Rheumatic Pain Syndromes

1. Regional Rheumatic Pain
Syndromes
Diana Girnita, MD PhD
UC Rheumatology Fellow

2. RRPS
 include disorders involving
 muscles
 Tendons
 Entheses
 Joints
 Cartilage
 ligaments
 fascia
 bone
 nerve.

4. Causative factors
 Injury
 Overuse
 Atrophy due to aging
 Inflammation processes
 Tendinitis/ tendinosis/ tendinopathy-mostly
degenerative changes and few inflammatory cells
 Tenosynovitis- inflammatory response of
tenosynovium

5. Concepts of management
 Drug therapy
 NSAIDS
 Analgesics: tylenol, tramadol, propoxyphen
 TCA- amytriptiline in chronic pain/ neurogenic/
myofascial
 Intralesions injections with lidocaine, steroids
(needle parallel with tendon fibers)
 Physical therapy

6. Disorders of Shoulder Region

7. Rotator cuff tendinitis (RCT) or
impingement sdr
 Most common cause
of shoulder pain
 Acute/ chronic
 May + calcific
deposits in the tendon
 Pain with active
ABDUCTION between
60-120
degrees/lowering the
arm

8. Chronic RCT
 Ache in the shoulder over the lateral deltoid
 Pain with abduction and internal rotation
 Difficulties dressing
 Night pain
 Less pain with passive abduction
 Pain with abduction against resistance

9. Impingement test
 Inject 2-5 ml 2% lidocaine in the subacromial
bursa- pain relief on abduction = test positiv

10. RCT
 Causes:
 Overuse/ overhead activity
 Aging/ decline in use
 Osteophytes in the acromioclavicular joint
 RA
 TX: rest, hot packs, cold, NSAIDs, CS injections
in the subacromial bursa

11. Rotator Cuff Tear
 Most common trauma with ruptured cuff (falls, FX)
 Classification
 Small <1cm
 Medium 1-3 cm
 Large 3-5 cm
 Massive >5cm
 Shoulder pain, weakness on abduction, and loss of
motion severe pain and mild weakness to no pain
and marked weakness.
 A positive drop-arm sign with inability to actively
maintain 90° of passive shoulder abduction (massive
tears)
 MRI /abnormal arthrogram for diagnosis
 TX: rest, PT, NSAIDs  surgery

12. Bicipital tendinitis& Rupture of
proximal Bicipital Tendon
 Pain in the anterior region of
shoulder
 Acute/Chronic.
 Tenderness over the bicipital
grove
 Supination of the forearm
against resistance
 Shoulder flexion against
resistance
 Tx: rest, hot packs, US, NSAIDs,
CS injection
 Full rupture of the long head of
tendon –bulbous enlargement of

13. Adhesive Capsulitis/ Frozen
Shoulder/ Pericapsulitis
 generalized pain and tenderness with severe loss
of active and passive motion in all planes.
 Rare<40 years
 Causes: inflammatory arthritis, DM, immobility,
depression, and neglect
 The joint capsule adheres to the anatomic neck,
and the axillary fold binds to itself, causing
restricted motion.
 The capsule becomes thickened and contracted
 Injecting dye : 0.3-5-10 ml, while in normal joint
could inject up to 28ml
 TX: NSAIDs,CS injections, PT

14. Suprascapular Neuropathy
 suprascapular nerve,
which innervates the
supraspinatus and
infraspinatus
 Cause: trauma,
overactivity of the
shoulder, local ganglion,
or scapula FX
 Weakness on abduction
and external rotation±
atrophy of the
supraspinatus and
infraspinatus
 Dg:EMG
 Tx: PT, CS injection into
the area of the
suprascapular notch.;
surgical decompression

15. Long Thoracic Nerve
Paralysis
• weakness of the serratus
anterior muscle,
resulting in a winged
scapula.
• Pain along the base of
the neck and downward
over the scapula and
deltoid region + fatigue
on elevation of the arm.
• The winging of the
scapula becomes
apparent when the
patient pushes against
the wall with arms
outstretched

16. Brachial Plexopathy
 deep, sharp shoulder pain of rapid onset made worse
by abduction and rotation + weakness of the shoulder
girdle.
 EMG: positive sharp waves and fibrillations
 Recovery may take from 1 month to several years.
 Causes: trauma, tumor, radiation, inoculation neuritis,
diabetes, infection, or median sternotomy done for
cardiac surgery, or it can be idiopathic

17. Thoracic Outlet Syndrome
 The neurovascular bundle is
bordered below by the first rib,
anteriorly by the scalenus
anterior muscle, and posteriorly
by the scalenus medius muscle
 Neurologic symptoms: Pain,
paresthesia, and numbness
radiating from the neck and
shoulder down to the arm and
hand, especially distributing to
the ring and little fingers.
 Weakness and vascular
symptoms consist of
discoloration, temperature
change, pain on use, and
Raynaud’s phenomenon

18. Adson Test
 patient holds a deep breath,
extends his neck, and then turns his
chin toward the side being
examined, is positive when the
radial pulse becomes extremely
weak or disappears.
 May be positive in normal people
 TX: conservative. Good posture is
emphasized. Stretching of the
scalene and pectoral muscles,
strengthening of the shoulder girdle
musculature

19. DISORDERS OF THE ELBOW
REGION

20. Olecranon Bursitis
 The bursa is characteristically swollen and tender
on pressure, but pain may be minimal and
generally no motion is lost
 Causes:
 gout, RA, or CPPD
 uremia in HD patients
 Septic bursitis

21. Lateral Epicondylitis
 tennis elbow
 Localized tenderness directly over
or slightly anterior to the lateral
epicondyle
 Pain during handshakes, lifting a
briefcase, <10% of patients due to
playing tennis; job and recreational
activities, including gardening
 Pathology: degeneration of the
common extensor tendon
 Tx: rest, Ice packs, heat, NSAIDs,
forearm brace
 Entrapment of the radial nerve at
the elbow, which is called radial
tunnel syndrome (aching, weakness
of extension of the middle finger;
forced forearm supination against
resistance aggravate the symptoms

22. Medial Epicondylitis/ Golfer’s
elbow
 Local pain and tenderness over the medial
epicondyle
 Resistance to wrist flexion exacerbates the pain.
 Cause: work/ leisure activitie/golf and throwing.
 MRI not needed for diagnosis, ---thickening and
increased signal intensity of the common flexor
tendon
 TX: rest, NSAIDS, CS injections

23. Tendinopathy, Complete and Partial
Rupture of the Distal Biceps Insertion
 Dull pain throughout the antecubital fossa of the
elbow, mild swelling at the tendon insertion
 Resisted elbow flexion and resisted supination
increase pain.
 Complete rupture of the distal biceps tendon is
uncommon (sudden forced extension against an
actively contracting biceps muscle)
 pain and weakness of elbow flexion and
supination.
 MRI confirms the diagnosis
 Tx: surgical repair

24. Cubital Bursitis/ bicipitoradial
bursitis
 swelling of the antecubital fossa and tenderness
with some restriction of pronation.
 Cause: RA/inflammatory arthritis; trauma or
overuse, associated with a partial tear of the
distal biceps tendon.
 MRI: confirm the diagnosis.
 TX: conservatively, including an image-guided
aspiration and corticosteroid injection.

25. Triceps Tendinitis and Triceps
Tendon Rupture
• pain is present in the posterior
elbow
• worse by extension and resisted
extension.
• Tenderness of the insertion of the
tendon
• Cause: overuse of the upper arm
(throwing; hammering);
• Tx: conservative/ surgery
• Rupture of the triceps tendon at
the insertion in the olecranon is
rare; usually trauma /CS injections
into the olecranon bursa/heavy
use of anabolic steroids.

26. Ulnar Nerve Entrapment
 numbness and paresthesia of the
little finger and adjacent side of the
ring finger and medial aspect of
the elbow. Hand clumsiness
 + decreased sensation and
weakness on abduction and
flexion; atrophy and weakness of
the ulnar intrinsic muscles of the
hand
 A positive Tinel’s sign, elicited by
tapping the nerve at the elbow
 EMG:dg
 TX: Avoiding pressure on the
elbow and repetitive elbow flexion/
surgical correction is needed.

27. DISORDERS OF THE WRIST
AND HAND

28. Ganglion
 cystic swelling arising from a joint or tendon
sheath that occurs most commonly over the
dorsum of the wrist.
 It is lined with synovium and contains thick
jellylike fluid
 Swelling to discomfort
 TX: aspiration and CS injection

29. De Quervain’s Tenosynovitis
 Repetitive activity that involves pinching with the
thumb while moving the wrist.
 New mothers as a complication of pregnancy,
lifting babies
 Pain, tenderness, ±swelling over the radial styloid
 Finkelstein test: pain increases when the thumb is
folded across the palm and the fingers are flexed
over the thumb as the examiner passively
deviates the wrist toward the ulnar side
 TX; splinting, NSAIDs, CS injection

30. Intersection Syndrome
 Occur in the radial side of the wrist.
 involves the site of the intersection and crossing
of the extensor carpi radialis longus and brevis
with the abductor pollicis longus and the extensor
pollicis brevis, which is about 4 cm from the wrist.
 Pain is present and worse with radial or twisting
motions.
 Cause: racket sports, skiing, canoeing, and
weight lifting.
 Tx: rest with possibly a thumb splint, NSAIDs, ice,
and a local steroid injection.

32. Tenosynovitis of the Wrist
 occurs in other flexor and extensor tendons of the
wrist
 Localized pain and tenderness, sometimes
swelling.
 Pain on resisted movement is often seen.
 Cause: repetitive use, trauma, inflammatory
arthritis, idiopathic.
 TX: avoiding overuse, splinting, and NSAIDs. A
local corticosteroid injection into the tendon
sheath

33. Pronator Teres Syndrome
 The median nerve is compressed at the level of
the pronator teres muscle.
 Aching in the volar aspect of the forearm,
numbness in the thumb and index finger,
weakness on gripping with the thumb, and
writer’s cramp.
 Tenderness of the proximal part of the pronator
teres aggravated by resistive pronation of the
forearm.

34. Anterior Interosseous Nerve
Syndrome
 Compression of the anterior interosseous nerve
near its bifurcation from the median nerve
produces weakness of the
 flexor pollicis longus,
 flexor digitorum profundus,
 pronator quadratus muscles.
 Sensation is not affected
 cannot form an O with the thumb and index
finger

35. Radial Nerve Palsy
 spiral groove syndrome
(bridegroom palsy,)- radial nv
compressed against the
humerus.
 wrist drop with flexion of MCP
and adduction of thumb
 Anesthesia in the web space and
hypesthesia from the dorsal
aspect of the forearm to thumb,
index, and middle fingers
 crutches or prolonged leaning of
the arm over the back of a chair
(Saturday night palsy), weakness
of the triceps and brachioradialis
muscles

36. Posterior Interosseous Nerve
Syndrome
 Posterior interosseous nerve entrapment in the
radial tunnel produces discomfort in the proximal
lateral portion of the forearm

37. Superficial Radial Neuropathy
(Cheiralgia Paresthetica)
 Burning or shooting pain and sometimes
numbness and tingling over the dorsoradial
aspect of the wrist, thumb, and index fingers.
 Hyperpronation and ulnar wrist flexion may be
provocative

38. Carpal Tunnel Syndrome
 paresthesias and numbness in the hands.
 The median nerve and flexor tendons pass
through a common tunnel at the wrist, whose rigid
walls are bounded dorsally and on the sides by
the carpal bones, and on the volar aspect by the
transverse carpal ligament

39. Carpal tunnel sdr
burning pain or tingling in the hand are common, often occurring during the
night and relieved by vigorous shaking or movement of the hand.
sensation of hand swelling when in fact no swelling is visible.
Occasionally the pain spreads above the wrist into the forearm or, rarely,
even above the elbow and up the arm.
Bilateral disease is common.

40. Causes and TX
 Pregnancy
 trauma
 Osteophytes
 ganglia
 tuberculosis, histoplasmosis, sporotrichosis,
coccidioidomycosis, rubella.
 Rheumatoid arthritis
 gout,/pseudogout, and other infl ammatory diseases of the
wrist can
 multiple myeloma
 myxedema and acromegaly
 Tx: milder cases, splinting the wrist in a neutral position;
Local injections of corticosteroids into the carpal tunnel
area, to surgical decompression of the tunnel by release of
the transverse carpal ligament

41. Ulnar Nerve Entrapment at
the Wrist
 ulnar nerve, on entering
Guyon’s canal, bifurcates into
the superficial and deep
branches
 pain, numbness,paresthesias
of the hypothenar area,
clumsiness,and a weak hand
grip; atrophy of hypothenar
area
 Causes: trauma, ganglia,
bicycling, inflammatory
arthritis, flexor carpi ulnaris
hypertrophy, fractures,

42. Trigger Finger (Volar Flexor
Tenosynovitis)
 Inflammation of the tendon
sheaths of the flexor digitorum
superficialis and flexor digitorum
profundus - extremely common
 Pain in the palm is felt on finger
flexion may radiate to the PIP and
MCP joints on the dorsal
 Dg:localized tenderness and
swelling of the volar tendon
sheaths.
 middle and index fingers are
most commonly involved
 nodule composed of fibrous tissue
can be palpated in the palm just
proximal to the MCP

43. Dupuytren’s Contracture
 thickening and shortening of the palmar fascia
 usually of the ring finger. The fifth, third,second
fingers are involved in decreasing order of
frequency
 Associated with DM, epilepsy, alcoholism
 Tx: Heat, stretching, ultrasound, and intralesional
CS injection to SX (Limited fasciectomy)

44. DISORDERS OF THE HIP
REGION

46. Trochanteric Bursitis
 Midle age F>M
 Aching over the trochanteric area
and lateral thigh.
 Walking, various movements,
and lying on the involved hip may
intensify the pain
 Dg; palpate the throchanteric
area and elicit point tenderness
 Pain worse with ER and
abduction against resistance
 Inseryion of gluteus medius and
minimus tendon
 Tx: CS injection, NSAIDs, weight
loss

47. Iliopsoas (Iliopectineal)
Bursitis
 Bursa: anterior to the
hip joint and lateral to
the femoral vessels
 Groin and anterior thigh
pain
 This pain becomes
worse on passive hip
hyperextension and
sometimes on flexion,
especially with
resistance.

48. Ischial (Ischiogluteal) Bursitis
 trauma or prolonged sitting on hard surfaces
 Pain when sitting or lying down, may radiate
down the back of the thigh.
 Dg:MRI and ultrasonography may be used to
confi rm the diagnosis.
 TX: Use of cushions and local CS injection

49. Piriformis Syndrome
 pain over the buttocks, often radiating
down the back of the leg as in sciatica;
limp
 tenderness of the piriformis muscle on
rectal or vaginal examination.
 Pain in the involved buttock is evident
on hip flexion, adduction and internal
rotation (FAIR)
 having the patient lie on the uninvolved
side with the upper knee resting on the
table. Buttock pain occurs when the
knee of the involved side is lifted

50. Meralgia Paresthetica
 lateral femoral
cutaneous nerve (L2–
L3)
 intermittent burning pain
associated with
hypesthesia and
sometimes with
numbness of the
anterolateral thigh.
 DM, pregnant, obese,
tight clothing
 Tx: CS injection to
medial to the anterior
superior iliac spine

51. Coccydynia
 pain in the coccyx area when pressure is applied,
with sitting most commonly
 patient squirms from buttock to buttock to relieve
the pressure and consequent pain, often chooses
to sit on a cushion
 F>M; due to lordosis which exposes coccyx to
trauma

52. DISORDERS OF THE KNEE
REGION

54. Popliteal Cyst (Baker’s cyst)
 Patient standing, examined from behing
 Associated with any disease having synovial
effusion: OA, RA
 A syndrome mimicking thrombophlebitis may
occur with rupture
 Dg: US
 Tx: CS injection/ surgery

55. Anserine Bursitis
 overweight, middle-aged to elderly
F w/ big legs and OA of the knees
 pain and tenderness over the
medial aspect of the knee about 2″
below the joint margin.
 Pain is worse by climbing stairs.
 TX: rest, stretching of the adductor
and quadriceps muscles, and CS
inj

56. Prepatellar Bursitis
 Swelling superficial to knee cap
 “housemaid knee”
 Consider septic prepatellar bursitis
(trauma, knee abrassion)

57. Medial Plica Syndrome
 Patella pain may be the predominant complaint,
and snapping or clicking of the knee, a sense of
instability, and possible pseudolocking of the knee

58. Popliteal Tendinitis
 Pain posterolateral of the knee secondary to
tendinitis of the popliteal tendons (hamstrings and
popliteus)
 Knee flexed at 90 degrees, tender to palpation
 Pain with running downhill
 Tx: rest, conservative

59. Pellegrini–Stieda Syndrome
 calcification of the medial collateral ligament of
the knee.

60. Patellar tendinitis
 jumper’s knee
 athletes engaging in repetitive running, jumping,
or kicking activities.
 Pain and tenderness are present over the patellar
tendon
 Dg: US
 Tx:rest, NSAIDS,
CS injection

61. Rupture of Quadriceps Tendon
and
Patellar Tendon
 sudden violent contractions of the quadriceps
muscle when the knee is flexed.
 trauma from sports, systemic diseases (CKD,
RA, hyperPTH, gout, SLE on steroids
 sudden sharp pain and cannot extend the leg
 Rx: high riding patella
 Tx:surgery

62. Peroneal Nerve Palsy/ FOOT
DROP
 painless foot drop with a steppage gait
 Sensation decreased
 Causes: Direct trauma, fracture of the lower
portion of the femur or upper portion of the tibia,
compression of the nerve over the head of the
fibula

63. Patellofemoral Pain Syndrome
 pain and crepitus in the patellar region
 Stiffness occurs after prolonged sitting and is
alleviated by activity; overactivity involving knee
flexion, particularly under loaded conditions such
as stair climbing
 pain occurs when the patella is compressed
against the femoral condyle or when the patella is
displaced laterally.
 Tx: analgesics, NSAIDs, ice, rest, isometric
strengthening
exercises for the quadriceps

64. DISORDERS OF THE ANKLE
AND
FOOT REGION

65. Achilles Tendinitis/ tendon
rupture
 Causes: trauma, athletic overactivity, improperly
fitting shoes with a stiff heel counter, inflammatory
dx (AS, reactive arthritis, gout, RA, CPPD; FK use
 Pain, swelling, and tenderness occur over the
Achilles tendon
 Rupture: occurs with a sudden onset of pain
during forced dorsiflexion
 Subcutaneous Achilles Bursitis
A subcutaneous bursa superficial to the
Achilles due to shoes pressure

66. Retrocalcaneal Bursitis
 Pain at the back of the heel, tenderness of the
area anterior to the Achilles tendon, and pain on
dorsiflexion.
 Local swelling is present, with bulging on the
medial and lateral aspects of the tendon
 Dg: MRI/ US

67. Plantar Fasciitis
 Pain in the plantar area of the heel arising and is most
severe for the first few steps.
 After an initial improvement, the pain may worsen
later in the day, especially after prolonged standing or
walking.
 The pain is burning, aching, and occasionally
lancinating.
 Palpation typically reveals tenderness anteromedially
 Tx: NSAIDs, use of heel pad or heel cup orthoses,
arch support, and stretching of the heel cord and
plantar fascia

68. Posterior Tibial Tendinitis/
rupture
 Pain and tenderness just posterior to the medial
malleolus occur in posterior tibial tendinitis.
 Cause: trauma, excessive pronation, RA, or
spondyloarthropathy.
 pain is present on resisted inversion or passive
eversion.

69. Peroneal Tendon Dislocation
and Peroneal Tendinitis
 Ankle sprain
 dorsiflexion with eversion
 severe pain and tenderness of the tendon area
that lies over the lateral malleolus

70. Hallux Valgus

71. Bunionette
 prominence of the 5th MT head from the overlying
bursa and a localized callus

72. Hammer Toe
2nd toe
 PIP joint is flexed and
the tip of the toe
points downward.

73. Metatarsalgia
 Pain arising from the metatarsal heads
 Pain on standing and tenderness on palpation of
the metatarsal heads are present.
 Calluses over the metatarsal heads are usually
seen.

74. Pes Planus/ Pes Cavus

75. Morton’s Neuroma
 Middle-aged women
 entrapment neuropathy of the
interdigital nerve occurring most
often between the 3rd and 4th
toes.
 Paresthesia and a burning,
aching pain in the 4th toe worse
with walking on hard surfaces
or wearing tight shoes or high
heels
 Tx: metatarsal bar or a local CS
into the web space or surgical
excision of the neurom

76. Tarsal Tunnel Syndrome
 posterior tibial nerve is compressed
at or near the flexor retinaculum
 the nerve divides into the medial
plantar, lateral plantar, and posterior
calcaneal branches.
 The flexor retinaculum is located
posterior and inferior to the medial
malleolus.
 Numbness, burning pain, and
paresthesias of the toes and sole
extend proximally to the medial
malleolus.
 relief by leg, foot, and ankle
movements.

77. DISORDERS OF THE ANTERIOR
CHEST WALL

78.  Tietze’s syndrome : gradual or abrupt with
swelling usually occurring in the second or third
costal cartilage. Pain, which ranges from mild to
severe, may radiate to the shoulder and be
aggravated by coughing, sneezing, inspiration, or
by movements affecting the chest wall.
Tenderness with palpation, and approximately
80% of patients have a single site.
 Costochondritis is more common; pain and
tenderness of the chest wall, without swelling.
Tenderness is present over more than one
costochondral junction, and palpation should
duplicate pain
 Xiphoid cartilage syndrome or
xiphoidalgia/xiphodynia, is pain over the xiphoid
area and tenderness on palpation. Pain may be
intermittent and brought on by overeating and
various twisting movements.

79. FINALLY DONE!!!
Reference:
Primer on the Rheumatic diseases
13th edition
&
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