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SOFT TISSUE PAINS
Nilesh Baxi
Family Physician, Tardeo, Mumbai 400 007.
The conditions described in this article are caused mostly by simple non-serious disease afflicting.• Tendons
• Tendinous attachment to bone
• Supporting collagen tissue
• Entrapped peripheral nerves
Most of these conditions require very simple management like local steroid injection, proper splinting and proper education to the patient
Bursitis
Olecranon bursitis - Miner’s elbow, student elbow, drunkard’s elbow
Ischial bursitis - Weaver’s bottom
Prepatellar bursitis - Clergyman’s knee, nun’s knee, housemaid’s knee~ Repeated trauma is the commonest cause and some occupations predispose to the formation of inflamed bursae.
~ Bursitis may also be associated with infection, urate crystals, RA etc.
~ The presentation may be acute or chronic.
~ Inflamed bursae must be aspirated and examined for crystals as well as cultured bacteriologically + for Mycobacterium tuberculosis.
~ Aspiration leads to pain relief and if infection is ruled out a local steroid injection will cure it. Chronic and recurrently inflamed bursae will require excision.
~ Do you know that there are more than 150 bursae in the whole body?
Dequervain’s Tenosynovitis
Tenosynovitis of the extensor pollicis brevis and abductor pollicis longus causes pain and tenderness over the radial side of the wrist.
O/E there may be swelling over the radial styloid.
Finkelstein test is diagnostic : make a fist with the thumb folded into the palm.
Then deviate the first gently to the ulnar side. Due to stretch on the inflamed tendon, there is sudden exacerbation of the pain.
Management : Local steroid injection with 1% lignocaine in the tendon sheath rapidly relieves the pain. Rarely, surgery may be required.
Enthesopathies
Enthesopathy denotes painful conditions characterised by inflammation at the site of attachment of tendons and ligaments to bone. Tennis elbow, Golfer’s elbow, tenderness over iliac crest and ischial tuberosity, achilles tendinitis, plantar fasciitis etc.
Lateral epicondylitis (Tennis elbow) and Medical epicondylitis (Golfer’s elbow) are usually caused by repetitive movements involving the long extensors of the hands and fingers or long flexors of the hands and fingers respectively. Decorating, book binding, window cleaning, golf, tennis etc. precipitate these. The pt. C/o of pain at the elbow radiating to the hand,.
O/E tenderness 1/2-1 cm distal to the lateral or medial epicondyle.
Treatment : Local steroid injection, ultrasound and elbow band.
Tenderness over iliac crest and ischial tuberosity, Achilles tendinitis, plantar fasciitis are usually associated with HLA-B27 spondyloarthropathies. Achilles tendinitis and plantar fasciitis are discussed briefly in The painful foot.
Entrapment Neuropathies
The peripheral nerves may be compressed at various levels during their course. This may give rise to pain, paraesthesia and weakness distal to the site of the lesion.
Carpal tunnel syndrome is the commonest nerve entrapment syndrome. This may be a purely local mechanical problem or rarely secondary to pregnancy, RA, Myxoedema, diabetes mellitus, acromegaly, Colle’s # or # of scaphoid bone.
Presentation
• Severe pain in the hand especially at night
• On shaking the hand several times the pain disappears
• The pain may radiate to elbow, shoulder
• Paraesthesia over thumb, index and middle fingers
•At times weakness in holding a pen or a book between thumb and index finger
O/E
• Diminished or lost sensation over thumb and lateral 2 fingers
• Weakness of thumb abduction
• Tinel’s sign - tapping the median nerve at the wrist causes pain in the fingers
• There may be wasting of the thenar muscles
• Delayed conduction of the median nerve at the wrist
Treatment
Mild to moderate cases
• Wearing a resting wrist splint at night
• A short acting diuretic
• A local steroid injection
Severe cases
• Surgical release of the flexor retinaculum.
Disease Nerve involved Site of pressure Symptoms+signs Saturday night palsy Radial Axilla Wrist drop Ulnar tunnel syn. Ulnar Behind medial epicondyle Pain on medial side of forearm and pain + loss of sensation of 4th and 5th fingers Ulnar carpeltunnel Ulnar Between pisiform and hook of hamate Weakness of intrinsic muscles and loss of sensation of 4th and 5th fingers Carpal tunnelsyn. Median Below flexor retinaculam Pain, paraesthesia + impaired sensation of thumb, index and middle finger Meralgiaparaesthetica Lat. Cutaneousnerve of the thigh Medial to ant. sup. iliac spine Pain and impairedsensation on lateralAspect of the thigh Common peroneal nerve compression Common peroneal Neck of fibula Shin pain, dorsum of the foot pain and foot drop Tarsal tunnel syn. Posterior tibial Flexor retinaculum Pain and paraesthesia of the sole • Thenar wasting is an absolute indication for surgery.
Fibrositis
Trunk and limb pain is accompanied by tenderness over several trigger points but without any objective signs. Inadequate deep sleep may contribute towards this condition. This condition may complicate painful neck and low backache due to other causes.
O/E consistent trigger points or tender spots or such points can be demonstrated. Do you know that apart from other trigger points, there are 14 well described trigger points:
Bilateral - on trapezius, 2nd costochondral junction, 1-2 cms distal to lateral epicondyles, supraspinatus, gluteus medius, medial fat pad of the lower part of the thigh.
Central - lower cervical and lumbar spine.
Treatment : Tricyclic antidepressants at night, soft collar at night, heat therapy, TNS, acupressure, massage may be helpful. Reassurance and education of the patient is very important.
Hypermobile joints
Ever noticed hypermobile or lax joints in young or middle aged person, c/o vague aches and pains which may be related to hands, knees and lower lumbar spine. The pain is aggravated by injury. It may be associated with Turner’s syndrome, Down’s syndrome, Marfan’s syndrome, Ehler-Danlos syndrome, homocystinuria, osteogenesis imperfecta, varicose veins, prolapsed mitral valve etc. In most of the cases there is no evidence of any underlying disease although it may be familial. Hypermobility in gymnasts and ballet dancers is due to training and not disease.
Hypermobility is demonstrated (bilateral) by,
• Touching the radial aspect of the forearm with the thumb
• Hyperextending elbow by more than 10o
• Hyperextending knee by more than 10o
• Hyperextending little finger to 90o
• Placing hands flat on the floor while standing with the knees straight
Beside repeated reassurance, there is no specific treatment. These patients develop OA earlier than normal population.
Trigger finger and thumb
The flexor tendons of the fingers move smoothly inside a covering fibrous sheath. Thickening or nodule formation in either the tendon or its fibrous sheath can lead to triggering i.e. sudden snapping and straightening of finger or thumb which was lagging behind. The middle and ring fingers are commonly affected. Injecting local steroid around the thickening or the nodule at the MP joint generally leads to quick cure. Rarely surgical division of the tendon sheath is required.
Body Weight Ideal Overweight Underweight Calories 30 kcal/kg Sedentary 1800 HMW 2200 20 kcal/kg
10% OW 1600
20% OW 1400
30% OW 120040 kcal/kg
10% UW 2000
20% UW 2200-2400
30% UW 2600-3000HMW = Heavy Manual Work; OW = Over Weight; UW = Under Weight
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