Soft Tissue Disorders
and Fibromyalgia
Jaya Ravindran
Consultant Rheumatologist
Introduction
 Definitions
 Approach to soft tissue disorders
 Overview of some soft tissue conditions:
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Flexor tenosynovitis
De Quervain’s
Carpal tunnel
Golfer’s/Tennis elbow
Rotator Cuff
Trochanteric bursitis
Achilles tendonitis
 Fibromyalgia
• WHAT ARE TENDONS, LIGAMENTS, ENTHESIS
AND BURSA?
Definitions
 Ligament
 A band of tough connective tissue that connects bone to bone
 Tendon
 a tough band of fibrous connective tissue that connects muscle to bone
 Enthesis
 the point at which a tendon inserts into bone, where the collagen fibres
are mineralised and integrated into bone tissue
 Bursa
 a fluid filled sac located between a bone and tendon which normally
serves to reduce friction between the two moving surfaces
• THOUGHT PROCESS/ISSUES IN SOFT TISSUE
DISORDERS?
Approach to soft tissue disorders
 History and examination paramount
 Differentiate from inflammatory/mechanical arthropathy
 Think about anatomy of area and mechanism of injury/overuse
to understand pathology
 Work history
 Precipitating activity
Approach to soft tissue disorders
 Could it be referred pain eg C5/6 Neck pain radiating
to shoulder – ask about neurological symptoms
 May be associated with inflammatory arthritis eg RA or
psoriatic arthritis or systemic illness
 Bloods not helpful in making diagnosis
 Imaging - X-ray and ultrasound may play a role in
certain soft-tissue disorders
• JOINT vs PERIARTICULAR?
Is it an articular or extra-articular
problem?
• ARTICULAR
PERI-ARTICULAR
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pain in plane of tendon
active > passive
linear swelling
localised tenderness
localised erythema/heat
pain all planes
active = passive
capsular swelling/effusion
joint line tenderness
diffuse erythema/heat
Management
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Rest
Simple analgesia
NSAIDs
Local steroid injection
Physiotherapy/Occupational therapy
Surgery in certain cases e.g. carpal tunnel
• Features of flexor tenosynovitis ?
Flexor tenosynovitis
 Inflammation of flexor tendon sheaths
 Pain and stiffness in flexor finger/thumb, may
extend to wrist
 Reduced active flexion, crepitus, thickened
tender tendon sheaths
 May be associated with nodule – “trigger finger”
 Can be associated with RA, Diabetes
 Treatment – injection hydrocortisone, surgery
• Features of De Quervains?
De Quervain’s (tenosynovitis)
 Inflammation of tendon sheath containing
extensor pollicis brevis and abductor pollicis
longus tendons
De Quervain’s (tenosynovitis)
 Pain, swelling radial wrist
 Localised tenderness, crepitus, pain worse over
radial styloid
 Finkelstein’s test
De Quervain’s (tenosynovitis)
 Finkelstein
 With the thumb flexed across the palm of the hand, ask the
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patient to move the wrist into flexion and ulnar deviation.
Positive if reproduces pain
De Quervain’s (tenosynovitis)
 Management
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Rest from precipitating activity
Splintage
Steroid injection
surgery
• Features and causes of carpal
tunnel syndrome?
Carpal tunnel syndrome
 Compression of median nerve as it passes
through carpal tunnel
Carpal tunnel syndrome
 Common, F>M, elderly/middle aged
 Mostly idiopathic
 Associated with (particularly if bilateral):
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Diabetes
Hypothyroidism
RA
Pregnancy
Acromegaly
Vasculitis
Trauma
Others (e.g. amyloid, sarcoid)
Carpal tunnel syndrome anatomy
 Median nerve supplies:
 Motor (beyond carpal tunnel in hand)
 L lateral two lumbricals
 O opponens pollicis
 A abductor pollicis brevis
 F flexor pollicis brevis
 Sensory
 Palmar surface thumb, lateral 2 ½ digits
Carpal tunnel syndrome
 Clinical features
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Numbness/parasthesia in median nerve distribution
Pain, can radiate up arm
Worse at night
‘Hang hand over end of bed’
Weakness of thumb (abduction)
Thenar wasting
Positive Tinel’s/Phalen’s
Carpal tunnel syndrome
Tinel’s
Phalen’s
Carpal tunnel syndrome
 Investigation
 Nerve conduction studies show reduce nerve conduction
velocities across wrist
 Management
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Avoidance of precipitating activity
Night time splints
Local steroid injection
Surgery – division of flexor retinaculum and decompression of
carpal tunnel (80% success)
• Features of epicondylitis ?
Tennis & Golfer’s Elbow
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Both enthesopathies
Tennis elbow = lateral epicondylitis = inflammation common extensor origin
Golfer’s elbow = medial epicondylitis = inflammation common flexor origin
Tennis elbow more common than Golfer’s
Tennis & Golfer’s Elbow
 Pain localised to specific area
 Elbow flexion/extension does not cause pain
 Pain upon:
 resisted wrist extension (Tennis)
 resisted wrist flexion (Golfer’s)
Tennis & Golfer’s Elbow
 Management
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Rest from precipitating activity
Elbow clasps
Local corticosteroid injection
Physiotherapy – ultrasound and acupuncture
Surgery (often ineffective)
• Rotator cuff disease features?
Rotator Cuff Pathology
 A range of various conditions, including:
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Supraspinatous tendinitis/rupture
Rotator cuff tear
Adhesive capsultitis (frozen shoulder)
Acute calcific supraspinatous tendonitis
Subacromial bursitis
Acromioclavicular joint OA
 Overlap in clinical features but distinct entities
Rotator Cuff – anatomy
 A sheath of conjoint tendons to support
glenohumeral joint, made up of:
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S
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T
S
supraspinatous - abduction
infraspinatous – external rotation
teres minor – external rotation
subscapularis – internal rotation
Rotator Cuff Syndrome
 Spectrum from mild supraspinatus tendinitis to
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complete tendon rupture
Chronic impingement of cuff under acromial arch
Pain often over acromial area extending into deltoid
Rotator Cuff Syndrome
 Painful mid arc
 Impingement test –
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abducted, flexed and
internally rotated
Supraspinatus stress
Rotator cuff investigation - ultrasound
• Full thickness tear
Rotator Cuff Syndrome
 Management
 Rest, NSAIDs
 Local steroid injection around tendon – subacromial space
and PT
 If chronic/rupture refer to Orthopaedics for surgical
opinion
Acute calcific supraspinatus
tendinitis
 Calcium hydroxyapatite deposition near supraspinatus
enthesis
 Young adults, F>M, acute pain
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over several hours
Normally resolves over few days
Treatment
 Minor – NSAID
 Moderate – consider steroid injection
 Severe – consider aspirating calcified
material
Adhesive capsulitis (Frozen
shoulder)
 Progressive pain and stiffness
 Global reduction in movement, but particularly
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external rotation
Three phases
 Pain (3-5 months)
 Adhesive phase (4-12 months)
 Recovery phase (12-42 months)
Adhesive capsulitis (Frozen
shoulder)
 Associated with diabetes
 Most patients recover by 30 months, but still have
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reduced movements
Management
 Analgesia, NSAIDs, Physiotherapy, steroid injection
 Surgical opinion in difficult cases (manipulation under
anaesthesia)
• ACJ disease features ?
Acromioclavicular OA
• High arc pain
• Local tenderness
• Adduction painful
• Impingement
• Trochanteric bursitis features?
Trochanteric bursitis
 Inflammation of the superficial
and deep bursa that separates
the gluteus muscles from the
posterior and lateral side of the
greater trochanter of the femur
Trochanteric bursitis
 Boring pain over lateral aspect of hip
 May radiate down lateral thigh
 Worse on walking or lying in bed at night
 Localised tenderness upon pressure over
greater trochanter
Trochanteric bursitis
 Management
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Rest
Analgesia
Steroid injection
Physio
Achilles tendonitis
 Inflammation of the achilles
tendon
 Sometimes at enthesis
 Sometimes in middle avascular
portion of tendon
 Can be seen with seronegatives
Achilles tendonitis
 Chronic tendonitis can lead to Achilles
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tendon rupture
Aetiology of tendonitis though to be
avascular degeneration of tendon
Tenosynovitis does not lead to rupture
Also can get acute traumatic rupture
All have localised pain and swelling of
Achilles tendon, with difficulty walking
Achilles tendonitis
 Investigation - ultrasound
 Management
 Rest, NSAIDs, physiotherapy
 Local steroid injection under U/S guidance
into paratenon can help tenosynovitis – if no
evidence of tear
Achilles rupture
 Acute rupture – sudden calf pain as if being
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hit on back of leg
Palpable gap in tendon
Some but little plantarflexion
Squeeze calf whilst prone - no plantarflexion
in affected leg (Simmond’s)
Management
 Surgery to repair tendon
 Conservative – below knee cast in ankle equinus 6
weeks
• Fibromyalgia features ?
Fibromyalgia
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“All over pain”
Fatigue
Sleep disturbance
Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion
Prevalence/Risk Factors
 Common
 Approx 2-5% depending upon definition
 Female (F:M ratio between 3:1 and 7:1)
 Middle age (typically 30-60)
Differential diagnosis
 Other conditions can mimic fibromyalgia:
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Systemic lupus erythematosus (SLE)
Hypothyroidism
Polymyalgia rheumatica
Malignancy
Myopathy
Metabolic bone disease
Management
 Patient education
 About condition
 Reassure that no serious pathology
 No harm in exercising
 Cognitive behavioural therapy (CBT)
 Low dose amitriptyline
 Graded aerobic exercise regime
THANK-YOU