Other Miscellaneous Joint Other Miscellaneous Joint DiseasesDiseases

Ankylosing spondylitisAnkylosing spondylitis

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ASAS

Prevalence 0.1-0.2% M>F Prevalence 0.1-0.2% M>F Late teens to age 40 Late teens to age 40 More common in whites than in More common in whites than in nonwhites nonwhites HLA-B27 positivityHLA-B27 positivityChronic progressive disease and develop Chronic progressive disease and develop disability due to spinal inflammation disability due to spinal inflammation leading to fusion, often with thoracic leading to fusion, often with thoracic kyphosis or erosive disease kyphosis or erosive disease Worse during first 10 yearsWorse during first 10 yearsBegins at sacroiliac joints Begins at sacroiliac joints

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SymptomsSymptoms

Morning stiffness and fatigue Morning stiffness and fatigue Fever and weight loss Fever and weight loss Radiation of pain into both buttocks Radiation of pain into both buttocks Criteria for diagnosis:Criteria for diagnosis:Morning stiffness that lasts more than 30 minutes Morning stiffness that lasts more than 30 minutes Improvement of back pain with exercise but not rest Improvement of back pain with exercise but not rest Nocturnal back pain during second half of the night Nocturnal back pain during second half of the night only only Alternating buttock pain Alternating buttock pain Achilles tendonitis, Plantar fascitisAchilles tendonitis, Plantar fascitis

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Signs:Signs:

Stooped posture and a stiff backStooped posture and a stiff backLoss of lumbar lordosis – straight backLoss of lumbar lordosis – straight backSchober test confirms-marking a 10-cm length Schober test confirms-marking a 10-cm length of the lumbar spine (with patient in the erect of the lumbar spine (with patient in the erect position), starting at the fifth lumbar spinous position), starting at the fifth lumbar spinous process. Instruct the patient to maximally flex his process. Instruct the patient to maximally flex his or her spine. Remeasure the distance between or her spine. Remeasure the distance between the marks. Normal flexion increases the distance the marks. Normal flexion increases the distance by at least 5 cm. by at least 5 cm. Loss of chest expansion (<3-cm difference Loss of chest expansion (<3-cm difference between minimum and maximum chest diameter) between minimum and maximum chest diameter) late stage of disease late stage of diseaseEyes can be involvedEyes can be involvedAortic valvular leak can happenAortic valvular leak can happen

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TestsTests

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TherapyTherapy

NSAIDsNSAIDsTNF alphaTNF alphaSteroidsSteroidsMethotrexateMethotrexateMonitor with ESR, CRPMonitor with ESR, CRP

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Physical therapyPhysical therapy

Exercise program and postural trainingExercise program and postural trainingSpinal extension and deep-breathing Spinal extension and deep-breathing exercises exercises Maintaining an erect posture during Maintaining an erect posture during daily activities daily activities Sleeping on a firm mattress with a thin Sleeping on a firm mattress with a thin pillow also tend to reduce the tendency pillow also tend to reduce the tendency toward thoracic kyphosis. toward thoracic kyphosis. Water therapy and swimmingWater therapy and swimming

Myofascial Pain SyndromeMyofascial Pain Syndrome

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?Myofascial trigger points ?Myofascial trigger points (MTrPs).(MTrPs).

200 paired muscles 200 paired muscles Any one of these muscles can develop Any one of these muscles can develop myofascial trigger points (MTrPs). myofascial trigger points (MTrPs). MTrPs are hyperirritable tender spots in MTrPs are hyperirritable tender spots in palpable tense bands of skeletal muscle palpable tense bands of skeletal muscle that refer pain and motor dysfunction, that refer pain and motor dysfunction, often to another location. often to another location.

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Major clinical components:Major clinical components:

The TrPThe TrPThe taut bandThe taut bandThe local twitch responseThe local twitch response

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Latent TrPsLatent TrPs

Cause motor dysfunction:Cause motor dysfunction:Stiffness, Stiffness, Restricted range of motion without painRestricted range of motion without pain

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Active TrPs Active TrPs

Most common:Most common:postural muscles- postural muscles- of the neck, of the neck, shoulder, and pelvic girdles and shoulder, and pelvic girdles and the masticatory musclesthe masticatory musclesOthers: upper trapezius, scalene, Others: upper trapezius, scalene, sternocleidomastoid, levator scapulae, sternocleidomastoid, levator scapulae, and quadratus lumborum muscles and quadratus lumborum muscles

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Features of myofascial pain:Features of myofascial pain:

Results in palpable nodules and the taut Results in palpable nodules and the taut bands associated with TrPs. bands associated with TrPs. TrP triggers:TrP triggers:Acute overload, overwork fatigue, direct Acute overload, overwork fatigue, direct impact trauma, and radiculopathy impact trauma, and radiculopathy Patients with active MTrPs usually Patients with active MTrPs usually complain of poorly localized, regional, complain of poorly localized, regional, aching pain in subcutaneous tissues, aching pain in subcutaneous tissues, including muscles and joints. including muscles and joints. They rarely complain of sharp, clearly They rarely complain of sharp, clearly localized cutaneous-type pain. localized cutaneous-type pain.

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Disturbances of autonomic functions - Disturbances of autonomic functions - abnormal sweating, persistent abnormal sweating, persistent lacrimation, persistent runny nose, lacrimation, persistent runny nose, excessive salivation, and pilomotor excessive salivation, and pilomotor activities activities Proprioceptive disturbances- imbalance, Proprioceptive disturbances- imbalance, dizziness, tinnitus, and distorted dizziness, tinnitus, and distorted perception of the weight of lifted objects perception of the weight of lifted objects

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Loss of motor functions:Loss of motor functions:

Spasm of other muscles, weakness of Spasm of other muscles, weakness of the involved muscle function, loss of the involved muscle function, loss of coordination by the involved muscle, and coordination by the involved muscle, and decreased work tolerance of the involved decreased work tolerance of the involved muscle. muscle.

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Taut band Taut band

By gently rubbing across the direction of By gently rubbing across the direction of the muscle fibers in a superficial muscle, the muscle fibers in a superficial muscle, the examiner can feel a nodule at the the examiner can feel a nodule at the MTrP and a ropelike induration that MTrP and a ropelike induration that extends from this nodule to the extends from this nodule to the attachment of the taut muscle fibers at attachment of the taut muscle fibers at each end of the muscleeach end of the muscleThe taut band can be snapped or rolled The taut band can be snapped or rolled under the finger in accessible muscles. under the finger in accessible muscles. With effective inactivation of the TrP, this With effective inactivation of the TrP, this palpable sign becomes less tense and often palpable sign becomes less tense and often (but not always) disappears, sometimes (but not always) disappears, sometimes immediately immediately

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Tender nodule Tender nodule

Palpation along the taut band reveals a Palpation along the taut band reveals a nodule exhibiting a highly localized and nodule exhibiting a highly localized and exquisitely tender spot that is exquisitely tender spot that is characteristic of a MTrP. characteristic of a MTrP.

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Local twitch response:Local twitch response:

Snapping palpation of the TrP Snapping palpation of the TrP frequently evokes a transient twitch frequently evokes a transient twitch response of the taut band fibers. Twitch response of the taut band fibers. Twitch responses can be elicited both from responses can be elicited both from active and latent TrPs. active and latent TrPs.

2020

Diferential DiagnosisDiferential Diagnosis

FeatureFeature Myofascial Pain Myofascial Pain (TrPs)(TrPs)

FibromyalgiaFibromyalgia

Female-to-Female-to-male ratiomale ratio

1:11:1 4-9:14-9:1

PainPain Local or regionalLocal or regional Widespread, Widespread, generalgeneral

TendernessTenderness FocalFocal WidespreadWidespread

MuscleMuscle Feels tense (taut Feels tense (taut bands)bands)

Feels soft and Feels soft and doughydoughy

MotionMotion Restricted range Restricted range of motionof motion

HypermobilityHypermobility

ExaminationExamination Examine for TrPsExamine for TrPs Examine for Examine for tender pointstender points

REACTIVE ARHTRITISREACTIVE ARHTRITIS

Triad of-Triad of-1.1. Nongonococcal urethritis, Nongonococcal urethritis, 2.2. Conjunctivitis, and Conjunctivitis, and 3.3. ArthritisArthritisPreceded by bloody dysentery Preceded by bloody dysentery

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Associated with:Associated with:

Gastrointestinal infections- Gastrointestinal infections- Shigella Shigella Salmonella and Salmonella and Campylobacter species and Campylobacter species and Genitourinary infections (especially with Genitourinary infections (especially with Chlamydia trachomatis).Chlamydia trachomatis).Usually develops 2-6 weeks after Usually develops 2-6 weeks after infectioninfection

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Prognosis:Prognosis:

A self-limited course, with resolution of A self-limited course, with resolution of symptoms by 3-12 months symptoms by 3-12 months Has a high tendency to recur Has a high tendency to recur HLA-B27 positivityHLA-B27 positivityM:F 9:1 Age: 20-40 yearsM:F 9:1 Age: 20-40 years

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Symptoms/Signs:Symptoms/Signs:

Malaise, fever, prostatitis, epidydimitisMalaise, fever, prostatitis, epidydimitisLow-back pain, heel painLow-back pain, heel painAchilles or plantar fascia inflammationAchilles or plantar fascia inflammationSmall joints of the hands and feet – Small joints of the hands and feet – sausage shaped digitssausage shaped digitsPalm and soles skin exfloiation and Palm and soles skin exfloiation and pustulespustulesPenile foreskin inflammationPenile foreskin inflammationSymptomatic treatmentSymptomatic treatment

TM joint diseaseTM joint disease

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TMJ function:TMJ function:

Movements- side to side, up and down, Movements- side to side, up and down, as well as protrusion and retrusion. as well as protrusion and retrusion. This allows movements needed for This allows movements needed for speaking, chewing, and making facial speaking, chewing, and making facial expressions. expressions.

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Causes for TMJ disease:Causes for TMJ disease: Rheumatoid arthritis, osteoarthritisRheumatoid arthritis, osteoarthritisOther causes- hypermobile TMJs, Other causes- hypermobile TMJs, nocturnal jaw clenching, nocturnal nocturnal jaw clenching, nocturnal bruxism, jaw clenching due to bruxism, jaw clenching due to psychosocial stresses, and local trauma psychosocial stresses, and local trauma Trigeminal neuralgia of mandibular Trigeminal neuralgia of mandibular divisiondivisionIncidence: 10 million people have TMJ Incidence: 10 million people have TMJ F:M ratio is roughly 4:1F:M ratio is roughly 4:1Common in adults aged 20-40 years Common in adults aged 20-40 years

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Symptoms Symptoms

Muscles of mastication: dull ache, Muscles of mastication: dull ache, unilateralunilateralPain radiates to the ear and jaw and is Pain radiates to the ear and jaw and is worsened with chewing worsened with chewing When opening the mouth locking of the jaw When opening the mouth locking of the jaw Ear clicking or popping Ear clicking or popping Headache and/or neck ache Headache and/or neck ache A bite that feels uncomfortable A bite that feels uncomfortable Neck, shoulder, and back pain Neck, shoulder, and back pain Bruxism, teeth clenching Bruxism, teeth clenching

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SignsSigns

Limitation of jaw opening (normal range is at least 40 Limitation of jaw opening (normal range is at least 40 mm as measured from lower to upper anterior teeth) mm as measured from lower to upper anterior teeth) Palpable spasm of facial muscles (masseter and Palpable spasm of facial muscles (masseter and internal pterygoid muscles) internal pterygoid muscles) Unilateral facial swelling Unilateral facial swelling Clicking or popping in the TMJ Clicking or popping in the TMJ Tenderness to palpation of the TMJ via the external Tenderness to palpation of the TMJ via the external auditory meatus (the tips of the fingers placed behind auditory meatus (the tips of the fingers placed behind the tragi at each external acoustic meatus and pulled the tragi at each external acoustic meatus and pulled forward while the patient opens the jaw) forward while the patient opens the jaw) Crepitus over joint (in advanced disease) Crepitus over joint (in advanced disease) Lateral deviation of mandibleLateral deviation of mandible

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TestsTests

Non specificNon specificTreatment:Treatment:Analgesics - Nonsteroidal anti-Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs) inflammatory drugs (NSAIDs) Muscle relaxants - Benzodiazepines Muscle relaxants - Benzodiazepines Moist heat and massage of masticatory Moist heat and massage of masticatory muscles muscles