar fascia Initial fascial nodules
Periarthritis
Dupuytren’s Contracture
Thickening & shortening of palmar fascia
Initial fascial nodules
Skin fixation to fascia
Dimpling or puckering
Finger flessum :4 > 5 > 3 > 2
Contraction of proliferative myofibroblast
M/F = 5/1, whites, Europe
Associations:
Diabetes m., Alcoholism, Epilepsy
Salehi I. M.D.

51. Fibromyalgia syndrome
Periarthritis
FMS & MFPS
Fibromyalgia syndrome
White Female:70-90%
Age at onset ; 35-40
Generalized pain
Tender points : 11 of 18
Control points
sleep disturbance
Lab : NL
Treatment :
Myofascial pain syndrome :
Localized pain
Trigger points
Salehi I. M.D.