3. SOFT TISSUE RHEUMATISM Upper Exterimity
Mohsen Akhiani M.D.

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

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

6. Soft Tissue Rheumatism Rotator Cuff Muscle

7. 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

8. Soft Tissue rheumatism Impingement Of Rotator Cuff

9. Soft Tissue Rheumatism Painful Arc

10. Soft Tissue Rheumatism Calcific Tendinitis

11. Soft Tissue Rheumatism Injection of Subacromion Bursa

12. 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

13. Soft Tissue Rheumatism MRI Of Complete-Cuff Tear

14. Soft Tissue Rheumatism Shoulder Arthrogram (Rotator Cuff)

15. Soft Tissue Rheumatism Bicipital Tendon

16. 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

17. Soft Tissue Rheumatism Yergason’s Sign And Speed Test

18. 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

19. 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

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

21. 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),

22. Soft Tissue Rheumatism Muscle Insertions Around The Elbow Joint

23. Soft Tissue Rheumatism Resisted Wrist Extension Test

24. Soft Tissue Rheumatism Medial Epicondylitis
Epidemiology: ages: 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)

25. Soft Tissue Rheumatism Resisted Wrist Flexion Test

26. 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

27. 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

28. Soft Tissue Rheumatism Ulnar Nerve Entrapment

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

30. Soft Tissue Rheumatism Anatomy Of Carpal Tunnel

31. 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%)

32. Soft Tissue Rheumatism Sensory Supply To The Hand

33. 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

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

35. Soft Tissue Rheumatism Thenar Muscle Atrophy

36. Soft Tissue Rheumatism Carpal Tunnel Syndrome (Local Injection)

37. 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

38. Soft Tissue Rheumatism De Quervain’s Tenosynovitis

39. Soft Tissue Rheumatism Finkelstein Test

40. Soft Tissue Rheumatism Flexor Tendon Sheaths Of The Hand

41. 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

42. Soft Tissue Rheumatism Dupuytren’s Contracture

43. 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

44. 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

45. 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

46. SOFT TISSUE RHEUMATISM LOWER EXTREMITY
Mohsen Akhiani M.D.

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

48. Soft Tissue Rheumatism The Bursa Of The Hip Joint

49. 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

50. 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

51. Soft Tissue Rheumatism CT Scan Of Iliopsoas Bursitis

52. 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

53. 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

54. Soft Tissue Rheumatism Meralgia Paresthetica

55. 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)

56. Soft Tissue Rheumatism Piriformis Syndrome

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

58. 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

59. 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

60. Soft Tissue Rheumatism Bursa Around The Knee Joint

61. 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

62. 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

63. 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

64. Soft Tissue Rheumatism Osgood-Schlatter’s Disease

65. 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

66. Soft Tissue Rheumatism Pellegrini-Stiedia Syndrome

67. 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

68. 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)

69. Soft Tissue Rheumatism Bursa Around the Foot

70. 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

71. 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)

72. 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)

73. Soft Tissue Rheumatism Plantar Fascia

74. 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

75. Soft Tissue Rheumatism Plantar Fasciitis

76. 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

77. Soft Tissue Syndrome The Tarsal Tunnel

78. 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

79. Soft Tissue Rheumatism Hallux Valgus Deformity And Bunion

80. 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

81. Soft Tissue Rheumatism Morton’s Neuroma

82. 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

83. Soft Tissue Rheumatism Pes Planus

84. Soft Tissue Rheumatism Pes Planus

85. 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

86. Soft Tissue Rheumatism Pes Cavus

87. Soft Tissue Rheumatism Pes Cavus

88. 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