Periarticular Disorders: Soft Tissue Rheumatism & Treatments

Soft Tissue Rheumatism

• Important parts being affected
  • Bursae
  • Tendons
  • Joint capsules
• · Soft Tissue Rheumatism can be divided into
  • Regional pain syndrome
  • Generalized pain syndrome
    • Fibromyalgia

Regional Pain Syndrome

• These are periarticular disorders
• Reason is repetitive trauma
  • It should be avoided
• No immunity, antibodies, etc involved

Shoulder Joint

• Frozen Shoulder
• Impingement
• Rotator cuff pathology
• Components: 4 muscles
• SIST mnemonic: Minor sister rotates your shoulder
  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres minor
• Subacromial Bursa: Most commonly affected bursa
  • If there is subacromial bursitis, the bursa gets tender, swollen, compressed, etc.
  • · Rotator cuff tear results in an unstable kinematic pattern
• All these muscles fuse to one continuous band that gets inserted into the tuberosity of the humerus.
• The primary function of the rotator cuff is to provide a stable fulcrum of motion & functional
• Glenohumeral Kinematics.

Also read: Cardiac Tamponade: Pathophysiology, Diagnosis & Treatment Options

Frozen Shoulder

• Diabetes mellitus
• Female
• >40 years
• Restriction of movement of shoulder and pain
• Adhesive capsulitis: Can do MRI (no need)
• Movement first restricted: External rotation of the shoulder joint
• NSAIDS to release pain
• Good physiotherapy can be given

Impingement Syndrome

• Impingement of Supraspinatus tendon
• It is beneath the Subacromial Bursa
• Most common reason is subacromial bursitis
• Pain-triggering movement is abduction
• If movement is 60-120 degrees, the patient experiences pain
• We can diagnose it by Neer's test and Hawkins-Kennedy test
• Treatment:
  • NSAIDs
  • Local steroids injections
  • Surgery is considered in worst case

Rotator Cuff Tear

• The most commonly affected tendon is supraspinatus tendon.
• Other tendons can also be affected
• Tear in young people because of trauma but in elder it is degenerative reasons
• Empty can test is done for diagnosis
  • A can with fluid is given to be emptied by the patient
  • The patient is told to internally rotate the shoulder
• The difference between the Hawkins-Kennedy test is it is tried to be done by elbow

Ellman's Classification for Partial-Thickness Rotator Cuff Tear

This helps in guiding management

• Grade I: 25% Tear of the Tendon thickness
• Grade II: 25%-50% Tear of the Tendon thickness
• Grade III > 50% Tear of the Tendon thickness

Also read: Therapies for Acute Decompensated Heart Failure (ADHF)

Patte's Classification for Complete Rotator Cuff Tear

• Stage I Proximal retracted Stump near the Bony Injection
• Stage II: The proximal retracted stump is at the level of the humeral head.
• Stage III: The proximal retracted stump is at the level of the glenoid.

Clinical Features of Rotator cuff tear

• Pain on the lateral aspect of the shoulder radiating to Deltoid insertion
• Pain & weakness are consistent complaints
• Night pain is very characteristic
• The patient would feel a Pop in the shoulder
• Arm Drop Sign
  • Examiner abducts the arm to the maximum
  • The patient is asked to lower the arm gradually
  • The patient will be able to lower his arm around 100°, after which he suddenly loses control of his arm & his arm drops down.
  • This strongly indicates a full-thickness tear.

Patte's Sign (Horn Blower's Sign)

• Done with the patient in sitting or standing
• The patient's arm is supported in 90° abduction in the scapular plane with the elbow flexed to 90°
• The patient is then asked to rotate the forearm externally.
• If the patient is unable to rotate the shoulder externally at this position (Horn Blower's sign is positive).
• This strongly suggests Teres Minor Tear.

Treatment of Rotator cuff tear

• Arthroscopic Rotator Cuff (RC) Repair combined with Tuberoplasty
  • Gold Standard treatment for Full Thickness RC Tears
• If it is a partial thickness Rotator Cuff (RC) Tear, Grade 1 & Grade II can be treated conservatively
  • But Grade III needs surgery

Also read: Constrictive Pericarditis: Pathogenesis, Etiology

Elbow

• Bursitis
  • Olecranon Bursitis: Students elbow
  • Treatment: Avoid trauma
• Tendinitis
  • Medial Epicondyle from where common flexor origins
    • Golfer's elbow
• Lateral epicondyle: there is a common extensor origin
  • Tennis Elbow
• Confirmation
  • Cozen's test
    • Conventional Cozen test
    • Reverse cozen test
• Treatment
  • Counterforce bracing Can be done

Wrist 

• De Quervain's tenosynovitis
  • Pain over radial styloid process
    • Abductor Pollicis Longus (ABL)
    • Extensor Pollicis Brevis (EPB)
  • Repetitive trauma can increase the pain
  • Test: Finkelstein test
• Dupuytren's contracture
  • Palmar Fascia is getting thicker.
  • Ring finger affected
• Diabetic Cheroarthropathy
  • Fixed deflection deformity
  • Leads to prayer sign
• Tenosynovitis causes the narrowing of the synovial membrane.
• Tendon get inflamed
• It results with tendon nodules
• The tendon movement is affected
• Extension is affected: Patient needs to exert a force
• Most commonly, Pulley is affected in trigger finger: A1 pulley
• Surgical release can be done
• A small fractured bone can be seen
• A mallet brace is inserted and treated

Also Read: Paroxysmal Supraventricular Tachycardia

Knee

• Subcutaneous prepatellar bursa: Housemaids Knee due to subcutaneous prepatellar bursitis
• Subcutaneous infrapatellar bursa: Clergyman's knee due to subcutaneous infrapatellar bursitis

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