Soft Tissue Rheumatism

Non Articular Rheumatism

deals with any ache or pain or numbness that is unrelated to any systemic disease and is localized to a particular problem

This is a category that includes the following:

Tendonitis: inflammation of the tendons

Bursitis: Inflammation of the bursae

Entrapment Neuropathy: pressure on the nerve causing numbness on a different site of the body

Enthesopathy: inflammation of where the tendons and ligaments enter the bone, an area void of periostium

Tenosynovitis (Tendonitis) – swelling of tendon and sheath (similar to the synovium) that covers the tendon near the joint

(1) Stenosing Tenosynovitis (aka Trigger finger): Symptoms: patient closes trigger finger but can not open it.

the flexor and extensor tendons that are moving the finger are inflamed at the palm of the hand.

inflammation Ý resistance of the tendons. Flexor muscle can overcome the resistance, extensors cant.

Can palpate the areas of inflammation under their palm of the hand

(2) De Quervain: inflammation where the extensors and the abductors attach to thumb at the radius.

Patient complains of wrist pain without having any inflammation of the wrist itself. Often can not pick up.

Finklestein Test: put thumb to palm, fold fingers then "do supination" (+) test = inability to do this.

(3) Tennis Elbow: Tendons involved in extension of the fingers and waving motion of wrist attach at the elbow

this area of elbow, the lateral epicondyle, can be inflamed or in the extensor tendons.

(4) Tenosynovitis of Bicepital Tendon (bicepital tendonitis): causes pain during supination. Usually due to inflammation of the longer head of the bicepital tendon

Patient complains of a vague pain in front of the shoulder

(5) Rotator Cuff Tendonitis or Rupture: One of the biggest tendons in the body: comes from the Supraspinatus, Infraspinatus, Teres Minor and Subscapularis to make one large tendon that attaches to the head of the humerus to function In abduction of the shoulder.

If ruptured or torn then abduction is difficult and very painful
If inflamed, then 2 finger pressure against arm can not be resisted by abductive counter force.
Ca⁺⁺ deposits in tendon may be seen on X-ray over area that rotator cuff attaches.

Bursitis

Bursae function as the grease of the joints under the tendons proximal to their attachment to bones.

There are approximately 120 Bursae in body. They are potential spaces that enlarge when inflamed.

Olecranon Bursa: Over the elbow. Elevation on the elbow presents. Usually due to trauma (wheel chair patients)

can also be induced by infection or uric acid crystal deposition from gout.
If there is inflammation in the bursa but not the elbow, mobility of joint is possible.
Aspiration from lateral or posterior aspect can confirm cause (not medial aspect due to ulnar nerve)
If due to trauma, will resolve by avoiding trauma.

Trochanteric Bursa: in the area of the large area of hip.

Illeo-pectinial bursa can cause pain in the groin area which can mimic pain from sacroileo joint or the hip or inguinal hernia. Pain from this bursitis can be pin pointed and function of the hip is not impaired
can cross legs over knee but can not sleep on the side of painful hip; extensor pain or focal pain to touch
Xylocaine resolves the pain.

Prepatellar Bursa: potential space under the skin in front of the knee. Can enlarge to size of orange

causes pain on extension of the knee, often without inflammation in the joint.
Common in roofers or people on their knees; gouty crystals may cause inflammation of the bursa

Anserine Bursa: under knee, just over tibia

Subacromial Bursa: shoulder area

Subdeltoid Bursa: shoulder area

Entrapment Neuropathy

can be anywhere from the exit of the nerve to thh periphery. Pressure will cause the pain or numbness to the area of innervation.

Carpal tunnel syndrome: caused by entrapment of the median nerve at the wrist by the palmaris longus tendon

causes numbness or tingling in 1^st, 2^nd, 3^rd, half of 4^th digits
palmaris longus applies pressure to a tendon like disc (covering carpal t) =retinaculum
Management: treat underlying disease, avoid trauma, wrist splint, inject steroid around nerve
Surgical Indications: failure of above or documented decrease in conductance on EMG and NCV

Sciatic nerve:

Meralgia prosthetica: Inguinal ligament entraps the femoral nerve causing pain or numbness in thigh.

often occurs with rapid weight gain (pregnancy) or cloth’s that bind (girdle).

Tarsal tunnel syndrome

Morton’s Metatarsalgia

Thoracic Outlet Syndrome – also called thoracic inlet syndrome

As the brachial plexus, subclavian artery and vein exit the thoracic cavity and enter the arm, they pass over the 1^st Rib and under the clavicle. The brachial plexus and subclavian artery also pass between the Scalenus medius and anterior. Entrapment results from compression of these arteries and nerves creating numbness or tingling in the hand.

Adson Maneuver can diagnose this syndrome (3 tests)

(1) Tilting head to side to put tension on Scalene Muscle, then measuring pulse in radial artery should reveal any compression of the artery by the Scalene Muscles.
(2) Measuring pulse a few seconds after putting arm in the air elucidates compression by pectoralis muscles
(3) Tingling and numbness when in the military position (shoulders back from wearing back pack) is positive for TOS: indicates pressure on plexus from the clavicle.