Regional Rheumatic Pain

September 26, 2011

Regional rheumatic pain is a family of syndromes including tendonitis, tenosynovitis, and bursitis. These conditions, although commonly seen in medical practice, are challenging to diagnose. They are usually diagnosed without laboratory testing or x-rays.

These conditions of the musculoskeletal system are the result of repetitive overuse along with abnormal body position or mechanics. Tendons, which attach muscle to bone, may be more vulnerable to injury if a person does not stretch before strenuous exercise. Bursae, which act as cushion around joints and in between muscles, can be subjected to extensive periods of pressure or force, causing inflammation. Less common causes for these conditions include aging, disuse, muscle atrophy or weakening, poor circulation, calcium deposits, or diseases such as arthritis. The health care provider should obtain a thorough history of patient activities, recent illnesses or trauma, and changes in habits or daily lifestyle. A detailed musculoskeletal exam should include pressing on painful areas, moving joints through their full range of motion both voluntarily and with manipulation, and resistance testing of the muscles. Knowing the anatomy of the affected area is important in making a diagnosis (Table 1).

Table 1. Common overuse syndromes by region
Location Syndrome
Shoulder: Rotator cuff tendons and bursa Rotator cuff tears, subacromial or subdeltoid bursitis
Elbow: Flexor and extensor carpi radialis tendons and sheaths Medial epicondylitis (golfer’s elbow) and lateral epicondylitis (tennis elbow)
Wrist: Abductor and extensor pollicus longus tendon and sheath DeQuervain’s tenosynovitis
Wrist: Flexor and extensor tendons and sheaths Tenosynovitis of the wrist
Knee: Prepatellar bursa Prepatellar bursitis (housemaid’s knee)
Heel: Retrocalcaneal bursa Retrocalcaneal bursitis (pump bump)

Shoulder pain is one of the most common complaints among older people as well as in young athletes. Overuse and calcium deposition are the most common causes of inflammation in this area. The shoulder has many parts, making it difficult to determine the source of the pain. Three components of the shoulder are often affected by overuse syndromes: (a) the rotator cuff muscles and their tendons, (b) the subacromial bursa, and (c) the subdeltoid bursa. Acute rotator cuff tendonitis usually causes pain on voluntary movement of the arm away from the body, while chronic ten-donitis causes a dull ache and difficulty performing daily tasks. Rotator cuff tendonitis is confirmed if the impingement test causes pain. If injection of lidocaine into specific shoulder bursa causes relief of pain with motion, then bursitis is the likely cause.

Elbow pain is also most commonly caused by overuse, although chronic elbow pain may be associated with bony abnormalities, calcifications, or nerve problems. Lateral epicondylitis, or tennis elbow, causes tenderness directly over or just in front of the lateral epicondyle, which is the bony prominence on the outer side of the elbow. Pain occurs with everyday activities such as shaking hands, opening a can, or lifting objects. This tenderness is due to inflammation or a tear of the tendon at that location. Medial epicondylitis, or golfer’s elbow, demonstrates pain with resistance to wrist movement downward as well as point tenderness over the medial epicondyle, the bony prominence on the inner side of the elbow.

DeQuervain’s tenosynovitis involves the tendons that pull the thumb up into the hitchhiker position. This condition is usually a result of overuse of the thumb from gripping pens or pencils too tightly or in mothers diapering their children using safety pins. Pain is elicited with pressure on the wrist at the base of the thumb. Swelling can develop in the area. The Finkelstein test confirms the diagnosis. First, fold the thumb over the palm and close the fingers over the thumb. Bending the wrist sideways away from the thumb will cause pain in a positive test. Tenosynovitis of the wrist is caused by excessive writing, typing, or other repetitive movements of the area.
Prepatellar bursitis, or housemaid’s knee, is often caused by frequent kneeling. History of such activity as well as visible swelling usually makes the diagnosis clear. In contrast to problems within the knee joint, the knee has full range of motion without pain. Pressure directly over the bursa on the lower half of the kneecap may reproduce the pain. Increased pain and tenderness with warmth and redness may mean the bursa is infected. The clinician should note a history of any recent trauma and obtain fluid from the bursa to see if it is infected. Infection is treated with antibiotics, and antibiotics are often given until infection is ruled out.

People with trochanteric bursitis will complain of hip pain, but the patient is able to point directly to the outside of the upper thigh. This pain is worse when the patient lies on the affected side or wears a purse or tool belt over the area. Heel bursitis, also known as “pump bump,” causes pain in the area around the Achilles tendon and the back of the heel bone. Pain is usually increased by having the patient move the foot downward. Swelling and a hard bump may be present. Improper footwear can cause pressure and irritation in this area, hence the name “pump bump.”

TREATMENT

Treatment aims at reducing symptoms and preventing reoccurrence. Avoiding the activity that causes overuse is extremely important. If the patient cannot do this, then the activity (e.g., typing) should be performed with proper alignment and posture. Rest and immobilization with possible splinting will relieve current inflammation. Once the inflammation decreases, physical therapy may be helpful in increasing muscle flexibility, strength, and endurance. Heat compresses are useful for tendonitis while cold compresses provide relief for bursitis, although some patients prefer the opposite.

Nonsteroidal anti-inflammatory medication is a mainstay for these disorders, sometimes along with other pain relievers. Injection of a mixture of cortico-steroids and anesthetics into the affected area provides short-term relief, reduces inflammation, and helps confirm the diagnosis.

See Also: Arthritis

Suggested Reading

  • Klippel, J. H., Crofford, L. J., Stone, J. H., & Weyand, C. M. (Eds.). (2001). Primer on the rheumatic diseases (12th ed.). Atlanta, GA: Arthritis Foundation.
  • Snider, R. K. (Ed.). (2001). Essentials of musculoskeletal care (2nd ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons.

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