Soft Tissue Rheumatism
Prof. Dr. Şansın Tüzün

" Soft tissue Rheumatism"
refers to aches or pains which
arise from structures
surrounding the joint such as
tendons, muscles, bursae and
ligaments.

This may be localized when
pain is felt in one region or
generalized when pain is felt
either all over or in many parts
of the body.
FIBROMYALGIA

Chronic musculoskeletal syndrome characterized by
diffuse pain and tender points

No evidence that synovitis or myositis are causes

Occurs in the context of unrevealing physical
examination, labaratory and radiologic examination

% 80-90 of patients are women, peak age is 30-50
years
Clinical Features

Generalized chronic musculoskeletal pain

Diffuse tenderness at discrete anatomic locations
termed tender points

Other features, diagnostic utility but not essential for
classification of fibromyalgia are; fatique, sleep
disturbances, headaches, irritable bowel syndrome,
paresthesias, Raynaud’s-like syndromes,
depression and anxiety
Classification Criteria

For classification criteria, patients must have
pain for at least 3 months involving the upper
and lower body, right and left sides, as well
as axial skeleton, and pain at least 11 of 18
tender points on digital examination
Central Sensitization Syndromes
MPS
Irritable Bowel
Syndrome
Restless Leg
Syndrome
Fibromyalgia
Chronic
Fatigue
Syndrome
Gulf War
Syndrome
Tension-type
Headache
Migraine
Primary dysmenorrhea
OTHERS
Central Sensitization
An exaggerated response of the central
nervous system to a peripheral stimulus
that is normally painful (hyperalgesia) or
non-nociceptive, such as touch
(allodynia)
Central Sensitization
Hyperexcitability
Hypersensitivity
Prolonged
or
Persistence Pain
The ability of CNS to undergo these
changes is called
“NEUROPLASTICITY”
CNS function is not fixed but is capable
of alterations depending on various peripheral and/or
environmental factors
“Common”s among CSSs
 Gender (Female)
 Family history
 Chronic pain/fatigue
 Abnormal neuroendocrine functions
 Absence of pathological findings
FMS and MPS
 Myofascial pain syndromes....... (20 - 30%)
 Fibromyalgia.............................. (3 - 5%)
Are they part of a continuum?
TrP PATHOGENESIS
Trauma
Stress
MUSCLE SPASM
(Taut Band)
Endocrine
Disorders
?
Pain
Central
Sensitization
Pain
TRIGGER POINT
Muscle Spasm
Sympathetic
Activation
MPS & FMS
Trigger points
Tender points
PAIN
GENERATOR
The most important criteria for
differential diagnosis
The presence of tender points (TeP) and widespread muscle pain in
FMS
compared with
Regional and characteristic referred pain patterns with discrete
muscular trigger points (TrP) and taut bands of skeletal muscle in
MPS
Myofascial Trigger Point
Diagnosis
Palpable Taut Band
Local Twitch Response
Jump Sign
Referred pain
Fibromyalgia
Pain in 11 of 18 tender point sites on digital palpation
“tender does not mean
painful”
Fibromyalgia Tender Points
CHRONIC FATIGUE SYNDROME
 CFS has recently emerged as a popular
diagnostic label for a centuries-old disorders
of fatigue and multiple somatic complaints.
 “ Yuppie flue “
 It shares many features with fibromyalgia
including the lack of objective physical or
laboratory abnormalities.
Syndrome
Relationship with Fibromyalgia
Depression
Irritable bowel
Migraine
Chronic fatiqe
Syndrome
Myofascial pain
25-60 % of FM cases
50-80 % of FM cases
50 % of FM cases
70 % of CFS cases meet FM
May be localized form of FM
Classify as CFS if;


Fatique persists or relapse for > 6 months
History, physical examination and appropriate
laboratory tests exclude any other cause for the
chronic fatique
Additionally;

Impaired memory of concentration, sore throat,
tender cervical or axillary lymph nodes,muscle
pain, multijoint pain, new headaches and
unrefreshing sleep
Treatment

Tricyclic antidepresants ( i.e. amitriptyline, desipramine
1-3h before bedtime)

Cardiovasculer fitness training

Biofeedback

Hypnotherapy

Cognitive behavioral therapy

Educating patient
MYOFASCIAL PAIN SYNDROMES

Presence of trigger points, which include a
localized area of deep muscle tenderness,
located in a taut band in the muscle, and
a characteristic reference zone of the
perceived pain that is aggravated by the
palpation of the trigger point
Comparison of FM and MFS
Variable
Fibromyalgia
Myofascial
pain
Examination
Tender points
Trigger points
Location
Generalized
Regional
Response to
local therapy
Not sustained
Curative
Sex
Females vs Males
9:1
Systemic
features
characteristic
F vs M
3:1
?
Treatment

Physical therapy

"Stretch and spray" technique: This treatment
involves spraying the muscle and trigger
point with a coolant and then slowly
stretching the muscle.

Massage therapy

Trigger point injection
Entrapment Neuropathies




Results from incresed pressure on a nerve as it passes through an
enclosed space
Knowledge of anatomy is essential for understanding of the clinical
manifestations of these syndromes
Splinting, NSAIDs and local corticosteroid injections usually suffice
when symptoms are mild and of short time.
Surgical procedures to decompress the nerve are indicated in more
severe cases
Thoracic Outlet Syndrome

Results from
compression of one or
more of the
neurovasculer elements
that pass through the
superior thoracic aperture

Anatomic abnormalities
and trauma to the
shoulder girdle region
play a far more pivotal
role
Potential narrowing areas

Between the scalenius
anterior and scalenius
medius

Costoclavicular space

Under the pectoralis
minor tendon
Signs and Symptoms


Paresthesias
Pain, radiating to the neck, shoulder and arm

Motor weakness

Atrophy of thenar, hypotenar and intrinsic
muscles of the hand

Vasomotor disturbances
Diagnosis

Neurologic examination

Certain clinical stress
tests (Adson and
hyperabduction
maneuvers)

A radiograph of
cervicothoracic region
(cervical rib, elongated
transverse process of
C7)
Treatment

Exercise designed to improve posture by
strengthening muscles

Avoidance of hyperabduction

Surgical intervention if; muscle wasting,
paresthesias replaced by continous sensory
loss, incapacitating pain,worsening of
circulatory impairment
Cubital Tunnel Syndrome

Compression neuropathy of
the ulnar nerve as it
transverses the elbow

Causes are; history of a
trauma, chronic pressure by
occupational stress or from
unusual elbow positioning

Arthritic conditions that results
in synovitis and osteophyte
production
Signs and symptoms

Paresthesias in the distribution
of the ulnar nerve

Aggrevated by prolonged use of
the elbow in flexed position

(+) Tinel’s sign

Atrophy of intrinsic muscles and
weakness in grasp

Wasting of the hypothenar
muscles and slight clawing of
the 4th and 5th fingers

Weakness in adduction of the
5th finger
Cubital Tunnel Syndrome
Diagnosis

Physical examination
(Tinel’s sign,
Wartenberg’s sign i.e.)

Radiographs

Electrodiagnosis
Treatment

Avoidance of prolonged elbow flexion

Local steroid injection along the ulnar groove

Surgical procedures to decompress the nerve
Ulnar Tunnel Syndrome

Entrapment of the ulnar nerve in
Guyon’s canal at the wrist (os
hamatum-os pisiform)

Compression is due to ganglia

Causes are; RA, OA

Chronic trauma due to
occupations
Signs and Symptoms

Combined sensory and motor deficits

Hypoesthesia in the hypothenar region and
4th and 5th fingers

Weakness of the intrinsic muscles of the
hand
Diagnosis


Pyhsical examination
Electrodiagnosis is helpful in determining the site of
the entrapmant
Treatment

Avoidance of trauma

Physical therapy

Surgical decompression
Carpal Tunnel Syndrome

Most common entrapment
neuroropathy

Compression of the median
nerve at the wrist

Causes are; occupation,
crystal-induced rheumatic
disorders

Complication of connective
tissue disorders

Uremia, metabolic and
endocrine diseases, infections,
pregnancy
Signs and Semptoms

Sensory loss in the radial three
finger and one-half of the ring
finger

Burning, pins-and-needles
sensations, numbness in the
fingers

Pain may radiate to the
antecubital region or to the
lateral shoulder area

Awaken at night by abnormal
sensation

(+)Tinel’s sign

(+) Phalen’s sign

Thenar atrophy
Diagnosis

History and physical examination

Radiographs

Electrodiagnosis
Treatment

Splints

Local corticosteroid
injection

NSAIDs

Physical therapy

Surgery ; patients with
progressive increases in
distal motor latency times
Tarsal tunnel syndrome

Entrapment
neuropathy of the
posterior tibial nerve
as it passes through
the tarsal tunnel
beneath the flexor
retinaculum on the
medial side of the
ankle
Tarsal tunnel syndrome …Etiology

Fracture or dislocation involving the talus
calcaneus,or medial malleolus

Rheumatoid arthritis

Tumors

Pronation related to the loss of the plantar
arch
Tarsal tunnel syndrome….Presentation

Burning or aching foot pain usually around
the plantar surface, distal foot, toes

May radiate up to the calf

Worse at night, when standing

Feels better when barefoot
Tarsal tunnel
syndrome….diagnosis

Tinel test
Nerve is tapped with a
finger or reflex
hammer at the flexor
retinaculum posterior
and inferior to the
medial malleolus
Tarsal tunnel syndrome… Management

Conservative






NSAIDs
Arch support
Orthoses to correct pronation
Proper shoes (1 inch heel and cushioned sole)
Avoid flat slippers
If symptoms persistent


Local injections
Decompression surgery