Inflammatory rheumatic disorders
Ashley W. Blom, David Warwick, Michael R. Whitehouse in Apley and Solomon’s System of Orthopaedics and Trauma, 2017
There are two basic lesions: synovitis of diarthrodial joints and inflammation at the fibro-osseous junctions of syndesmotic joints and tendons. The preferential involvement of the insertion of tendons and ligaments (the entheses) has resulted in the term enthesopathy. Synovitis of the sacroiliac and vertebral facet joints causes destruction of articular cartilage and periar-ticular bone. The costovertebral joints also are frequently involved, leading to diminished respiratory excursion. When peripheral joints are affected, the same changes occur. Inflammation of the fibro-osseous junctions affects the intervertebral discs, sacroiliac ligaments, symphysis pubis, manubrium sterni and the bony insertions of large tendons. Pathological changes proceed in three stages: (1) an inflammatory reaction with cell infiltration, granulation tissue formation and erosion of adjacent bone; (2) replacement of the granulation tissue by fibrous tissue; and (3) ossification of the fibrous tissue, leading to ankylosis of the joint. Ossification across the surface of the disc gives rise to small bony bridges or syndesmophytes linking adjacent vertebral bodies. If many vertebrae are involved the spine may become absolutely rigid.
Myofascial Pain Syndrome
Gary W. Jay in Chronic Pain, 2007
There are six different classifications of TrPs (17):Active MTrP is tender and, with direct compression, produces referred pain as well as referred motor phenomena and may induce autonomic phenomena, induces tenderness in the pain reference zone, it will mediate, after appropriate stimulation, an LTR, is associated with a taut band of muscle, and other associated phenomena include muscle shortening, weakness, and decreased range of motion (17). Latent MTrP is painful only when directly palpated/compressed, but may have all the other clinical characteristics of an active TrP, including decreased range of motion of the muscle, weakness, and muscle shortening. Referred pain is typically not seen (17). Primary MTrP is centrally located in the muscle, typically activated by an acute or chronic muscle work overload, or by repetitive overuse of the muscle in which it occurs, and not secondary to TrP activity in another muscle (17). Key MTrP is responsible for activating one or more satellite TrPs in its zone of reference; inactivation will also inactivate associated satellite TrPs (17). Satellite MTrP is centrally located in the muscle, induced via mechanical or neurogenic stimulation by the activity of a key TrP, inactivated when the key TrP is inactivated, may be found in the key TrP’s zone of reference, in an overloaded synergist that is substituting for the muscle in which the key TrP is found, in an antagonist muscle countering the increased tension of the key muscle, or in a muscle linked neurogenically to the key TrP (17). Attachment TrP is found at the musculotendinous junction and/or where the muscle attaches to the bone; this induces an enthesopathy (see the following text) secondary to unrelieved tension/relative spasm of the taut band produced by a central TrP (17). Enthesopathy is typically a well-circumscribed area of pain or tenderness found in the specific regions of muscle attachment: musculotendinous junctions or where tendons and ligaments attach to bone. This differs from the more diffuse TrP referred pain that may not be well localized. Enthesopathy may develop into enthesitis, which is typically post-traumatic in nature, found at muscle insertions, and can be associated, with continued muscle stress, with fibrosis and calcification (17). The central MTrP is found at the center of muscle fibers and is associated with dysfunctional end plates in the motor endplate zone. Contraction knots cause the nodular findings on examination. Both local and referred pain are secondary to sensitized nociceptors via a local energy crisis. Finally, tension from contraction knots causes the taut band beyond the palpable nodule. These TrPs differ greatly in etiology from attachment TrPs, which are found in the attachment zone secondary to taut muscle band tension. An associated inflammatory reaction causes palpable induration, and local and referred pain is secondary to nociceptors sensitized by persistent taut band tension. The taut band at the attachment TrP is secondary to contraction knots in the central TrP. Active TrPs may spontaneously convert to latent TrPs, and vice versa. Both active and latent TrPs can induce increased muscle tension, shortening of the muscle, and decreased range of motion. These finding are most typically made on examination, as pain is the patient’s primary complaint when active TrPs are palpated.
Imaging in Ankylosing Spondylitis
Barend J. van Royen, Ben A. C. Dijkmans in Ankylosing Spondylitis Diagnosis and Management, 2006
Isolated enthesitis not related to the spine, including the Achilles tendon and plantar fascia, is also a characteristic feature of AS. Again, the recognition of enthesitis at the plantar fascia or Achilles tendon does not require imaging as this clinical pattern of disease points toward AS and SpA, especially in the context of inflammatory back pain. On ultrasound, proliferative new bone can be occasionally seen in chronic enthesitis at the various sites of disease. Acute enthesitis is characterized by hypoechoic thickening of insertions (Figs. 5 and 6). A number of unblinded studies have used sonography to assess the lower limbs for enthesopathy in patients with SpA and these showed that clinically unsuspected enthesitis was not uncommon and often missed by clinical examination (30,31). It is possible that clinically unrecognized enthesitis in the lower limbs may be of value in the diagnostic evaluation of AS but this awaits further controlled studies. Recently power Doppler (PD) ultrasound has been used to assess enthesitis. In patients with SpA, a characteristic pattern is evident with increased PD signal adjacent to the bony insertion (32). Furthermore PD signal improvement was noted following therapy with infliximab (33).
Two Cases of Uncommon Traumatic Enthesopathy
Published in Journal of Musculoskeletal Pain, 1998
Gerald G. Hirschberg, Janet Lord
Background: Traumatic enthesopathy is an injury at the attachment of a tendon or ligament into bone. Untreated, it can lead to chronic pain. Findings: Two patients with trauma to the shoulder followed by severe chronic pain were diagnosed with traumatic enthesopathy and responded well to appropriate therapy. Conclusions: Diagnosis of traumatic enthesopathy is made by analysis of the mechanism of injury and by palpation of the involved area. Treatment of enthesopathy with sclerosing therapy is rapidly effective.
An Unusual Cause of Enthesopathy of the Bicipital Tuberositas of the Radius: Screw Irritation
Published in Journal of Musculoskeletal Pain, 2013
Cengiz Isik, Husamettin Cakici, Kamil Cagri Kose, Fuat Akpinar
Background: A 36-year-old woman was suffering from a right forearm ulna-radius diaphysis displaced fracture and a non-displaced fracture of the radius neck. Open reduction and internal fixation with screws and a plate for the ulna and radius diaphysis fractures and a long-arm plaster splint treatment was performed. Findings: Four months later, the patient presented with pain, swelling, and restricted mobility on the antecubital side of the right forearm. Radiography showed that the screw which was used for ulna fixation caused enthesopathy of the neighboring bicipital tuberosity of the radius. Removal of the screw improved the symptoms and angular degree of pronation-supination movements from 20° to 70°. Two years after screw removal, radiography showed resolution of enthesopathy of the radius bicipital tuberosity. Conclusions: When inserting a screw for ulna and radius diaphysis fractures, maximum care must be taken to avoid screw irritation of the bicipital tendon enthesis. When this complication does occur, removal of the causative screw may completely solve the problem.
Ultrasound of enthesopathy in rheumatic diseases
Published in Modern Rheumatology, 2009
Paolo Falsetti, Caterina Acciai, Lucia Lenzi, Bruno Frediani
Enthesopathy is the pathologic change of the insertion of tendons, ligaments and joint capsules on the bone. It is a cardinal feature of spondyloarthropathies (SpA), but it can occur in other rheumatic disease. Recent studies using magnetic resonance imaging (MRI) and ultrasonography (US) have demonstrated that enthesopathy can often be asymptomatic, in both the axial and peripheral skeleton. Therefore, a systematic US study of peripheral entheses could be useful in the diagnostic process of patients with rheumatic diseases, in particular SpA. Recently, power Doppler US (PDUS) has been proved to be useful for differentiating mechanical/degenerative and inflammatory enthesopathy and for monitoring the efficacy of therapy. This article reviews the main histopathologic aspects of enthesopathy and describes the normal US features of enthesis and the basic US features of enthesopathy, in its various stages. The usefulness of US and PDUS in the diagnosis and assessment of enthesopathy is discussed on the basis of the literature and our experience.
Related Knowledge Centers
- Inflammation
- Ligaments
- Tendinopathy
- Tendons
- Pain
- Joint Capsules
- Entheses