Soft-tissue rheumatism is a convenient term for a number of conditions with similar features . They cause musculoskeletal or joint pain that arises, not from the joint itself, but from surrounding structures such as the tendon sheaths and bursae. These conditions are benign and in most cases self-limiting. They are often regarded as trivial except by those who have them. Many are best treated by local corticosteroid injection rather than by anti-inflammatory drugs. It is also important to remove aetiological factors whenever possible; mechanical factors such as overuse and repetitive strain are probably particularly important. Common soft-tissue rheumatic syndromes are shown.
There are numerous bursae around the body and any of these can become inflamed; olecranon bursitis (student’s elbow) and prepatellar bursitis (housemaid’s knee) are two examples. Bursitis may appear for no obvious reason or it can be secondary to trauma, repetitive injury or an arthritis such as RA or gout. Occasionally, bursitis is due to infection, when aspiration will be necessary. In many cases no treatment is required other than protection of the inflamed site. Injection of corticosteroid may be useful and, very occasionally, large and troublesome bursae may require excision. Ischial bursitis causes pain over the ischial tuberosity and makes sitting difficult. A ring cushion is usually helpful.
Tenosynovitis can occur in any tendon sheath. The flexor tendons of the fingers are often affected and cause the condition known as trigger finger. Patients characteristically wake with one finger fixed in flexion. Some force is needed to extend the finger and this produces pain. There is a palpable nodule in the flexor tendon. Injection of this nodule with a corticosteroid preparation usually provides relief.
De Quervain’s tenosynovitis gives rise to pain in the anatomical snuff box and may be mistaken for OA of the first carpometacarpal joint. The point of maximum tenderness should be injected with a combination of corticosteroid and local anaesthetic.
The enthesis is the specialized area at the junction of tendons or ligaments and bone. Inflammation of the junction of the common extensor origin of the muscles of the forearm and the lateral humeral epicondyle results in ‘tennis elbow’. This condition is seldom due to tennis, more often it is caused by housework or some repetitive manual occupation. Often there is no obvious cause. There is pain in the elbow, but it is not clearly localized. However, on examination, the joint is normal and there is an area of exquisite tenderness over the lateral epicondyle. It is usually treated by injecting this tender area with a combination of corticosteroid and local anaesthetic. Since the condition resolves within a year or two whatever is done, in mild cases it may be best ignored.
Golfer’s elbow is a similar problem at the junction of the origin of the flexor muscles of the forearm and the medial humeral epicondyle. Another common site is the greater trochanter of the femur (trochanteric syndrome). In plantar fasciitis, the inflammation arises on the undersurface of the heel at the origin of the plantar fascia. This common condition is best treated with an injection of corticosteroid and a protective heel pad; it normally resolves within a year or two.
Nerve compression syndromes
Carpal tunnel syndrome is described. A similar condition in the foot, tarsal tunnel syndrome, gives rise to burning pain with pins and needles in the sole of the foot and toes. As in carpal tunnel syndrome, the pain is often worse at night and may wake the patient from sleep. In cases of diagnostic difficulty, nerve conduction studies will show a block at the appropriate level. In Morton’s metatarsalgia, pain arises from a digital nerve in the foot, usually between the third and fourth metatarsal heads. It is due either to a neuroma or to compression by a bursa. There is pain in the forefoot that radiates into the toes. It is usually aggravated by wearing shoes and relieved by removing them. Manual compression of the forefoot reproduces the symptoms. The condition sometimes responds to local injection and to the use of a metatarsal pad. If not, surgical exploration and excision of the bursa or digital nerve is required.
This is a convenient term for a group of soft-tissue syndromes that produce the same clinical picture-a painful stiff shoulder. Some people reserve the term for the later stage of the disease when the glenohumeral joint is comletely immobile. Many other terms, such as periarthritis or capsulitis, are used to describe this condition, but without much pathological justification. In some cases, 10cal tenderness points to a lesion such as supraspinatus rendinitis, bicipital tendinitis or subacromial bursitis. In st cases, however, it is not possible to identify a specific cause and differentiation makes little difference the outcome or treatment.
Frozen shoulder is a common condition occurring in aduIts at any age. It is usually but not always unilateral. there is pain in the shoulder that may radiate to the arm and is usually most troublesome at night. In most cases the condition appears without obvious cause but it may occasionally be related to overuse or injury. A similar clinical picture is produced by acute calcific periarthritis . Examination shows restriction of glenohumeral movement. Analgesics and exercises to prevent stiffness are sufficient treatment in mild cases. If there is restriction of movement, intra-articular injection of corticosteroid is required, followed by exercises to mobilize the joint. The response is variable but the condition usually resolves eventually.
Shoulder-hand syndrome is a rare condition in which a frezen shoulder is followed by sympathetic nervous system mediated abnormalities in the corresponding hand, defuse swelling, warmth and erythema. It may be idiobut pathic but also occurs after strokes and head injuries. Untreated, hand involvement may progress to atrophy and constractures. ACTH is usually very effective, combined with an exercise programme to restore function.
This is used to describe a functional condition of voluntary muscle that gives rise to widespread pains arising from muscles and their insertions. In some cases there is a large psychogenic component and in this respect the condition has a lot in common with irritable bowel syndrome, with which it is often associated. It begins in early adult life, with females being particularly affected. Widespread aches and pains are characteristic, moving from place to place, varying in severity and often aggravated by cold and stress. Patients have a characteristic sleep disturbance, lacking non-rapid eye movement (REM, 6) sleep, waking unrefreshed and feeling tired. Interruption of sleep in normal volunteers will reproduce the syndrome. The characteristic physical sign in fibromyalgia is multiple areas of localized soft-tissue tenderness known as trigger points. They are particularly found around the dorsal spine in the interscapular region, around the base of the neck, over both sacroiliac joints, over the lateral epicondyles of the elbows (resembling tennis elbows), and over the medial sides of the knees. In some patients, crops of nodules appear in the muscles, but these have no consistent pathological basis and are believed to be part of the functional abnormality. Blood tests and X-rays are normal.
The condition is chronic or recurrent but entirely benign. Treatment measures include:
AN EXERCISE PROGRAMME. The rationale for this is the observation that it is difficult to induce fibromyalgia experimentally in trained athletes.
MEASURES TO IMPROVE SLEEP. Amitriptyline at night is particularly useful.
HEAT, MASSAGE AND LOCAL OINTMENTS to relieve pain. Analgesic and anti-inflammatory drugs are seldom helpful.
LOCAL INJECTION of trigger points.
REASSURANCE AND EXPLANATION.
Musculoskeletal conditions are sometimes a cause of chest pain. An example is Tietze’s disease. In this condition, pain arises from the costosternal junctions. It is usually unilateral and affects one, two or three joints. There is local tenderness, which helps to make the diagnosis. The condition is benign and self-limiting. It often responds well to anti-inflammatory drugs, or may be treated with local injections of corticosteroid and local anaesthetic.
The muscles of the lower leg are enclosed in a compartment of fascia, with little room for expansion to occur. Compartment syndromes may be acute (anterior tibial syndrome), e.g. following exercise, or chronic. The former sometimes requires immediate surgical decompression to prevent muscle necrosis. Chronic compartment syndromes produce pain in the lower leg that is aggravated by exercise and may therefore be mistaken for a vascular or neurological disorder.
Repetitive strain syndrome
This term describes a muscular condition which arises as a result of excessive repetitive activity, usually involving the hands in occupations such as keyboard workers and those who work on assembly lines. Although overuse is the fundamental cause, the condition is more likely to arise in stressful circumstances and when other workers are affected. It presents with pain in the hands and forearms together with various other symptoms such as weakness, cramps, sensory disturbances and a feeling of swelling. There are usually no objective abnormalities. It is important to distinguish this condition from others like te nnis elbow, tenosynovitis and carpal tunnel syndrome which can also arise from repetitive manual work. Treatment involves remaining at work but stopping or reducing the activity which caused the problem, exercise and physiotherapy. The condition recovers with time but in severe cases this takes years. Prevention is therefore most important and involves ensuring a good ergonomic position at work, taking regular breaks and recognizing problems quickly if they occur.