Amit Murli Patel. Physical Therapy Management of Tuberculous Arthritis of the Elbow SRJI Vol- 2, Issue- 1, Year- 2013

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PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITIS OF

THE ELBOW

Amit Murli Patel BPT, MPT-Orthopaedics*

ABSTRACTBACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in India.

The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. CASE

DESCRIPTION: The patient was a 35-year-old man referred for physical therapy evaluation and intervention

for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a

primary care provider for additional tests to rule out systemic pathology. An open debridement of the synovium

and a biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as

Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that

resolved all patient complaints and restored full elbow function.DISCUSSION:

Tuberculous arthritis hascharacteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it

should be considered when patients have chronic or vague musculoskeletal complaints.

KEYWORDS: Tuberculous arthritis, Elbow arthritis, Knee effusion, Physical therapy managemet.

INTRODUCTION

Tuberculous arthritis occurs in approximately

1% to 5% of all patients with TB.5

It can involve any

of the bones or joints of the body but is usually

confined to one location, with 10% of tuberculous

arthritis in the upper extremity6

and up to 8% in the


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elbow.7 The sites most frequently affected are the

spine, sacroiliac, hip, and knee.8 Because weight-

bearing joints are the most frequently involved,

some authors5 suspect that trauma plays a role in the

pathogenesis of bone and joint TB.

Tuberculous arthritis is usually secondary to

hematogenous dissemination of tubercle bacilli from

a primary pulmonary lesion.1,8

Less commonly, it

can occur by spreading through the lymphatic

system or into adjacent tissue.8

Joints can become

infected by activation of dormant lymphatic or blood

stream areas of morbidity.9 In the long bones, TB

originates in the epiphysis in response to

mycobacteria and causes tubercle formation in the

marrow, with secondary infection of the trabeculae.8

The joint synovium responds to the

mycobacteria by developing an inflammatory

reaction, followed by formation of granulation

tissue. The pannus of granulation tissue formed then

begins to erode and destroy cartilage and eventually

bone, leading to demineralization.5

Because TB is

not a pyogenic infection, proteolytic enzymes, which

destroy peripheral cartilage, are not produced. The

joint space, therefore, is preserved for a considerable

time. If allowed to progress without treatment,

however, abscesses may develop in the surrounding

tissue.5

Asaka et al10

described an abscess around the

elbow joint and between the biceps brachii and

brachioradialis muscles in a patient with tuberculous

arthritis.

In India, the most common early symptoms of

tuberculous arthritis are insidious onset of local pain

and swelling around the joint. In advanced cases,

which occur primarily in countries where TB is more

common and often is allowed to progress, sinuses

and joint deformities may develop.8 The

granulomatous process eventually imparts a boggy

or doughy feeling to the joint and periarticular

structures.9 Localized pain may precede other

symptoms of inflammation or radiograph changes by

weeks or even months.9

Other symptoms include

joint stiffness, reduced range of motion, fever, night

sweats, or weight loss.8,11

Because of the rarity of

tubercular infections of joints and because the usual

signs of inflammation (eg, erythema, heat) do not

occur, diagnosis of tuberculous arthritis affecting

peripheral joints is often delayed.8,11 When diagnosis

is not timely, joint contractures and limited

functional improvement after treatment are more

likely to occur, especially if bone and articular

cartilage are destroyed.12 Authors have reported

diagnoses of olecranon bursitis,13,14

tennis elbow,15

and pyogenic arthritis, osteomyelitis, neopathic

articular disease, and neoplasm before an eventual

diagnosis of tuberculous arthritis.

The purpose of this case report is to describe a

case of tuberculous arthritis of the elbow. The

patient described in this report had numerous

previous diagnoses for chronic elbow pain and was

ultimately referred for physical therapy evaluation

and intervention.

CASE DESCRIPTION

Patient: The patient was a 35-year-old, Athlete,

right-handdominant man who reported

experiencing intermittent sharp pain with insidious

onset and swelling in his left elbow 10 months

previously. He reported that his symptoms were

aggravated with movements of the elbow and eased

with rest. There was no known history of left elbow

or arm injury. The patient did not report any recent


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fever or weight loss, and he said that he was healthy

except for the elbow pain. He stated that he had been

an intravenous (IV) drug user for 5 years, during

which he used his left arm for injections, but he said

he had not used any IV drugs for 2 years prior to the

physical therapist examination and evaluation. The

patient was not working at the time of the

examination His goal was to play Tennis pain-free.

The patient had a 10-month history of evaluations

for left elbow pain, swelling, and decreased range of

motion. The patient had been diagnosed with lateral

epicondylitis, degenerative joint disease, synovitis,

and tenosynovitis by 3 different physicians at 3

different facilities, and he had been treated with

nonsteroidal anti-inflammatory drugs. After 10

months, an orthopedic surgeon examined the patient.

The physician referred the patient to the physical

therapist for examination, evaluation, and

intervention for chronic elbow pain and ordered

electromyography (EMG) and nerve conduction

studies (NCS).

Three series of elbow radiographs were taken

prior to the physical therapy evaluation. Each of the

3 series of elbow radiographs was taken at a

different facility

The first series, taken 10 months previously,

showed no noticeable abnormalities. Two months

later, a second series was negative for fracture, but

there were cyst-like structures and mild exostotic

bone formation in the region of the lateral

epicondyle, and there was another cyst-like structure

in the proximal shaft of the ulna (Fig. 1). The lateral

view showed exostotic bone formation at the

anterior distal humerus, which the radiologist stated

may have been indicative of an old injury.

Figure 1. Anteroposterior radiograph of elbow

showing cyst-like structures (arrows).

Figure 2. Lateral radiograph of elbow showing a

posterior fat-pad sign (arrows)

The third radiographic series 4 months before

the physical therapy evaluation revealed a posterior

fat-pad sign, which the radiologist suggested may

have been created by joint effusion or an occult

fracture (Fig. 2). Normally, the posterior fat pad,

which lies deep in the olecranon fossa, is not visible

on the lateral view. It can be displaced out of the

fossa by blood or synovial fluid within the joint, thus

becoming visible.17

The radiologist who interpreted

the third series recommended further evaluation if

the patients complaints continued.


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Nerve conduction studies of motor and sensory

components of the left median, ulnar, and radial

nerves completed just prior to the physical therapy

evaluation were within normal limits.

Electromyograms of the middle deltoid, biceps

brachii, brachioradialis, pronator teres, abductor

pollicis brevis, and first dorsal interosseus muscles

also were within normal limits. The patient had

positive purified protein derivative (PPD) tests since

the previous year. A standard posteroanterior chest

radiograph for patients with a positive PPD test was

normal. A normal chest radiograph shows no

pleurisy with effusion.

Pleurisy with effusion results when the pleural

space is seeded withMycobacterium tuberculosis.18

EXAMINATION

The patient held his left elbow in a flexed

position and apparently was guarding the elbow

against his body. He had diffuse left elbow effusion,

with the left elbow joint girth 1.5 cm greater than the

right elbow joint girth measured at the elbow flexion

crease. There was no ecchymosis at the time of

examination, but wasting of the biceps and triceps

muscles was noticeable. The patient had elbow

active and passive range of motion of 30 to 110

degrees, with pain at both flexion and extension end

ranges. Wrist range of motion was normal, but the

patient did have a sharp pain at the lateral and

medial condyles during end ranges of pronation and

supination, respectively.19

The shoulder was cleared

for pathology using overpressure during active

flexion, abduction, and while the patient was

reaching behind his back. The therapist performed

overpressure by applying a force to the patients end

range at the point where his active range of motion

stopped. The wrist was cleared when overpressure

was performed during active flexion and extension.

Because both procedures failed to reproduce the

patients elbow pain, the therapist considered the

shoulder and wrist cleared as the source of his

pathology. The therapist tested light touch sensation

by moving the index fingers along the patients C4-

T2 dermatomes and upper-extremity nerve fields

bilaterally. Sensation was recorded as intact and

symmetrical. Muscle stretch reflexes were not tested.

Manual muscle tests of the upper-extremity

musculature were performed during the examination

as described by Kendall and McCreary.19 The

trapezius, middle deltoid, wrist flexor, dorsal and

palmar interosseus, and extensor pollicis longus

muscles were painless and rated normal bilaterally.

The patient said that he was unable to hold the left

biceps brachii, triceps brachii, and wrist extensor

muscles in the test position against resistance

because he said that it reproduced his pain. Because

pain limited the patients effort during these muscle

tests, grading was not done.

Palpation revealed a mild increase in warmth

around the left elbow compared with the right

elbow. Palpation at the olecranon and both lateral

and medial epicondyles caused a sharp pain that did

not radiate. Palpation of the patients entire anterior

forearm also reproduced his elbow pain.

EVALUATION

A posterior fat-pad sign has been reported to be

a possible sign of interarticular fracture or

swelling.17

Due to local tenderness, swelling, and a

documented fat-pad sign on this patients

radiographic report, the therapist chose to rule out

systemic pathology or a fracture before initiating


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aggressive stretching or joint immobilization

intervention. The patient began a light physical

therapy regimen of active range of motion exercises

for 10 to 15 minutes 3 times a week on an upper-

body cycle to maintain his present range of motion,

followed by ice massage for 10 minutes. The patient

was instructed to use ice bags for 10 to 15 minutes

on his own throughout the day. He was also

instructed to stop playing tennis. The therapist

discussed the case with a physician, who

subsequently ordered follow-up radiographs,

including an oblique view to rule out an

interarticular fracture as was originally advised in

the most recent radiologists report.

RE-EVALUATION AND INTERVENTION

The new radiographs showed a smaller

posterior fat-pad sign but no fractures or evidence of

other pathologies in osseous structures. Therefore,

the patient continued his physical therapy program

and was re-evaluated 2 weeks after the initial

evaluation. During the week 2 follow-up, the patient

reported that the pain had lessened and that his

elbow was tender to palpation only at the olecranon.

Both active and passive ranges of motion were

unchanged, as was the elbow flexion crease girth.

Resistive exercises were added because the patient

expressed concern about the atrophy in his biceps

and triceps muscles. Because he was reporting less

elbow pain with palpation and range of motion end

ranges, the therapist decided to allow the patient to

perform seated biceps muscle curls and supine

triceps muscle extension exercises in a pain-free

range. The patient performed 3 sets of 10 repetitions,

3 times a week, in the clinic under the therapists

supervision.

During the week 4 follow-up evaluation, the

patient reported increased pain in the area of the

medial and lateral epicondyles. Examination of

elbow girth, active and passive ranges of motion,

and palpation revealed no other changes. Based on

the patients continued pain and swelling, the

physician and Therapist agreed that a magnetic

resonance image (MRI) could be informational. At

the same time, the physician referred the patient

back to the orthopedic surgeon for re-evaluation

following the MRI. Physical therapy was

discontinued until the MRI and orthopedic

evaluations were completed. The MRI showed a

large joint effusion and increased marrow signal

within the radial neck (Fig. 3).

Figure 3. T2 weighted sagittal view of the elbow.

Note the increased marrow signal within the

radial neck (arrows).

Signal intensity refers to the strength of the

radiowave that a tissue emits following excitation.

The strength of the radio wave determines the degree

of brightness of the imaged structures. A bright

(white) area in any image is said to demonstrate a


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high signal intensity, and a dark (black) area

demonstrates a decreased intensity.17 Hematopoietic

marrow normally displays a low to intermediate

signal intensity, whereas fluid displays a higher

signal intensity on T2 weighted MRI.17

The

radiologist suspected infection and recommended

aspiration of synovial fluid and a biopsy. During the

second orthopedic evaluation, 2 months after the

MRI, the surgeon aspirated the elbow and ordered a

bone scan. A culture of the aspirated fluid was

negative for growth, but the bone scan image was

consistent with possible septic arthritis and

osteomyelitis.

At the orthopedic follow-up 3 months later, the

surgeon ordered an open debridement and biopsy

based on the bone scan reports and performed an

arthrotomy of the left elbow with open debridement

of synovium and biopsy of the capitellum and radial

head the next day. The culture was positive for acid-

fast bacilli, which was later identified as

Mycobacteria tuberculosis. Following identification

of TB, a physician specializing in infectious diseases

evaluated the patient. The bacterium was sensitive to

ethambutol, pyrazinamide, isoniazid, and rifampin,

and the patient began a 4-drug anti-TB regimen for

no less than 1 year.

OUTCOMES

Four months after initiating the drug regimen,

the patient reported that he was pain-free, and he

was discharged from the orthopedic surgeons care.

The therapist attended a weekly orthopedic clinic

during which patient was evaluated by an orthopedic

surgeon.

At 12 months after the diagnosis of TB, the

patient had recovered normal elbow range of motion,

and manual muscle tests of the biceps brachii,

triceps brachii, and wrist extensor muscles were

normal and painless.19 He said that he was working

and playing Tennis without pain. The patient

performed janitorial work, which consisted of Room

cleaning, walls, and bathroom fixtures.

DISCUSSION

Tuberculous arthritis usually occurs in an

insidious manner, with pain and swelling of the

affected joint. It is rare among people born in the

India and is more often found in people born in other

countries or those with a compromised immune

system. The patient in this case report had chronic

elbow pain and swelling without signs of infection.

Lack of signs of infections is consistent with other

cases of tuberculous arthritis described.15,16

He also

reported a history of IV drug use, which, along with

direct joint trauma, interarticular steroid injections,

and systemic illness, has been found to be a

predisposing factor for tuberculous arthritis.16

These

factors and this patients history suggest an onset of

TB that is consistent with reports of other patients

who developed tuberculous arthritis.

Joint effusion, such as that seen in this patient,

often occurs with tuberculous arthritis and has been

shown to affect muscles and nerves around the

elbow.20,21

Chen and Eng20

noted compression of the

posterior interosseous nerve at the region of the

arcade of Frohse. Prem et al21

noted wasting of

muscles around the upper limbs and shoulder girdle

along with obliteration of bony landmarks due to

swelling around an elbow infected with tuberculous

arthritis. Yao and Sartoris1

also stated that weakness

and muscle wasting could be present around


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involved joints. The patient in this case report did

not have sensory deficits, but he did have noticeable

wasting of his biceps and triceps muscles. Persistent

effusion in the knee affects afferent activity of

intracapsular receptors and can cause reflex

inhibition of the quadriceps femoris muscle.2224

A

similar mechanism may have occurred in this

patient, causing wasting of the biceps and triceps

muscles due to capsular distention and intracapsular

pressures. An alternative hypothesis might also

attribute the muscle wasting to disuse secondary to

pain during elbow motion.

Radiographs can be powerful diagnostic tools,

but they are not always beneficial during evaluation

of a patient with tuberculous arthritis. Some authors

have described normal chest radiographs in patients

with tuberculous arthritis20,25

and old or active

pulmonary disease evident in only 50% of chest

radiographs in patients with tuberculous arthritis.8,16

Elbow radiographs can also be negative, even when

the disease is present.15

Unlike pyogenic organisms

that produce rapid destruction of bone, TB has a

gradual progression of symptoms.26

It has been

reported to begin in the distal end of the humerus,

olecranon, or synovium of the elbow joint.13,25 The

first radiograph report of the patients elbow was

normal.

The second series of radiographs identified a

cyst-like structure and mild exostotic bone formation

that was not identified on the first and final

radiographs. Munk and Lee26

contended that a

normal appearance on imaging is the rule with TB

infections because the underlying bone reacts (by

forming cysts and producing sclerotic borders at the

margins of the infected lesion) in an attempt to wall

off the infectious process. Thus, a cyst-like

appearance in the involved bone is not uncommon.

The third set of radiographs revealed no

abnormalities in bone or joint space, with the

exception of a positive fat-pad sign. Greenspan17

reported that a positive fat-pad sign could be

indicative of interarticular swelling or a fracture. The

fourth set of radiographs eliminated the possibility

of a fracture that had not been diagnosed, but they

revealed a smaller fat-pad sign, which most likely

appeared because of interarticular swelling. When

radiographs are normal, an MRI may be beneficial

by revealing early changes such as edema that are

not visible on radiographs.27 The patients MRI

identified the complex effusion in his elbow, but a

biopsy that was needed for the definitive diagnosis.

Biopsy is the most definitive test for

tuberculous arthritis.6,9,13,15

Some authors have

reported that synovial fluid or tissue cultures

establish a diagnosis in 90% of the cases of

tuberculous arthritis.11 Material for the culture may

be obtained from aspiration of joint fluid, but this

may be inconclusive, as it was in this patients case.

Laboratory tests such as sedimentation rate,

granulocyte count, and lymphocyte count are not

thought to be helpful.7 This patients prior tuberculin

skin tests were positive, which is consistent with

researchers findings for patients with tuberculous

arthritis.6,10,20,25

However, as was described in cases

involving a 66-year-old woman15

and a 76-year-old

man16 with tuberculous arthritis of the elbow, a

negative TB skin test does not exclude diagnosis of

tuberculous arthritis. Repeated negative tuberculin

tests, however, practically eliminate TB as a possible

etiology.7

Before the advent of anti-TB

chemotherapy, the classic treatment in adults

consisted of excision or arthrodesis of the elbow


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joint.28 The disadvantage of arthrodesis was loss of

motion, and the risk of excision was an unstable

elbow.28 Anti-TB agents are effective in halting the

destructive process and treating the infection.

However, they cannot repair the anatomical defects

that can occur in later stages.8

During these stages,

fibrous tissue can result in ankylosis of the joint.

Similarly, the untreated cases can evolve to bony

ankylosis.16

The literature provides few specifics for

the physical therapist management of TB.

Investigators29

have reported using prolonged

immobilization for an average of 18 months. With

the introduction of TB drugs, this is no longer

necessary.12 Some authors6,28 advocated

immobilizing the elbow for 1 to 2 months at 90

degrees to relieve pain and, in the event of fusion, to

achieve a functional position. After removing the

cast, rehabilitation proceeded daily for 3 to 6

months, with a back splint used between therapy

sessions to prevent extension deformity and help the

elbow flexors regain power.6

No specific

descriptions of the splint or interventions were

reported.

Surgery may be necessary in certain cases when

the disease does not respond to drugs or to correct

deformities or improve joint function.8 Vohra and

Kang25 treated 6 cases of elbow TB, ranging from

the disease being restricted to within the synovial

membrane to extensive articular cartilage

involvement. Patients were treated with 3 to 6 weeks

of immobilization after surgery followed by

encouraging active movements and using night

splints for 2 to 5 months. No other intervention

specifics were given. Other authors30

reported that

using a hinged long arm brace for a month after

surgically removing granulation tissue returned the

patients elbow to being pain-free with full range of

motion. Chen et al12 reported that a continuous

passive movement (CPM) device improved

functional results after synovectomy and intra-

articular debridement. Following surgery, the arc of

movement was set at 30 to 90 degrees and then

increased to a level that the patients were able to

tolerate. Patients used the CPM device for 2 to 4

weeks until movement exceeded 120 degrees. The

average flexion deformity in a group of 8 patients

who used the CPM device was 24 degrees versus 34

degrees in a group of 8 patients who were treated

with active and passive movement. Active and

passive movement was not defined.

The patient in this report responded well to

antibiotics and regained full elbow function without

immobilization or surgery. This improvement could

have been due, in part, to the location of the disease

in the joint. Vohra and Kang25

stated that prognosis

is excellent in synovial and extra-articular lesions,

whereas involvement of articular cartilage reduces

the chances of maintaining good range of motion. In

addition, this patients improvement could have been

due to diagnosing tuberculous arthritis early and

administering anti-TB treatment before severe

destruction occurred. Chen et al12 noted that joints

with severe intra- and extra-articular destruction

usually become stiff with fibrosis and adhesions.

Martini and Gottesman28

hypothesized that, unlike

the lower-limb joints, the elbow is nonweight

bearing and therefore more able to recover a normal,

painless range of motion, as this patient was able to

do.

CONCLUSION

Patients with tuberculous arthritis are not often


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examined or treated by physical therapists in India

due to the relative rarity of TB infections of joints.

Because of its often slow progression,

tuberculous arthritis is a frequently misdiagnosed

condition, which delays treatment and can lead

deformities and functional deficits.

This patients disease was identified as a result

of diagnostic tests and communication between a

physical therapist and other health care providers.

Physical therapists and other health care providers

can learn from this case to consider tuberculous

arthritis in the differential diagnosis of unexplained

musculoskeletal complaints, especially in patients

with compromised immunity or from an area where

TB is endemic.

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4. Zuber PL, McKenna MT, Binkin NJ, et al. Long-term risk of tuberculosis among foreign-born persons inthe United States. JAMA. 2007;278:304 307.

5. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with patient presentations and discussion. Am JMed. 1970;48:77 84.

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7. Martini M, Ouahes M. Bone and joint tuberculosis: a review of 652 cases. Orthopedics. 2005;11:861866.

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19.Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore, Md: William & Wilkins;1983:18293.

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CORRESPONDING AUTHOR:

* Amit Murli Patel BPT, MPT-Orthopaedics, Assistant Professor & Vice Principal, College Of Physiotherapy,

Ahmedabad E-Mail : [email protected]

Documents

Amit Murli Patel. Physical Therapy Management of Tuberculous Arthritis of the Elbow SRJI Vol- 2, Issue- 1, Year- 2013