|
Introduction: At some time
in the course of life, virtually everyone will experience pain
in a tendon, muscle, or other �soft tissue� location. In this
sense, conditions know as regional pain syndromes (RPSs)
may be the most common rheumatic illnesses known to man.
Some of these ailments, however, will be severe enough that
they will be brought to the attention of a health care
professional.
Technically, RPSs are not arthritis
(inflammation of the joint) but usually represent tendinitis
(inflammation of the cord-like tendons attaching muscles to
bones) or bursitis (inflammation of the pouch-like bursa that
provides cushioning to bony surfaces). Most commonly, they
arise from overuse of the affected part of the body.
Consequently, most individuals with these conditions have a
good long-term outlook. Less commonly, a RPS may be the sign
of another inflammatory arthritic condition, such as
rheumatoid arthritis (RA), ankylosing
spondylitis (AS), or psoriatic arthritis (PsA)
or part of the condition know as fibromyalgia (see
related sections).
Features of RPSs:
The main symptoms that prompt a patient with a RPS to seek
medical care are pain and loss of function. The pain is
usually worse with activity of the affected area but if the
injury or inflammation is particularly intense, symptoms may
be present at rest. Because of the large number of RPSs that
may be observed, we will group them together according to the
region of the body affected.
Shoulder: Because the shoulder is
the most mobile joint in the body, it is prone to injury and
overuse of its many surrounding soft tissues. The group of
tendons known as the rotator cuff allows for normal
shoulder motion but may be injured or inflamed for various
reasons. There is also a major bursa in the shoulder that can
be a source of pain. Because it is often difficult to
differentiate rotator cuff tendinitis from bursitis, these
conditions are often lumped together under the heading of
impingement syndrome, named for the �catching� sensation
that occurs with motion of an affected shoulder. When more
extensive damage occurs, a partial or complete tear of the
rotator cuff may occur.
The biceps tendon, which runs along the front
of the upper arm, may also be a source of pain when the
attachment site in the front part of the shoulder is
irritated. In such patients, the symptoms are more localized
to this region. When the structure enclosing the shoulder
known as the joint capsule becomes inflamed or scarred,
severe limitation of motion typically occurs, a condition
known as adhesive capsulitis or �frozen shoulder.�
This disorder can also occur after injury to the shoulder, as
a consequence of a pinched nerve in the neck, or as a
complication of diabetes.
Elbow: Muscles that allow for use
of the forearm are attached to bony knobs on either side of
the elbows known as epicondyles. Injury or inflammation
to these attachment sites causes localized pain that is
aggravated by prolonged use of the hands or wrists, a
condition known as epicondylitis. When occurring on the
outer, or lateral, side of the elbow, the common term
for this condition is �tennis elbow,� while when occurring on
the inner, or medial, side of the elbow, many refer to
this condition as �golfer�s elbow.� Nonetheless, one does not
have to play these sports to experience these conditions.
On the tip of the elbow is a structure known as
the olecranon bursa. After repetitive pressure or
injury to the elbow or sometimes because of an inflammatory
disease such as RA or gout, swelling may develop in this area
as a result of bursitis. When bacteria invade through the
skin, the bursa may become infected, requiring drainage of the
fluid and antibiotics.
In the region that most people refer to as the
�funny bone,� there is a nerve that is exposed in a small
groove on one side of the medial epicondyle. This groove
encloses the ulnar nerve, which supplies sensation to a
portion of the hand and is known as the cubital tunnel.
Cubital tunnel syndrome is caused by pressure to this nerve by
either prolonged resting of the elbow on a hard surface or
inflammation of the elbow joint, which reduces the space
available to the nerve. Numbness or pain of the 4th
and 5th fingers is the most common symptom.
Hand and Wrist:
Just as the elbow has the cubital tunnel, the wrist has the
carpal tunnel, located on the palm side of the wrist,
enclosed by a fibrous band, and containing many tendons,
arteries, and nerves. When pressure increases inside this
region, pressure is placed on the median nerve,
resulting in the common condition known as carpal tunnel
syndrome. Patients with this ailment typically report
pain, numbness, and/or weakness of the hand and wrist,
particularly in the thumb through middle finger. Job-related
overuse is a common cause, but not the only contributor to the
development of carpal tunnel syndrome. Inflammatory conditions
such as RA, hormonal conditions such as thyroid disease, and
pregnancy are among the many illnesses that can lead to this
condition.
A ganglion cyst is an area of localized
swelling that most commonly occurs on the back of the hand or
wrist. This cyst is often a consequence of prolonged use and
form as the lining around the joint or tendon fills up with
fluid. The ganglion cyst may not be painful, and many patients
tolerate this lesion very well. Only if the cyst enlarges
quickly is it typically associated with pain.
Because there are many tendons leading into the
hand, acting as �pulleys� on the fingers, there are many forms
of tendinitis that can affect the hand or wrist. When pain
and/or swelling occur at tendons at the base of the thumb,
this condition is known as DeQuervain�s tenosynovitis.
Swelling of the tendons on the palm side of the hand may
produce a painful locking or snapping sensation when the
finger is flexed, known as stenosing tenosynovitis or
�trigger finger.� Inflammatory diseases as well as
prolonged pressure to the hand (use of a cane, for example)
may all precipitate this condition. More extensive thickening
of the soft tissues on the hands may produce incomplete
opening of the hand, a condition known as Dupuytren�s
contracture, often found in the setting of diabetes or
alcoholism but also occurring without a known cause in some
patients.
Hip: The hip joint is located
deep in the groin, and patients with true hip joint disease
usually experience pain in this region. Bursitis of this
region is more often the cause of what patients experience as
hip pain. There are three sets of bursa in the hip: the
trochanteric bursa on the outside of the hip and thigh,
the ischial bursa on the buttock, and the iliopsoas
bursa in the groin.
Trochanteric bursitis is often caused by
tightness a muscle along the side of the buttock and thigh,
which is connected to a tendon known as the iliotibial band.
This irritates the bursa and often leads to a �snapping�
sensation along the side of the hip. Ischial bursitis is
commonly experienced on the buttock and is aggravated by
sitting on hard surfaces. Iliopsoas bursitis can easily be
confused with hip joint disease due to its location in the
groin but is associated with normal hip range of motion.
Another condition causing pain in the front
portion of the thigh caused by compression of the lateral
femoral cutaneous nerve is termed meralgia paresthetica.
Patients with this problem often feel a burning or tingling
sensation in the region supplied by the nerve. Tight fitting
clothing may contribute to the development of meralgia
paresthetica, but a cause cannot be clearly found in many
affected individuals. Thankfully, this disorder is often
short-lived.
Knee: The knee is a common joint
to become involved in a number of forms of arthritis, but the
soft tissues around the knee may also be sources of pain. A
major cause of symptoms in some individuals is due to injury
or inflammation of a bursa on the inner area below the knee,
known as anserine bursitis. This region may be swollen,
and patients often report that they must sleep with a pillow
between their legs at night to avoid placing pressure on the
inflamed structure. When the swelling and pain occur over the
kneecap, this disorder is known as prepatellar bursitis,
which is often caused by prolonged kneeling or inflammatory
diseases such as gout.
In the back of the knee, some of the lining of
the joint or hamstring tendons may produce an area of swelling
known as a Baker�s cyst. This condition often arises
from underlying osteoarthritis or RA affecting the knee and
may or may not be associated with pain. This cyst, however,
can rupture and cause swelling and pain in the calf in a
minority of patients.
Foot and Ankle: As
is seen in the hand and wrist region, there are a number of
tendons that can become injured or inflamed in the area of the
foot and ankle. Tendinitis may affect the posterior tibial
tendon, located above the instep on the inside of the
ankle, the Achilles tendon, located in the back of the
heel, or a number of tendons on the top of the foot and ankle
region. Individuals wearing shoes that apply pressure to the
heel may develop pain and swelling in the heel known as
retrocalcaneal bursitis, or �pump bumps.� There is
also a fibrous layer of tissue on the bottom of the foot that
attaches to the bottom of the heel that may become irritated
or inflamed, leading to a common condition known as plantar
fasciitis. Patients with this disorder often feel their
most intense pain in this region when first stepping out of
bed in the morning or after a prolonged period of rest. RPSs
of the foot and ankle region are often due to strain and
overuse, but both AS and PsA must be considered when these
problems are encountered, as they are common manifestations of
these forms of arthritis.
A nerve supplying the first two toes and sole
known as the medial plantar nerve may be compressed by
swelling or irritation of the overlying tissues. The result is
numbness and/or burning pain along the area this nerve
supplies. This is known as tarsal tunnel syndrome,
analogous to carpal tunnel syndrome of the hand and wrist
region. Those with flatfoot deformities abnormal angulation of
the ankle, or an inflammatory disease in this region are prone
to developing this problem.
In the ball of the foot, between the �web
spaces� of the toes are nerves that supply sensation to each
toe. When the bones are pushed together, these nerves can
become irritated and develop an area of swelling known as a
Morton�s neuroma. Patients with this problem often
experience a burning pain in the toes, at times accompanied by
numbness. Choices in footwear often play a major role in the
development of this condition, and women wearing high heels or
other tight-fitting shoes typically are at greatest risk for
developing a Morton�s neuroma.
Back and Neck:
While osteoarthritis often contributes to lower back and neck
pain, perhaps the most common reason for these problems is
strain to the soft tissues around the vertebrae. These
problems may be a result of repetitive strain or one-time
injury but don�t always have a clear-cut cause. Occasionally,
a knotted up muscle, known as a �trigger point� may be
observed. A more specific condition that occurs in the lower
back and buttock is piriformis syndrome. Patients with
this disorder have localized pain on one side or the other
that may radiate down the leg and mimic sciatica. It is
caused by a muscle that becomes tight and painful and which
may place pressure on the sciatic nerve. At the base of the
neck near the midline, swelling and pain can occur in a
process known as interspinous bursitis. In most
patients with lower back or neck pain, however, it is
difficult to pinpoint a specific region responsible for the
symptoms even in the hands of the most skilled physician.
Chest: Any type of chest pain can
be alarming, given the high prevalence of heart disease in the
United States. In many patients, however, the chest wall
itself is the cause of the pain. The muscles of the chest wall
may become strained or injured, but another condition may
occur affecting the cartilage joining the ribs to the sternum
(breastbone) known as costochondritis. These patients
are often tender over a well-localized area on the chest and
less commonly may exhibit swelling over this region, which is
sometimes referred to as �Tietze�s syndrome.�
Diagnosis: Most RPSs can
be diagnosed by a careful review of the symptoms and an
examination by the health care professional. The location of
the pain and the activities that aggravate symptoms will
typically suggest on of the above conditions. When the
practitioner examines a patient, he/she will be able to elicit
pain in the affected area with pressure, motion, or a number
of maneuvers that the patient is asked to perform.
Laboratory testing is not necessary for the
vast majority of RPSs unless a concurrent inflammatory
rheumatic disease such as RA is suspected. Similarly, x-ray
studies are not needed in the vast majority of patients, and
if the problem is only in the soft tissues, plain x-rays will
not be able to image these areas. If the RPS is a part of a
disease such as AS or PsA, an area of �reactive bone� will
occasionally be seen where the tendon or ligament inserts.
Magnetic resonance imaging (MRI) is useful to diagnose
complications such as tears or ruptures in the tendons (a
rotator cuff tear of the shoulder, for example) and in
selected cases to rule out other diagnoses but does not have a
role in the routine diagnosis of RPSs.
Therapy: Treating RPSs
involves a combination of medical therapy, stretching and
strengthening exercises, splinting or bracing, injections, or
in a few situations surgical treatment.
Non-steroidal anti-inflammatory drugs (NSAIDs)
such as ibuprofen (Motrin) and naproxen (Naprosyn) are often
effective at relieving the symptoms of RPSs. When used
short-term (a few weeks or less), these medications are
generally quite, but more long-term use can be associated with
damage to the lining of the stomach, uncommonly progressing to
bleeding ulcers, and reduced kidney function. Analgesics
such as acetaminophen (Tylenol), tramodol (Ultram), or
propoxyphene (Darvon, Darvocet) may also reduce symptoms but
lack the anti-inflammatory effect of NSAIDs and treat the
problem less directly.
Exercises that promote stretching and/or
strengthening of the involved region are the mainstay of
therapy in most RPSs and reduce the tension of inflamed
tendons or muscles. While results are not immediate, the
benefit eventually achieved will typically be more durable. In
fact, the vast majority of patients who do not feel exercises
helped their RPS never truly performed the exercises
consistently or for a sufficient period of time. In certain
situations, the help of a physical or occupational therapist
may be useful to help supervise an exercise program.
Splints or braces over an
inflamed or painful tendon or other soft tissue structure
helps rest this region and allow it to heal. Some splints may
be difficult to wear during certain activities during the day
but can be valuable in protecting painful muscles or tendons
from overuse. These devices are less useful in the larger
joints such as the shoulder or hip but are quite helpful in
treating RPSs of the hand, wrist, foot, and ankle in
particular. Some of these items can be purchased over the
counter at the pharmacy, but many patients achieve better
results with a custom-made splint fashioned by a therapist.
Injections of corticosteroids, with or
without local anesthetic, typically provide rapid relief of
symptoms for patients with a number of RPSs, and results may
be long-lasting. The risk of infection and other complications
is quite low, and while many areas are painful to inject, when
performed by a skilled practitioner the pain of the procedure
is brief and can be minimized. Most patients report more pain
from their underlying condition than from the injection
itself. These injections can be repeated, but to avoid
excessive scarring in the soft tissues the interval between
procedures in the same region should be no less than about
three months. When a number of successive injections are
required to relieve symptoms, other treatment options should
be considered.
Surgery has a role only in a minority of
patients with RPSs. Rotator cuff tears and other permanent
injuries may be appropriately referred to a surgeon, and
carpal tunnel syndrome, tendinitis of the hand/wrist, plantar
fasciitis, and other conditions listed above may also require
surgery if standard therapies listed above are without
benefit. The decision on when to pursue such procedures
requires a good deal of discretion on the part of the surgeon
and referring practitioner, but the patient is ultimately the
one who must make this decision based on the degree to which
the RPS is interfering with daily activities.
A combination of these therapies usually
results in satisfactory outcomes for the majority of patients
with RPSs. Using these tools, the primary care physician,
occasionally in conjunction with the specialist and physical
or occupational therapist working together with the patient�s
preferences will typically yield favorable results over time. |
