Soft Tissue Rheumatic Disorders

Abstract

By the end of this chapter, you should be able to:

Full text

461
© The Author(s) 2021
H. Almoallim, M. Cheikh (eds.), Skills in Rheumatology,
https://doi.org/10.1007/978-981-15-8323-0_22
Soft Tissue Rheumatic Disorders
RoaaMahroos andHaniAlmoallim
22.1 Introduction
Soft tissue disorders are common focal pathologi-
cal syndromes affecting soft tissue structures like
tendons, ligaments, bursa, fascia, and the site of
insertions of these structures to bones (enthesis).
They are commonly encountered disorders in
daily clinical practice particularly in outpatient
settings. A systemic disease does not always
accompany them;, however, they can be associated
with spondyloarthritis. They are most likely
caused by overuse, repetitive trauma, and occupa-
tional history. This chapter will present in a simpli-
ed approach different types of bursitis, tendinitis,
enthesitis, and fasciitis encountered in clinical
practice. The emphasis will be placed on diagnos-
tic workup based on comprehensive history- taking
skills and musculoskeletal (MSK) examination
ndings. Outlines of management principles will
be reviewed as most of these disorders respond to
conservative therapy (pain management, physio-
therapy, and avoidance of aggravating movements)
and it rarely needs surgical intervention. There are
other soft tissue disorders discussed in “Diabetes
and Rheumatology” Chap. 21. Detailed techniques
of MSK examination of several of these disorders
are discussed in Chap. 2.
22.1.1 Learning Objectives
By the end of this chapter, you should be able to:
• Discuss the anatomy and classication of
common soft tissue disorders (bursa, liga-
ments, tendons, and fascia) that cause local-
ized pain syndromes.
• Describe the clinical presentation of the most
common types of soft tissue disorders.
• Construct a diagnostic approach for different
types of soft tissue disorders.
• Outline management principles of these
disorders.
22.1.2 Classication ofSoft Tissue
Disorders
A selective group of soft tissue disorders will be
reviewed in this chapter based on the following
classication (Fig.22.1). It is based on the site of
involvement of these structures. It is important to
consider soft tissue disorders in the differential
diagnosis of regional pain syndromes.
R. Mahroos (*)
Doctor Samir Abbas Hospital (DSAH),
Jeddah, Saudi Arabia
e-mail: roaa.mahroos@dsah.sa
H. Almoallim
Medical College, Umm Al-Qura University (UQU),
Makkah, Saudi Arabia
e-mail: hmmoallim@uqu.edu.sa
22

462
1. Bursitis
Shoulder
Subacromial
bursitis
Scapulothoracic
bursitis
Elbow
Olecranon bursitis
Hip
Ischiogluteal bursitis
Greater trochanteric
bursitis
Knee
Prepatellar bursitis
Anserine bursitis
Gastrocnemius
semimembranosus
bursitis
2. Tendinitis
Achilles tendinitis Rotator cuff tendinitis
3. Enthesitis
Epicondylitis Achilles tendinitis Planter fasciitis
4. Fasciitis
Palmar fasciitis Eosinophilic fasciitis Planter fasciitis
Fig. 22.1 Classication of soft tissue disease in rheumatology
R. Mahroos and H. Almoallim

463
22.1.3 Bursitis
It is important to realize the anatomical denition
of a bursa in order to recognize the clinical pre-
sentation of bursitis. A bursa is simply the sac
structure that is formed of two layers lled with
synovial uid that protects other structure under-
neath it from injuries caused by pressure. This
sac acts as cushions. Bursitis is simply inamma-
tion of this sac.
The most common sites are shoulder (subdeltoid,
olecranon), hip (ischial tuberosity, trochanteric),
knee (prepatellar bursa), and foot (retrocalcaneal)
[1–9]. Table 22.1 represents a comprehensive a
general review of the clinical presentation, investiga-
tion, and treatment of bursitis. Table22.2 represents
a review of specic types of bursitis.
22.1.4 Tendinitis
A tendon is a thick brous cord that attaches
muscle to bone. Inammation in the tendon is
called tendinitis. The most common sites for ten-
(continued)
Table 22.1 Review of the Bursitis history, physical examination, investigation, and treatment
History • Pain: Assess duration, site, localization, increases with movement, relation to position,
interferes with activity, recurrence, other joint pains, stiffness, and functional disability (at
home, work, and leisure activities)
• Occupation: Repetitive movement disorder that increase pressure in the joint and its
surrounding soft tissue structures. For example, overhead lifting, pushing up elbows when
arising from bed, carrying heavy objects, prolong sitting on hard surface, and repeated
kneeling
• History of trauma: Systemic review for evidence of a systemic disease (see Chap. 1) like
rheumatoid arthritis (RA), crystal-induced arthritis (gout, pseudogout) and uremia
• History suggestive of infection: Fever, (infective endocarditis, cellulitis), skin abrasions in
supercial bursae (olecranon and prepatellar bursa) wounds, and diabetic, alcoholic [5–7]
and immunosuppressed patients are at increased risk of septic bursitis [8, 9]
• Obesity
Physical
examination
• Swelling: Mainly supercial
• Tenderness: With active range of motion (ROM) testing
• Reduced active ROM: With less or no pain with passive ROM
• Local tenderness: With palpation over the bursa
• In septic bursitis: Fever, swelling, redness, tenderness, and hotness [10]
Investigations 1. If history and physical examination suggest septic bursitis
a. CBC, blood culture, and glucose
2. Bursa uid aspiration: [11]
Deep bursa use US or MRI guided aspiration, and uid for
a. Cell count:
Normal WBC: less than 200/ L.
Noninammatory WBC: 200–2000/ L.
Inammatory WBC: 2000–100, 000/ L.
Septic bursitis WBC: may be exceeding 100, 000/ L
b. Gram stain and culture in liquid media: [10] It is
Positive in two-thirds of patients with septic bursitis [8].
The most common organisms: Staphylococcus aureus In about 80% of cases, [8, 9, 12,
13] streptococci beta-hemolytic strain, rare coagulase negative staph, Enterococcus, E.
coli, and Brucella, or TB in subacute and chronic endemic areas
c. Crystal analysis utilizing compensated polarized microscopy
d. Bursa uid glucose: Serum glucose ratio of <50% [14]
3. Imaging typically not helpful in acute supercial bursitis:
a. Plain X-ray: When there is history of trauma or foreign body and to exclude crystal-
induced arthritis particularly chondrocalcinosis
b. CT or MRI: Particularly in septic bursitis to conrm the presence of abscesses or uid
collection
22 Soft Tissue Rheumatic Disorders

464
Table 22.1 (continued)
Treatment 1. Patient education
a. Avoid aggravating factors that increase joints pressure
b. Joint protection program using cushion and pads
c. Rest joint position to decrease pressure
d. Weight reduction
2. Pain control and decrease inammation:
a. NSAIDs (see Chap. 4):
selective cyclooxygenase 2 inhibitor (celecoxib 200mg twice daily) or nonselective
(naproxen 500mg twice daily for few days in acute bursitis)
b. Local glucocorticoid injection:
after ruling out septic bursitis with negative culture
there is limited data on efcacy and safety;, in general it is more effective than NSAID in
speeding recovery, relieving pain, and preventing recurrence of olecranon and
subacromial bursitis [7]
long-acting glucocorticoid (methylprednisolone 40mg for large bursa, subacromial or
trochanteric, and 10mg for small bursa, anserine or Ischia) mixed with equal amount of
1% lidocaine
injection should not be repeated for 6–8 weeks
c. Apply ice for 20min 6–4 times per day
d. Heat not more than 20min
Septic bursitis:
treatment in immunocompetent or nondiabetic patients:
Oral antibiotic (dicloxacillin or second-generation cephalosporin or clindamycin) for 10
days if there is improvement
frequent aspiration of the bursa and continue antibiotic for 5days post sterilization
in severe cases and in immunosuppressed patients:
IV broad-spectrum antibiotic to cover pseudomonal plus anti-methicillin-resistant S.
aureus (MRSA) (vancomycin) for 2–3 weeks, till the culture and sensitivity results are
available [15]
repeat bursa drain and debridement or open surgical drain in deep bursitis
Table 22.2
Subacromial bursitis
Anatomy Subacromial bursa lies between acromion process and supraspinatus muscle at top of the
humorous
Bursitis results from inammation of supraspinatus tendon
Action of
supraspinatus
muscle
Abduction of the shoulder
Symptoms • severe pain at rest and movement of the affected shoulder
• prevent active movement
Signs • tenderness over the bursa just below the acromion
• this may extend over deltoid muscle
• tender and possibly restricted active ROM, while passive abduction is harmless with
possibility of mild tenderness
Treatment Pain is markedly relieved after injecting local anesthesia, immobilization, rest of the joint, and use
of NSAIDs
If not improving after 72 h, inject methylprednisolone 40mg with lidocaine
Comment It is associated with:
• rotator cuff tear that presents with supraspinatus muscle weakness
• polymyalgia rheumatic when it is usually bilateral
Scapulothoracic bursitis [2–4]
Anatomy The bursa is located in medial angle of scapula and adjacent to second and seventh ribs
Symptoms Pain and popping sensation with scapulothoracic movement
It increases with working overhead, pushing up, reaching up, and shoulder shrugging
Signs Localize tenderness and crepitus with movement
R. Mahroos and H. Almoallim

465
(continued)
Table 22.2 (continued)
Treatment • spontaneous regression in most of the patients [1]
• physiotherapy: Postural and scapular strengthening exercise [2]
• US heat stretching test might help
• if pain persists, glucocorticoid injections under uoroscopy might be considered
• surgery might be indicated in refractory cases [3]
Olecranon bursitis (student’s elbow) [9–12]
Anatomy The bursa is located just over the extensor aspect of the extreme proximal end of the ulna
Aggravated
positions
Leaning on elbow, repetitive forward leaning position, or any position where pressure
is exerted on the bursa
Symptoms Pain in the posterior point of the elbow with normal ROM
Signs Tenderness, worsening of pain with elbow exion, and swelling in posterior point of the elbow
Treatment Consider bursal uid aspiration if swollen to rule out septic and/or crystal-induced bursitis
Treat underlying condition if sepsis or crystal-induced bursitis have been conrmed.
Glucocorticoid injection is superior to NSAIDs in preventing recurrent bursitis [4]
Referral to orthopedic surgery if recurrent with thick synovium
Ischiogluteal bursitis (Weaver’s bottom)
Anatomy The bursa is located between gluteus medius muscle and ischial tuberosity
Symptoms Pain in sitting and lying position. Also, pain in lower buttock after prolonged sitting
On hard surfaces
Signs Tenderness over ischial tuberosity
Treatment NSAIDs, glucocorticoid injection, foam rubber cushion, and stretching with knee to chest exercise
Greater trochanteric bursitis
Anatomy The bursa is located between the tendon of gluteus medius and posterolateral prominence of
greater trochanter
This bursitis is more common in females rather than males
Symptoms Night pain, lateral hip pain, 40% radiate to the lateral site of the thigh, worsening if lying on
affected side, and patient cannot walk in severe case
Iliotibial band syndrome (snapping hip) and leg length discrepancy predispose patients to develop
trochanteric bursitis
Signs • tenderness on lateral hip joint pain region over the greater trochanter
• hip joint resisted hip abduction may reproduce symptoms
• antalgic gait
Notes:
The differences between greater trochanteric bursitis and gluteus medius tendinopathy are gluteus
medius tendinopathy causes pain and tenderness superior to the greater trochanter, positive
Trendelenburg test, signicant muscle weakness, and positive one—Leg mini-squat test, patient
cannot complete a single repetition squat on affected leg to 60°
Recommended X-ray: Lateral, anteroposterior, and frog-leg views to rule out other causes
affecting hip joint itself
Treatment Radiating radicular pains from the lower back need to be ruled out as well.
Heat and passive stretching exercise with hip adduction can be tried with weight reduction and
avoiding stairs
Some resistant cases may need to be injected with glucocorticoid and lidocaine
Spinal needles should be used in obese patients
Prepatellar bursitis (Housemaid’s knee) [1–9]
Anatomy The bursa is located between the patella and the skin
Symptoms Positive history of kneeling down frequently and/or history of trauma
Anterior knee pain that increases with exion
Swelling may be observed
Signs Tenderness over the patella. Swelling, hotness, and redness particularly in septic or crystal-
induced bursitis
Treatment Rule out septic bursitis and/or crystal-induced bursitis with bursal uid aspiration
Rest joint and avoid trauma. Glucocorticoid injection may be considered
In refractory cases refer to surgery
22 Soft Tissue Rheumatic Disorders

466
dinitis are around shoulder, elbow, and ankle
joints. One of the pathophysiological mecha-
nisms for tendinitis is micro-tears, affecting these
tendons from repeated stressors like in overuse,
or in traumatic situations.
In some situations where there is inamma-
tion of the tendon sheath, the condition is called
tenosynovitis. Table 22.3 represents a compre-
hensive, general review of the clinical presenta-
tion, investigation, and treatment of tendinitis.
Table 22.4 represents a review of rotator cuff
tendinitis.
Tendinosis is a chronic proses associated with
an atrophic and degenerative change of the ten-
don caused by recurrent tendinitis. US or MRI is
required to diagnose it and to differentiate
between different causes.
22.1.5 Rotator Cu Tendinitis
andRotator Cu Tear
Rotator cuff tendinitis (RCT) is a common type
of tendinitis that affects the shoulder. The patient
usually presents with lateral shoulder pain and
limited active ROM.It is the most common cause
of shoulder pain in clinical practice. A brief
approach to shoulder pain is presented in Chap.
2. Table 22.4 represents a comparison between
RCT and rotator cuff tear (RCTr) in terms of de-
nition, diagnostic, and therapeutic interventions.
Table 22.2 (continued)
Anserine bursitis (Goose’s foot)
Anatomy The bursa is located medially around 6cm below the joint line at the attachment of medial
collateral ligament to medial tibia
It is the site of insertion of three tendons: gracilis, sartorius, and semitendinosus muscles
Symptoms Risk factors: Positive history of repeated knee exion in excessive running, stair climbing.
More common in obese elderly females and/or with valgus knee alignment
Pain at night over the upper tibia around 6cm below medial joint line
It is important to ask the patient to point with one nger the area of pain
Signs Local tenderness over the exact anatomical location of the bursa. Rule out medial collateral
ligament instability (see Chap. 2)
Treatment Rest. Repeated knee bending should be avoided;, also avoid crossing the leg or frequent squatting positions
Use pillow under the knee as a relaxation technique. Ice bags may be applied. NSAIDs can be used,
and if there is no improvement after 6–8 weeks, local glucocorticoid injection can be considered.
Gastrocnemius semimembranosus bursitis (Baker’s cyst)
Anatomy The bursa is located between gastrocnemius and semimembranosus muscles on the medial side
distal to the crease in the popliteal fossa back of the knee
Most common in adult from 35–70 years old, and it increases with age because the
communications between the knee and bursa increase [16]
Symptoms Asymptomatic accidental nding during physical examination or radiological investigation
Posterior knee pain and stiffness that increase with activity
Swelling or discomfort in prolong that standing and hyperexion
Signs Swelling in posterior aspect of the knee, more marked with knee extension
Absence of swelling on knee exion up to 45° (Foucher’s sign)
Ecchymosis below the medial malleolus (cresent’s sign) in rupture baker’s cyst
Causes One third of causes is due to trauma. Two thirds of the causes are due to other diseases
(osteoarthritis, rheumatoid arthritis, septic arthritis and meniscal tear)
Complication Pseudothrombophlebitis, leg ischemia, compartment syndrome, nerve entrapment, and ruptured [17]
Treatment Investigation by US or MRI
Treat underlying disease
If asymptomatic no treatment
In arthrocentesis and intra-articular corticosteroid injection result in decrease size after 4 weeks by
US follow-up [18]
Direct cyst injection if it does not communicate with the joint
Surgery is indicated in recurrences and lack of response to glucocorticoid injection
R. Mahroos and H. Almoallim

467
Table 22.3 Review of the tendonitis history, examination, diagnosis, treatment, and prevention
History • Localized pain over the tendon with active movement particularly
• Limited activity
• Occupation: overuse and/or sporting activity, usually in middle age group of patients
Risk factors Intrinsic
• Age over 35 years and obesity
• Biomechanical abnormalities: Mostly located in lower limbs (pes planus [at foot], pes cavus,
reduced planter dorsiexion, pelvic inequality and kyphosis)
• Previous tendinitis or rupture
• Fluoroquinolones use [19]
Extrinsic
• Training error (sudden increase and inadequate rest)
• Environmental (hard gym oors, frozen turf)
• Poor equipment (inappropriate footwear)
• Poor ergonomics excessive movement
Examination • Localized tendon pain
• Pain with tendon loading
• Pain with passive stretching
• Pain with active movement
• Normal ROM on passive test
• Muscle weakness in chronic tendinitis and tendon tear
Diagnosis US and MRI:
• Help to diagnose partial or complete tendon tear
• Tendon thickness
• To rule out other causes particularly if patient did not improve on treatment
Treatment • Avoid aggravating activity
• Apply ice over the tendon for 15min 4–6 times daily
• NSAIDs and local glucocorticoid injection in severe cases
• Physiotherapy: Range of motion stretching and strengthening exercises, eccentric exercise, and
aerobic tness
• Surgery: probably after 6 months if no improvement or acute tendon rupture
Table 22.4 Review of the tendonitis history, examination, diagnosis, treatment, and prevention [21, 22]
Anatomy Rotator cuff muscles Origin on scapula Insertion on humerus
Supraspinatus
Subscapularis
Infraspinatus
Teres minor
Supraspinous fossa
Subscapular fossa
Infraspinous fossa
Lateral border
Insertion on humerus
Superior facet of greater tuberosity
Lesser tuberosity
Middle facet of greater tuberosity
Inferior facet of greater tuberosity
Muscle action Rotator cuff muscles Mscle action
Supraspinatus
Subscapularis
Infraspinatus
Teres minor
Abduction
Internal rotation
External rotation
External rotation
Denition Rotator cuff tendinitis Rotator cuff tear
Inammation in the tendon Injury in the tendon can be partial or complete tear
Risk factors Excessive overhead activity, repetitive stressful movement, obesity, anatomic variants, scapular
instability, dyskinesia or hypermobility, old age, Chronic diseases (such as diabetes and
hyperlipidemia), and Lifting heavy objects [19]. Acute tear can also occur with a fall or forceful
injury.
Symptoms • Shoulder pain increasing with overhead activity
• Shoulder pain could be laterally or posteriorly. It depends on the muscle involved
• Limited shoulder movement particularly active ROM.
• In the case of rotator cuff tear, muscle weakness is more pronounced, and patients can be
asymptomatic.
Signs See (Chap. 2)
Special tests See (Chap. 2)
(continued)
22 Soft Tissue Rheumatic Disorders

468
Table 22.5 History, examination, diagnosis, and treatment of enthesitis
Sites The common sites for enthesitis are in planter fascia at calcaneus and Achilles tendon in the heel.
However, there is a scoring system to measure the extent of enthesitis in different body sites
Causes Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, inammatory bowel disease (IBD),
celiac disease, Whipple disease, acne-associated arthritis, fracture, trauma, and idiopathic
secondary usually to repetitive trauma or mechanical misalignment or over weight
History suggestive of SpA (see Chap. 1): Red eyes, pain with eyes movement, oral or genital ulcer,
genital discharge, back pain or other joint pain, diarrhea or bloody diarrhea resent gastroenteritis,
history of psoriasis, or family history of psoriasis
Symptoms Pain that increases with activity and possibly swelling
Signs • local tenderness increase with movement
• swelling
• warmth
• decrease active ROM and stiffness
• other sites: Iliac crest, greater trochanter, medial and lateral epicondyles in elbow, tibial
tuberosities, plantus, costochondral junction, and humeral tuberosities
• Most enthesitis in SpA is not detected at clinical examination
Investigations Special test: HLA B 27
X-ray: Nonspecic nding: like intra-tendon focal edema, calcic deposit spars, soft tissue
swelling, and thickening
US: Better than clinical examination in the detection of enthesitis of the lower limbs in SpA.There
are specic radiographic denitions for enthesitis at different body sites
Treatment Exercise program
Proper shoe wearing using custom made devices
Occupation-related measures
Local steroid injection in severe and resistant cases
In SpA: NSAIDs can be tried rst, no clear evidence of efcacy for sulfasalazine [23]
and/or methotrexate [24] in enthesitis mainly presentation in SpA.However, several studies
showed efcacy of anti-TNF-alpha therapy and IL-17 antagonists in severe enthesitis [25]
22.1.6 Enthesitis
It is inammation at the site of insertion of ligaments,
tendons, fascia, and articular capsules into the bone.
It might be associated with pain at free nerve ending.
It is the hallmark of spondyloarthritis (SpA) particu-
larly when paravertebral ligaments are involved caus-
ing spondylitis. Extensive search for a systemic
spondyloarthritic disease (see Chap. 1) should be
sought in patients presenting with common enthesitis
like Achilles tendinitis and plantar fasciitis [21, 22].
However, most of these enthesitis disorders have no
systemic correlation, and they are induced by regional
pathophysiological mechanisms. Table 22.5 repre-
sents a review about enthesitis. Tables 22.6, 22.7 and
22.8 summarize common enthesitis encountered in
clinical practice: Achilles tendinitis, epicondylitis,
and plantar fasciitis (Table 22.6).
Investigations Radiology: X-rays for tendon calcications or bone deformation.
US high sensitivity and/or MRI to conrm diagnosis, asses rotator cuff tear and degeneration.
Treatment Acutely—if there is signicant tear refer the patient to orthopedic surgery.
In partial tear or tendinitis consider conservative therapy:
• Avoid aggravating activity.
• Apply ice over tendon for 15mins 4–6 times daily.
• NSAIDs. Local glucocorticoid inject with lidocaine may be considered.
• Physiotherapy: Range of motion stretching and strengthening exercises.
Subacute treatment—If no improvement is achieved within two to three months:
• Glucocorticoids—subacromial glucocorticoid injection is a common treatment to controlling
the symptoms [20].
Table 22.4 (continued)
R. Mahroos and H. Almoallim

469
Table 22.6 Achilles Tendonitis [21, 22]
Anatomy It is the largest tendon in the body formed by the union of tendons of soleus and gastrogenemius
muscles to form Achilles tendon. It inserts posteriorly at the calcaneus
Muscles action Plantar exion
Epidemiology • patients are usually 30–40 years of age
• males are equally affected like females
• rupture Achilles tendon is ve times more common in males
Risk factors Excessive supination, increase intensity of training program and increasing time in training
(basketball and football players), repetitive stress, obesity, male gender, previous history,
mechanical factors: Pes planus and pes cavus deformities, over pronation of foot, and drugs—
Fluoroquinolone or local glucocorticoid use
Symptoms • pain with activity relieved after rest
• pain 2–6cm above insertion of the tendon, swelling, and possibly redness
• in rupture Achilles tendon patient feels struck violently in the back of ankle or hears loud
popping sound with severe pain
• absence of pain dose not rule out Achilles tendon rupture
Signs • gait and excessive foot supination. This is common with genu varaus deformity in the knee
• examine the patient in prone position with feet hanging off at the end of the bed
• inspect for bruising, swelling, and foot misalignment
• palpation: Hotness, thick tendon or defect, edema, hematoma, tenderness
2–6cm above calcaneus and compare it with the other side
• palpate the tendon in while in dorsiexion of the ankle, plantar exion, and
Neutral position
• assess retrocalcaneal bursitis as one of the differential diagnosis for heel pain
• crepitus in chronic tendinitis
• assess for peripheral vascular disease (pulse, capillary rell, hair loss, and edema)
Notes:
The retrocalcaneal bursitis causes pain, fullness, or swelling proximal and anterior to the
insertion of Achilles tendon in to the calcaneus
The posterior tibial tendinitis causes pain in medial side of the ankle
Special tests • calf squeeze or (Thompson test): Sensitivity of 96% and specicity of 93% [21] (see
Chap. 2)
• Matles test: Sensitivity of 88% and specicity of 85%: [21]
The patient lies prone with knees exed to 90°. Observe whether the affected foot is
dorsiexed or neutral (both are abnormal) compared with the uninjured side, where the foot
should appear plantar-exed
Investigations Radiology: US and/or MRI to conrm diagnosis, monitor treatment response, and/or to assess
why the patient is not responding if another diagnosis is missing
Treatment Avoid aggravating activity, support Achilles tendon with bandage, apply ice, NSAIDs can be
used, avoid glucocorticoid at it is associated with high risk of tendon rupture [22]. Consider
corrections of mechanical defects by providing custom-made orthotics that provide arch support
Consider rehabilitation and occupational therapy programs with eccentric exercise for around 12
weeks. Air heel brace cast can be used in severe cases
Supercial heat and cold compressors
Deep heat by (US and iontophoresis)
Surgery can be considered in refractory cases after 3–6 months if no improvement all measures
Acute tendon rupture: Apply ice, analgesic, rest the ankle, and consider immobilization trial in
few degrees of plantarexion. Consider surgical referral for partial ruputure: there is still no
clear rule for surgical intervention
22 Soft Tissue Rheumatic Disorders

470
Table 22.7 Lateral and medial epicondylitis
Types Lateral epicondylitis (tennis elbow):
15 times more common than medial epicondylitis
Females are equally affected like males
Medial epicondyle (golfer
elbow):
Less common
Denition It is inammation at bony origin for wrist extensors muscles
(extensor carpi radialis brevis “inserted in posterior base of
third metacarpal” and extensor digitorum communis), due to
overuse. The elbow of the dominant arm is affected more
It is inammation at bony origin
for wrist exors muscles (pronator
teres and exor carpi radialis)
Muscles
action
Extensor and abductor of the hand at wrist joint Flexors of ngers and thumb.
Also, exors and pronators of the
wrist
Risk factors Age: Player 30 years or older, smoking, obese,
Tennis ball player , Occupation: Computer user and repeat
movement for 2 h daily [27, 28]
Physical
exam
• localize tenderness in lateral epicondyle
• pain on resisted wrist extension while elbow in exion
• pain in resisted supination and hand shaking
• pain in resisted middle nger extension
• Normal ROM of the elbow except in severe cases
• few degrees of extension might be affected
• examine radial nerve
• in compression neuropathy the pain diffuses distally to
epicondyle and is associated with muscle weakness
• Localized tenderness in medial
epicondyle
• Pain on resisted wrist exion
while elbow in extension
• pain with resisted forearm
pronation
• examine ulnar nerve
Investigation It is a clinical diagnosis and investigations are usually not required
X-rays if indicated to look for osteophytes and calcication in epicondyle
Treatment Phase 1: Symptom less than 6 weeks
• rest the joint and use splint
• physiotherapy (eccentric exercise)
• NSAID: There is limited evidence, oral NSAIDs helps to reduce pain and improve the function
in 6 weeks [27], and there is limited benet of topical NSAIDs in acute epicondylitis [29]
Phase 2: If symptoms do not improve for 6–12 weeks
• repeat 3 views X-ray to identify other possible causes
• continue eccentric exercise
• local injection of corticosteroid. If no improvement, repeat in 2–4 weeks for total of 2
Doses. Use of local corticosteroid injection in lateral epicondylitis improves many patient
Symptoms in 6 weeks but does not prevent recurrences and long-term outcome worseness
[30, 31]
Phase 3: If symptoms do not improve after 12 weeks
• do US and/or MRI
Alternate treatment option might be considered as platelet-rich plasma injections, autologous blood
injections, prolotherapy, extracorporeal shock wave therapy, and percutaneous needle tenotomy [32]
• surgery if more than 6 months with failed conservative therapy including corticosteroid
injection
• 1. debridement +_ arthroscopic drain
• 2. open debridement
• 3. Pericutanous tenotomy
22.1.7 Achilles Tendinitis
See Table22.6.
22.1.8 Epicondylitis [26, 27]
See Table22.7
22.1.9 Fasciitis
A fascia is a layer of fibrous connective tissue
(collagen) below the skin that covers underly-
ing tissues (muscles, blood vessels, and
nerves). Fasciitis is the inflammation of the
fascia that causes fibrosis and loss of elastic-
ity. The most common types of fasciitis are
R. Mahroos and H. Almoallim

471
planter fasciitis, palmar fasciitis, and eosino-
philic fasciitis (these types can be secondary
to autoimmune rheumatological diseases and
malignancies).
22.1.10 Plantar Fasciitis
See Table22.8.
22.1.11 Palmar Fasciitis
See Table22.9.
22.1.12 Eosinophilic Fasciitis
See Table22.10.
Table 22.8 Planter fasciitis anatomy, history, physical exam, investigation and treatment
Planter fasciitis
Anatomy It is a thick white tissue with longitudinal bers attach to medial process of calcaneal tuberosity
divide to ve slips continuing forward to form brous of exor sheathes on plantar aspect one for
each toe
History Age 40–60 years old
Pain in planter region that worse when initiate walking during the rst few steps in morning
Aggravating factors: prolong standing or jumping, at foot, high arch foot, heel spurs, running,
excessive training during aerobic exercise and obesity [33, 34]
Symptoms suggestive of SpA (see Chap. 1) [35]
Physical
examination
• local tenderness
• limited ankle dorsiexion
The examiner should dorsiex the patient toes with one hand, then pull the plantar
Fascia tight, and then palpate with thumb or index nger of other hand, the fascia
From heel particularly the medial aspect where the plantar fascia originates to the
Forefoot: Tenderness can be elicited
Investigations • HLA-B27 and CRP if SpA is suspected
• X-rays: Lateral and axial lms to detect thickness, fat pad abnormality, heel spur
And to rule out other causes
• MRI in resistant cases [36]
• US: 80% sensitivity and 88, 5% specicity to detect fascia thickening and edema [37]
Treatment • 80% resolve spontaneously by 12 months
• decrease physical activity and consider stretching exercise
• arch support with custom made orthotics and avoid at shoes
• ice massage
• NSAIDs can be tried for 2–3 weeks
• inject with local glucocorticoid and lidocaine in resistant cases
Mechanical defects should be corrected otherwise symptoms may recur
• botulinum toxin injection might be considered
• for resistant cases refer to surgery for cast and possible splint extracorporeal shock wave
therapy
• if still no response fasciotomy can be considered as 5–10% of cases ultimately required it
22 Soft Tissue Rheumatic Disorders

472
Table 22.10 Eosinophilic fasciitis denition, risk factors, symptoms, physical exam, investigation and treatment
Eosinophilic Fasciitis (Shulman’s syndrome or diffuse fasciitis with eosinophilic)
Denition Inammation of the fascia with eosinophils inltration causes brosis in early stages
Risk factors Hematological malignancy leukemia, myelodysplasia, and aplastic anemia [39]
Symptoms Stage 1:
• pitting edema bilaterally most involving both arms and legs with sparing ngers and toes
• proximal area more than distal in the extremities
• no Raynaud’s phenomenon
Stage 2:
• sever induration of the skin and subcutaneous tissue with peau d’s orange appearance
• Groove sign is an induration due to retraction of the subcutaneous tissue along the
supercial veins
• mild myositis with normal CK level
Stage3:
• Neuropathy like carpal tunnel syndrome
• exion deformity of the digits
• muscle atrophy
• no sclerodactyly and normal nailfold capillary
Investigations • CBC and peripheral blood lm look for hematological malignancy
• peripheral eosinophilia in 80% of the cases and the degree of eosinophilia does not correlate
with disease activity
• elevated ESR and CRP
• aldolase can be elevated with normal CK
• presence of polyclonal hypergammagloblinemia
• tissue biopsy shows inammation and brosis in all skin layers except the epidermis and
eosinophils inltration can be seen in early stages
• MRI ndings fascial thickening with enhancement
Treatment • treat underlying causes
• some patients may experience spontaneous improvement as the disease can be self-limited
• complete remission can be seen after 2 years or more
• high dose of prednisolone 20–60 mg/ day
• in resistant cases use hydroxychloroquine and methotrexate
Poor prognostic
factors
• young age at onset of the disease
• trunk involvement
Table 22.9 Palmar fasciitis: denition, risk factors, symptoms, physical exam, investigation and treatment
Palmar fasciitis (palmar bromatosis)
Denition Inammation of the palmar fascia which causes brosis
Risk factors Malignancy most common as ovarian cancer but can also be associated with breast, lung,
pancreas, stomach, colon, and metastasis [38]
Symptoms • Pain in palm with swelling: inability to close hands resulting in limitation of activity and
function
• joints pain
• vasomotor symptoms
• symptoms suggestive malignancy
Physical
examination
• tenderness and swelling of bilateral palms with tight fascia and brosis (woody hands)
• symmetrical polyarthritis and exion deformity of the ngers
• Nailfold capillary is normal
Investigations • tissue biopsy shows extensive brosis with broblast and mononuclear cell inltration
• screening for malignancy
Treatment • treat underlying malignancy if patient has metastasis and has poor prognosis
• NSAIDs
• corticosteroid
• ganglion blockade
R. Mahroos and H. Almoallim

473
Acknowledgments The authors would like to thank Dr.
Waleed Haz for his assistance in the development of this
chapter.
References
1. Dillon JP, Freedman I, Tan JS, et al. Endoscopic
bursectomy for the treatment of septic pre-patellar
bursitis: a case series. Arch Orthop Trauma Surg.
2012;132:921.
2. Higuchi T, Ogose A, Hotta T, etal. Clinical and imag-
ing features of distended scapulothoracic bursitis:
spontaneously regressed pseudotumoral lesion. J
Comput Assist Tomogr. 2004;28:223.
3. Conduah AH, Baker CL 3rd, Baker CL Jr. Clinical
management of scapulothoracic bursitis and the snap-
ping scapula. Sports Health. 2010;2:147.
4. Lehtinen JT, Macy JC, Cassinelli E, Warner JJ. The
painful scapulothoracic articulation: surgical manage-
ment. Clin Orthop Relat Res. 2004;99
5. Valeriano-Marcet J, Carter JD, Vasey FB.Soft tissue
disease. Rheum Dis Clin N Am. 2003;29:77.
6. Söderquist B, Hedström SA. Predisposing factors,
bacteriology and antibiotic therapy in 35 cases of sep-
tic bursitis. Scand J Infect Dis. 1986;18:305.
7. Roschmann RA, Bell CL.Septic bursitis in immuno-
compromised patients. Am J Med. 1987;83:661.
8. Cea-Pereiro JC, Garcia-Meijide J, Mera-Varela A,
Gomez-Reino JJ.A comparison between septic bursi-
tis caused by staphylococcus aureus and those caused
by other organisms. Clin Rheumatol. 2001;20:10.
9. Perez C, Huttner A, Assal M, etal. Infectious olec-
ranon and patellar bursitis: short-course adjuvant
antibiotic therapy is not a risk factor for recurrence in
adult hospitalized patients. J Antimicrob Chemother.
2010;65:1008.
10. Rubayi S, Montgomerie JZ. Septic ischial bursi-
tis in patients with spinal cord injury. Paraplegia.
1992;30:200.
11. Schumacher HR.Arthrocentesis, synovial uid analy-
sis, and synovial biopsy. In: Schumacher HR, editor.
Primer on rheumatic diseases. 10th ed. Atlanta, GA:
Arthritis Foundation; 1993. p.67–72.
12. Enzenauer RJ, Pluss JL.Septic olecranon bursitis in
patients with chronic obstructive pulmonary disease.
Am J Med. 1996;100:479.
13. Mathew SD, Tully CC, Borra H, etal. Septic sub-
acromial bursitis caused by mycobacterium kansasii
in an immunocompromised host. Mil Med. 2012;
177:617.
14. Canoso JJ, Yood RA.Reaction of supercial bursae in
response to specic disease stimuli. Arthritis Rheum.
1979;22:1361.
15. Coste N, Perceau G, Léone J, et al. Osteoarticular
complications of erysipelas. J Am Acad Dermatol.
2004;50:203.
16. Lindgren PG, Willen R. Gastrocnemio-
semimembranosus bursa and its relation to the knee
joint. I. Anatomy and histology. Acta Radiol Diagn
(stockh). 1977;18:497.
17. Levitin PM.Letter:diagnosis of baker’s cyst. JAMA.
1976;236:253.
18. Acebes JC, Sanchez-Pernaute O, Diaz-Oca A,
Herrero-Beaumont G. Ultrasonographic assessment
of Baker’s cysts after intra-articular corticosteroid
injection in knee osteoarthritis. J Clin Ultrasound.
2006;34:113.
19. Mehta S, Gimbel JA, Soslowsky LJ. Etiologic and
pathogenetic factors for rotator cuff tendinopathy.
Clin Sports Med. 2003;22:791.
20. Buchbinder R, Green S, Youd JM. Corticosteroid
injections for shoulder pain. Cochrane Database Syst
Rev. 2003:CD004016.
21. Alfredson H, Lorentzon R.Chronic Achilles tendino-
sis: recommendations for treatment and prevention.
Sports Med. 2000;29:135.
22. McLauchlan GJ, Handoll HH.Interventions for treat-
ing acute and chronic Achilles tendinitis. Cochrane
Database Syst Rev. 2001:CD000232.
23. Song I-H, Hermann KG, Haibel H, Althoff CE,
Listing J, Burmester GR, Krause A, Bohl-Bühler M,
Freundlich B, Rudwaleit M, Sieper J.Effects of etan-
ercept versus sulfasalazine in early axial spondyloar-
thritis on active inammatory lesions as detected by
whole-body MRI (ESTHER): a 48-week randomised
controlled trial. Ann Rheum Dis. 2011;70(4):590–6.
24. Chen J, Liu C. Methotrexate for ankylosing spon-
dylitis. Cochrane Database Syst Rev. 2004;(3):
CD004524.
25. Dougados M, Combe B, Braun J, Landewé R, Sibilia
J, Cantagrel A, Feydy A, van der Heijde D, Leblanc V,
Logeart I. A randomised, multicentre, double-blind,
placebo-controlled trial of etanercept in adults with
refractory heel enthesitis in spondyloarthritis: the
HEEL trial. Ann Rheum Dis. 2010;69(8):1430–5.
26. Nirschl RP. The etiology and treatment of tennis
elbow. J Sports Med. 1974;2:308.
27. Gruchow HW, Pelletier D. An epidemiologic study
of tennis elbow. Incidence, recurrence, and effec-
tiveness of prevention strategies. Am J Sports Med.
1979;7:234.
28. Green S, Buchbinder R, Barnsley L, et al. Non-
steroidal anti-inammatory drugs (NSAIDs) for treat-
ing lateral elbow pain in adults. Cochrane Database
Syst Rev. 2002:CD003686.
29. Burnham R, Gregg R, Healy P, Steadward R. The
effectiveness of topical diclofenac for lateral epicon-
dylitis. Clin J Sport Med. 1998;8:78.
30. Tonks JH, Pai SK, Murali SR.Steroid injection ther-
apy is the best conservative treatment for lateral epi-
condylitis: a prospective randomised controlled trial.
Int J Clin Pract. 2007;61:240.
31. Olaussen M, Holmedal O, Lindbaek M, etal. Treating
lateral epicondylitis with corticosteroid injections or
non-electrotherapeutical physiotherapy: a systematic
review. BMJ Open. 2013;3:e003564.
32. Peerbooms JC, etal. Positive effect of an autologous
platelet concentrate in epicondylitis in double –blind
22 Soft Tissue Rheumatic Disorders

474
randomized controlled trial: platelet-rich plasma ver-
sus corticosteroid injections with a 1-year follow-up.
Am J Sports Med. 2010;38:255.
33. Placzek R, Drescher W, Deuretzbacher G, et al.
Treatment of chronic radial epicondylitis with botu-
linum toxin A. A double-blind, placebo-controlled,
randomized multicenter study. J Bone Joint Surg Am.
2007;89:255.
34. Warren BL, Jones CJ.Predicting plantar fasciitis in
runners. Med Sci Sports Exerc. 1987;19:71.
35. Warren BL.Anatomical factors associated with pre-
dicting plantar fasciitis in long-distance runners. Med
Sci Sports Exerc. 1984;16:60.
36. Harvey CK. Fibromyalgia. Part II. Prevalence in
the podiatric patient population. J Am Podiatr Med
Assoc. 1993;83:416.
37. Sabir N, Demirlenk S, Yagci B, et al. Clinical util-
ity of sonography in diagnosing plantar fasciitis. J
Ultrasound Med. 2005;24:1041.
38. Cox NH, Ramsay B, Dobson C, Comaish JS. Woody
hands in a patient with pancreatic carcinoma: a variant
of cancer-associated fasciitis-panniculitis syndrome.
Br J Dermatol. 1996;135:995.
39. Hoffman R, Dainiak N, Sibrack L, etal. Antibody-
mediated aplastic anemia and diffuse fasciitis. N Engl
J Med. 1979;300:718.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license and indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
R. Mahroos and H. Almoallim