PHYSİOPATHOLOGY AND
REHABİLİTATİON OF NONARTİCULAR
RHEUMATİSM
Dr. Pembe Hare Yiğitoğlu
Near East University Faculty of Medicine
Department of Physical Medicine and Rehabilitation
2012
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Fibromyalgia
Myofascial Pain Syndrome
Bursitis
Impingement Syndrome
Calcific Tendinitis
Bicipital Tendinitis
De Quervain’s Tenosynovitis
Patellar Tendinitis
Adhesive Capsulitis
Lateral Epicondylitis
Medial Epicondylitis
Plantar fasciitis
FIBROMYALGIA
• Fibromyalgia is a disorder characterized by
– chronic widespread musculoskeletal pain,
– stiffness,
– paresthesia,
– disturbed sleep,
– easy fatigability,
– multiple painful tender points, which are widely
and symmetrically distributed.
• Fibromyalgia affects predominantly women in
a ratio of 9:1 compared to men.
• The prevalence of fibromyalgia in the United
States was reported to be 3.4% in women and
0.5% in men.
PATHOGENESİS
• Disturbed sleep has been implicated as a factor in
the pathogenesis.
• Nonrestorative sleep or awakening unrefreshed
has been observed in most patients with
fibromyalgia.
• Sleep electroencephalographic studies in patients
with fibromyalgia have shown disruption of
normal stage 4 sleep [non–rapid eye movement
(NREM) sleep] by many repeated α-wave
intrusions.
• Serotonin is a neurotransmitter that regulates
pain and NREM sleep.
• Deficiency of serotonin might also be involved
in the pathogenesis of fibromyalgia.
• Low levels of serotonin metabolites have been
reported in the cerebrospinal fluid (CSF) of
patients with fibromyalgia.
• Growth hormone is secreted normally during
stage 4 sleep, which is disturbed in patients with
fibromyalgia. This may explain the extended
periods of muscle pain following exertion.
• The level of the neurotransmitter substance P has
been reported to be increased in the CSF of
fibromyalgia patients and may play a role in
spreading muscle pain.
• Patients with fibromyalgia have a decreased
cortisol response to stress.
• Autonomic dysfunction has also been
suggested to play a role in the pathogenesis of
fibromyalgia.
• This may account for the dry eyes and mouth
and the cold sensitivity and Raynaud’s-like
symptoms seen in patients with fibromyalgia.
• Reduced blood flow to the areas in the brain
involved in the signaling, integration, and
modulation of pain is demonstrated.
(the thalamus, caudate nucleus, and pontine tectum)
• Approximately 30% of patients fit a psychiatric
diagnosis, the most common being
– depression,
– anxiety,
– somatization, and
– hypochondriasis.
CLINICAL MANIFESTATIONS
• Symptoms are generalized musculoskeletal
aching, stiffness and fatigue.
• Patients complain of muscle pain after even mild
exertion, and some degree of pain is always
present.
• The pain has been described as a burning or
gnawing pain or as stiffness.
• Patients may complain of joint pain and perceive
palpation of the tender points.
• Fibromyalgia may be triggered by emotional
stress, infections and other medical illness,
surgery, hypothyroidism, and trauma.
• It has appeared in some patients with
hepatitis C infection, HIV infection, parvovirus
B19 infection, or Lyme disease.
FMS DİAGNOSİS
• The Symptom Severity (SS) scale and the
Widespread Pain Index (WPI) are combined to
recommend a new case definition of
fibromyalgia:
• (WPI >7 AND SS >5) OR (WPI 3–6 AND SS >9).
• This allows people with fewer painful areas
but more severe symptoms to be diagnosed.
Treatment
• Antidepressants
– Tricyclic antidepressants
– Selective serotonin reuptake inhibitors (SSRI’s)
– Duloxetine (Cymbalta),
• Pregabalin (Lyrica),
• Aerobic exercise programs
• NSAIDs have not been proved to be effective in
the treatment of fibromyalgia.
• Avoid corticosteroids and narcotics.
MYOFASCIAL PAIN SYNDROME
• Myofascial pain syndrome is characterized by
localized musculoskeletal pain and tenderness
in association with trigger points.
• Myofascial pain may follow trauma, overuse,
or prolonged static contraction of a muscle,
which may occur when reading or writing at a
desk or working at a computer.
• In addition, this syndrome may be associated
with underlying osteoarthritis of the neck or
low back.
• Trigger points are a diagnostic feature of this
syndrome.
• Pain is referred from trigger points to areas
distant from the original tender points.
• Palpation of the trigger point reproduces or
accentuates the pain. The trigger points are
usually located in the center of a muscle belly.
• Trigger point sites palpation may cause the
muscle to twitch.
• Myofascial pain most often involves the
posterior neck, low back, shoulders, and
chest.
Treatment
• Stretching: Intermittent cold and stretch
• Thermotherapy: Hot pack, ultrasound
• Electrotherapy: Interferential current,
transcutaneous nerve stimulation
• Cold laser therapy
• Acupuncture
• Dry needling
• Myofascial trigger point injection
• Medication
• Exercise therapy
– Stretching and postural exercises
– Strengthening
– Conditioning - swimming
BURSITIS
• Bursa is a thinwalled sac lined with synovial
tissue.
• The function of the bursa is to facilitate
movement of tendons and muscles over bony
prominences.
• Bursitis is inflammation of a bursa.
• Excessive frictional forces from overuse, trauma,
systemic disease (e.g., rheumatoid arthritis,
gout), or infection may cause bursitis.
• Subacromial bursitis (subdeltoid bursitis) is the
most common form of bursitis.
• The subacromial bursa, which is contiguous with
the subdeltoid bursa, is located between the
undersurface of the acromion and the humeral
head and is covered by the deltoid muscle.
• Bursitis is caused by repetitive overhead motion
and often accompanies rotator cuff tendinitis.
• Another frequently encountered form is
trochanteric bursitis, which involves the bursa
around the insertion of the gluteus medius onto
the greater trochanter of the femur.
• Patients experience pain over the lateral aspect
of the hip and upper thigh and have tenderness
over the posterior aspect of the greater
trochanter.
• External rotation and resisted abduction of the
hip elicit pain.
• Treatment of bursitis consists of
– prevention of the aggravating situation,
– rest of the involved part,
– nonsteroidal anti-inflammatory drug (NSAID),
– local glucocorticoid injection.
ROTATOR CUFF TENDINITIS AND
IMPINGEMENT SYNDROME
• Tendinitis of the rotator cuff is the major cause of
a painful shoulder and is currently thought to be
caused by inflammation of the tendon(s).
• The rotator cuff consists of the tendons of the
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supraspinatus,
infraspinatus,
subscapularis and
teres minor muscles.
• Of the tendons forming the rotator cuff, the
supraspinatus tendon is the most often affected.
• This is probably because of
– its repeated impingement between the humeral head
and the undersurface of the anterior third of the
acromion and coracoacromial ligament above,
– the reduction in its blood supply that occurs with
abduction of the arm.
• The process begins with edema and
hemorrhage of the rotator cuff, which evolves
to fibrotic thickening and eventually to rotator
cuff degeneration with tendon tears and bone
spurs.
• Subacromial bursitis also accompanies this
syndrome.
• Severe pain is experienced when the arm is
actively abducted into an overhead position.
• The arc between 60° and 120° is especially
painful.
• Tenderness is present over the lateral aspect
of the humeral head just below the acromion.
CALCIFIC TENDINITIS
• This condition is characterized by deposition
of calcium salts, primarily hydroxyapatite,
within tendon.
• The supraspinatus tendon is most often
affected because it is frequently impinged on
and has a reduced blood supply when the arm
is abducted.
BICIPITAL TENDINITIS
• Bicipital tendinitis, or tenosynovitis, is
produced by friction on the tendon of the long
head of the biceps as it passes through the
bicipital groove.
• When the inflammation is acute, patients experience
anterior shoulder pain that radiates down the biceps
into the forearm.
• Abduction and external rotation of the arm are painful
and limited.
• The bicipital groove is very tender to palpation.
• Pain may be elicited along the course of the tendon by
resisting supination of the forearm with the elbow at
90°(Yergason’s supination sign).
TREATMENT OF TENDİNİTİS
• NSAIDs,
• Local glucocorticoid injection,
• Physical therapy relieve symptoms.
• Surgical decompression of the subacromial
space may be necessary in patients refractory
to conservative treatment.
DE QUERVAIN’S TENOSYNOVITIS
• In this condition, inflammation involves the
abductor pollicis longus and the extensor pollicis
brevis as these tendons pass through a fibrous
sheath at the radial styloid process.
• The usual cause is repetitive twisting of the wrist.
• It may occur in pregnancy, and it also occurs in
mothers who hold their babies with the thumb
outstretched.
• Patients experience pain on grasping with
their thumb, such as with pinching.
• Swelling and tenderness are often present
over the radial styloid process.
• The Finkelstein sign is positive.
• It is elicited by having the patient place the
thumb in the palm and close the fingers over
it.
• The wrist is then ulnarly deviated, resulting in
pain over the involved tendon sheath in the
area of the radial styloid.
• Treatment consists initially of splinting the
wrist and an NSAID.
• When severe or refractory to conservative
treatment, glucocorticoid injections can be
very effective.
PATELLAR TENDINITIS
(JUMPER’S KNEE)
• Tendinitis involves the patellar tendon at its
attachment to the lower pole of the patella.
• Patients may experience pain when jumping
during basketball or volleyball, going up stairs.
• Tenderness is noted on examination over the
lower pole of the patella.
• Treatment consists of rest, icing, and NSAIDs,
followed by strengthening and increasing
flexibility.
ADHESIVE CAPSULITIS
(FROZEN SHOULDER)
• Adhesive capsulitis is characterized by pain
and restricted movement of the shoulder,
usually in the absence of intrinsic shoulder
disease.
• Adhesive capsulitis, however,
– may follow bursitis or tendinitis of the shoulder
– or be associated with systemic disorders such as
chronic pulmonary disease, myocardial infarction,
and diabetes mellitus.
• Prolonged immobility of the arm contributes
to the development of adhesive capsulitis.
• The capsule of the shoulder is thickened, and
a mild chronic inflammatory infiltrate and
fibrosis may be present.
• The shoulder is tender to palpation, and both
active and passive movement is restricted.
• In most patients, the condition improves
spontaneously 1–3 years after onset.
• While pain usually improves, most patients
are left with some limitation of shoulder
motion.
• Local injections of glucocorticoids, NSAIDs,
and physical therapy provide relief of
symptoms.
LATERAL EPICONDYLITIS
(TENNIS ELBOW)
• Lateral epicondylitis, or tennis elbow, is a
painful condition involving the soft tissue over
the lateral aspect of the elbow.
• The pain originates at or near the site of
attachment of the common extensors to the
lateral epicondyle and may radiate into the
forearm and dorsum of the wrist.
• This painful condition is caused by repeated
resisted contractions of the extensor muscles.
• The pain usually appears after work involving
repeated motions of wrist extension and
supination against resistance.
• Most patients with this disorder injure
themselves in activities like tennis, carrying
suitcases, or using a screwdriver.
MEDIAL EPICONDYLITIS
• Medial epicondylitis is an overuse syndrome
resulting in pain over the medial side of the
elbow with radiation into the forearm.
• The cause of this syndrome is considered to be
repetitive resisted motions of wrist flexion and
pronation, which lead to microtears and
granulation tissue at the origin of the pronator
teres and forearm flexors, particularly the flexor
carpi radialis.
• It occurs in work-related repetitive activities or
while playing golf or throwing a baseball.
• On physical examination, there is tenderness
just distal to the medial epicondyle over the
origin of the forearm flexors.
• Pain can be reproduced by resisting wrist
flexion and pronation with the elbow
extended.
LATERAL AND MEDİAL EPICONDYLITIS
TREATMENT
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Discontinuation of aggravating activities,
Use of analgesic medications,
Physical modalities,
Bracing (e.g., medial/lateral counter-force strap
and neutral wrist splint),
• Corticosteroid injections,
• Operative treatment can be warranted for those
who fail to improve with conservative measures.
PLANTAR FASCIITIS
• Plantar fasciitis is a common cause of foot
pain in adults.
• Plantar fasciitis is thought to be the result of
repetitive microtrauma to the tissue.
• Several factors that increase the risk of
developing plantar fasciitis include
– obesity,
– pes planus (excessive pronation of the foot),
– pes cavus (high-arched foot),
– limited dorsiflexion of the ankle,
– prolonged standing,
– walking on hard surfaces,
– faulty shoes.
• Patients experience severe pain with the first steps on
arising in the morning or following inactivity during the
day.
• The pain usually lessens with weight-bearing activity
during the day, only to worsen with continued activity.
• Pain is made worse on walking barefoot or up stairs.
• On examination, maximal tenderness is elicited on
palpation over the inferior heel corresponding to the
site of attachment of the plantar fascia.
• The patient is advised to reduce or discontinue
activities that can exacerbate plantar fasciitis.
• Orthotics provide medial arch support and can be
effective in relieving symptoms.
• A short course of NSAIDs can be given to alleviate
symptoms.
• Local glucocorticoid injections have also been
shown to be efficacious but may carry an
increased risk for plantar fascia rupture.
REFERENCES
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Physical Medicine & Rehabilitation
DeLisa’s Physical Medicine & Rehabilitation
Harrison’s Rheumatology
Primer on the Rheumatic Diseases