SOFT TISSUE RHEUMATISMSOFT TISSUE RHEUMATISMUpper ExterimityUpper Exterimity

Mohsen Akhiani M.D.Mohsen Akhiani M.D.

Soft Tissue RheumatismSoft Tissue Rheumatismshoulder Regionshoulder Region

Rotator Cuff TendinitisRotator Cuff TendinitisRotator Cuff TearRotator Cuff TearBicipital tendinitisBicipital tendinitisAdhesive CapsulitisAdhesive Capsulitis

Soft Tissue RheumatismSoft Tissue RheumatismShoulder painShoulder pain

Periarthritis (80%)Periarthritis (80%)Glenohumeral joint (1%)Glenohumeral joint (1%)Refferal pain (15%)Refferal pain (15%)

Soft Tissue RheumatismSoft Tissue RheumatismRotator Cuff MuscleRotator Cuff Muscle

Soft Tissue RheumatismSoft Tissue RheumatismRotator Cuff TendinitisRotator Cuff Tendinitis

Epidemiology: F>M, middle and old agesEpidemiology: F>M, middle and old ages Most common cause of shoulder painMost common cause of shoulder pain Etiology: overused, overhead activity, Etiology: overused, overhead activity,

degeneration, osteophyte, athletic injury, degeneration, osteophyte, athletic injury, inflammatory arthritisinflammatory arthritis

Clinical manifestation: painful arch (60-120), Clinical manifestation: painful arch (60-120), acute calcific (younger patients), chronic (middle acute calcific (younger patients), chronic (middle or old age), night pain, pain and tenderness in or old age), night pain, pain and tenderness in abduction and internal rotation, impingement abduction and internal rotation, impingement sign and test sign and test

Treatment: rest, physical therapy, pendullar Treatment: rest, physical therapy, pendullar exercise, NSAIDs, steroid injection exercise, NSAIDs, steroid injection

Soft Tissue rheumatismSoft Tissue rheumatismImpingement Of Rotator CuffImpingement Of Rotator Cuff

Soft Tissue RheumatismSoft Tissue RheumatismPainful ArcPainful Arc

Soft Tissue RheumatismSoft Tissue RheumatismCalcific TendinitisCalcific Tendinitis

Soft Tissue RheumatismSoft Tissue RheumatismInjection of Subacromion BursaInjection of Subacromion Bursa

Soft Tissue RheumatismSoft Tissue RheumatismRotator Cuff TearRotator Cuff Tear

Epidemiology: F>M, middle and old agesEpidemiology: F>M, middle and old ages Etiology: trauma, fracture or dislocation of Etiology: trauma, fracture or dislocation of

shoulder joint, degeneration, rotator cuff shoulder joint, degeneration, rotator cuff tendinitistendinitis

Clinical manifestation: pain and weakness Clinical manifestation: pain and weakness on abduction, drop arm signon abduction, drop arm sign

Diagnosis: X-Ray, ultrasound, arthrography; Diagnosis: X-Ray, ultrasound, arthrography; MRIMRI

Treatment: acute tearing in young patientsTreatment: acute tearing in young patients (surgery), steroid injection (after 6 weeks in (surgery), steroid injection (after 6 weeks in

acute form), physical therapyacute form), physical therapy

Soft Tissue RheumatismSoft Tissue RheumatismMRI Of Complete-Cuff TearMRI Of Complete-Cuff Tear

Soft Tissue RheumatismSoft Tissue RheumatismShoulder Arthrogram (Rotator Cuff)Shoulder Arthrogram (Rotator Cuff)

Soft Tissue RheumatismSoft Tissue RheumatismBicipital TendonBicipital Tendon

Soft Tissue RheumatismSoft Tissue RheumatismBicipital TendinitisBicipital Tendinitis

Etiology: sport injury, special activityEtiology: sport injury, special activity Clinical manifestation: acute or chronic pain Clinical manifestation: acute or chronic pain

on anterior of shoulder, tenderness on on anterior of shoulder, tenderness on palpation of bicipital groove, associated with palpation of bicipital groove, associated with

Rotator cuff tendinitisRotator cuff tendinitis Diagnosis: yergason’s sign, speed test, pope Diagnosis: yergason’s sign, speed test, pope

eye sign (tendon rupture)eye sign (tendon rupture) Treatment: rest, physical therapy, NSAIDs, Treatment: rest, physical therapy, NSAIDs,

steroid injection, surgerysteroid injection, surgery

Soft Tissue RheumatismSoft Tissue RheumatismYergason’s Sign And Speed TestYergason’s Sign And Speed Test

Soft Tissue RheumatismSoft Tissue RheumatismAdhesive Capsulitis (1)Adhesive Capsulitis (1)

Epidemiology: age>40 years, F>MEpidemiology: age>40 years, F>M Etiology: any type of shoulder problem, Etiology: any type of shoulder problem,

immobility, diabetes, CVA, anti tuberculosis immobility, diabetes, CVA, anti tuberculosis and convulsive drugs, any chronic disease and convulsive drugs, any chronic disease

Clinical manifestation: generalized pain and Clinical manifestation: generalized pain and tenderness, sever loss of active and passive tenderness, sever loss of active and passive motion in all planemotion in all plane

Soft Tissue RheumatismSoft Tissue RheumatismAdhesive Capsulitis (2)Adhesive Capsulitis (2)

Diagnosis: underlying disease (FBS), X-RayDiagnosis: underlying disease (FBS), X-Ray

MRI, arthrography (loss of joint cavity space)MRI, arthrography (loss of joint cavity space) Treatment: NSAIDs, steroid (local injection Treatment: NSAIDs, steroid (local injection

or systemic), physical therapy (pendulum or systemic), physical therapy (pendulum exercise, wall climbing), manipulation under exercise, wall climbing), manipulation under anesthesia in refractory casesanesthesia in refractory cases

Soft Tissue RheumatismSoft Tissue RheumatismElbow RegionElbow Region

Lateral epicondylitisLateral epicondylitisMedial EpicondylitisMedial EpicondylitisOlecranon bursitisOlecranon bursitisUlnar nerve entrapmentUlnar nerve entrapment

Soft Tissue RheumatismSoft Tissue RheumatismLateral EpicondylitisLateral Epicondylitis

Epidemiology: ages (35-50), F=MEpidemiology: ages (35-50), F=M Etiology: inflammation of common extensor Etiology: inflammation of common extensor

tendon, tennis player, gardening, tendon, tennis player, gardening, Clinical manifestation: pain in lateral Clinical manifestation: pain in lateral

epicondyle, radiation to forearm, weakness epicondyle, radiation to forearm, weakness on grasping, differentiation with radial nerve on grasping, differentiation with radial nerve entrapmententrapment

Diagnosis: pain on resisted wrist extension, X-Diagnosis: pain on resisted wrist extension, X-Ray (calcification, exostosis)Ray (calcification, exostosis)

Treatment: NSAIDs, physical therapy, steroid Treatment: NSAIDs, physical therapy, steroid injection, surgery (>6 months), injection, surgery (>6 months),

Soft Tissue RheumatismSoft Tissue RheumatismMuscle Insertions Around The Elbow JointMuscle Insertions Around The Elbow Joint

Soft Tissue RheumatismSoft Tissue RheumatismResisted Wrist Extension TestResisted Wrist Extension Test

Soft Tissue RheumatismSoft Tissue RheumatismMedial EpicondylitisMedial Epicondylitis

Epidemiology: ages: 30-50 years, M/F=2/1Epidemiology: ages: 30-50 years, M/F=2/1 Etiology: inflammation of common flexor Etiology: inflammation of common flexor

tendontendon Clinical manifestation: local pain and Clinical manifestation: local pain and

tenderness radiation to forearm, weaknesstenderness radiation to forearm, weakness On grasping, pain on resisted wrist flexion, On grasping, pain on resisted wrist flexion,

differentiation with ulnar nerve entrapment differentiation with ulnar nerve entrapment (50%), calcification in X-Ray (20%)(50%), calcification in X-Ray (20%)

Treatment: alteration of activities, NSAIDs, Treatment: alteration of activities, NSAIDs, steroid injection, surgery (>6 months)steroid injection, surgery (>6 months)

Soft Tissue RheumatismSoft Tissue RheumatismResisted Wrist Flexion TestResisted Wrist Flexion Test

Soft Tissue RheumatismSoft Tissue RheumatismOlecranon BursitisOlecranon Bursitis

Etiology: low grade chronic trauma (student, Etiology: low grade chronic trauma (student, miner, hemodialysis), inflammatory arthritis, miner, hemodialysis), inflammatory arthritis, septicseptic

Clinical manifestation: pain and tenderness Clinical manifestation: pain and tenderness is minimal , clear or blood tinged fluid in is minimal , clear or blood tinged fluid in aspirationaspiration

Treatment: avoid special habit, fluid Treatment: avoid special habit, fluid aspiration and steroid injection, antibiotic in aspiration and steroid injection, antibiotic in septic bursitis, surgery in refractory cases septic bursitis, surgery in refractory cases

Soft Tissue RheumatismSoft Tissue RheumatismUlnar Nerve EntrapmentUlnar Nerve Entrapment

Etiology: occupation, trauma, prolonged bed Etiology: occupation, trauma, prolonged bed rest, fracture, inflammatory arthritisrest, fracture, inflammatory arthritis

Clinical manifestation: numbness and Clinical manifestation: numbness and paresthesi of little finger and adjacent side paresthesi of little finger and adjacent side of fourth digits, tenderness of ulnar nerve of fourth digits, tenderness of ulnar nerve groove, decreased sense and motor power groove, decreased sense and motor power of little finger, tinel’s signof little finger, tinel’s sign

Diagnosis: NCVDiagnosis: NCV Treatment: avoiding pressure on elbow and Treatment: avoiding pressure on elbow and

repetitive elbow flexion, surgery repetitive elbow flexion, surgery

Soft Tissue RheumatismSoft Tissue RheumatismUlnar Nerve EntrapmentUlnar Nerve Entrapment

Soft Tissue RheumatismSoft Tissue Rheumatismwrist And Hand Regionwrist And Hand Region

Carpal tunnel syndromeCarpal tunnel syndromeDe quervain’s tenosynovitisDe quervain’s tenosynovitisTrigger fingerTrigger fingerGanglionGanglionDupuytren’s contractureDupuytren’s contracture

Soft Tissue RheumatismSoft Tissue RheumatismAnatomy Of Carpal TunnelAnatomy Of Carpal Tunnel

Soft Tissue RheumatismSoft Tissue RheumatismCarpal Tunnel Syndrome (1)Carpal Tunnel Syndrome (1)

Epidemiology: F/M=5/1, symptomatic CTS Epidemiology: F/M=5/1, symptomatic CTS (3% F, 2% M), peak age (30-60)(3% F, 2% M), peak age (30-60)

Etiology: Inflammatory disease (RA, SLE, Etiology: Inflammatory disease (RA, SLE, PSS), crystal arthropathy, job trauma, local PSS), crystal arthropathy, job trauma, local (osteophyte, tumors), metabolic (DM 6%, (osteophyte, tumors), metabolic (DM 6%, myxedema, acromegaly), infection myxedema, acromegaly), infection (tuberculosis, fungal, rubella), pregnancy, (tuberculosis, fungal, rubella), pregnancy, idiopathicidiopathic

Clinical manifestation: nocturnal symptom Clinical manifestation: nocturnal symptom (sensitivity 51-77%, specificity 27-68%), flick (sensitivity 51-77%, specificity 27-68%), flick sign (sensitivity and specificity 90%)sign (sensitivity and specificity 90%)

Soft Tissue RheumatismSoft Tissue RheumatismSensory Supply To The HandSensory Supply To The Hand

Soft Tissue RheumatismSoft Tissue RheumatismCarpal Tunnel Syndrome (2)Carpal Tunnel Syndrome (2)

loss of two point discrimination (highly specific, loss of two point discrimination (highly specific, low sensitivity), weakness and atrophy in low sensitivity), weakness and atrophy in chronic cases, Phalen’s maneuver (40-80% chronic cases, Phalen’s maneuver (40-80% sensitivity and specificity), Tinel’s sign sensitivity and specificity), Tinel’s sign (sensitivity 25-60%, specificity 68-87%), (sensitivity 25-60%, specificity 68-87%), tourniquet testtourniquet test

Diagnosis: physical examination, EMG-NCV Diagnosis: physical examination, EMG-NCV Treatment: treating associated conditions, Treatment: treating associated conditions, splinting, NSAID’s, steroid (local injection or splinting, NSAID’s, steroid (local injection or systemic), diuretic,vitamin B6, surgery (sever systemic), diuretic,vitamin B6, surgery (sever symptom>1 year, atrophysymptom>1 year, atrophy

Soft Tissue RheumatismSoft Tissue RheumatismTinel’s Sign And Phalen’s TestTinel’s Sign And Phalen’s Test

Soft Tissue RheumatismSoft Tissue RheumatismThenar Muscle AtrophyThenar Muscle Atrophy

Soft Tissue RheumatismSoft Tissue RheumatismCarpal Tunnel Syndrome (Local Injection)Carpal Tunnel Syndrome (Local Injection)

Soft Tissue RheumatismSoft Tissue RheumatismDe Quervain’s TenosynovitisDe Quervain’s Tenosynovitis Epidemiology: age>40, F>MEpidemiology: age>40, F>M Etiology: repetitive activity with thumb Etiology: repetitive activity with thumb

pinching and moving wrist, inflammation of pinching and moving wrist, inflammation of tendon sheath (abductor pollicis longus and tendon sheath (abductor pollicis longus and extensor pollicis brevis)extensor pollicis brevis)

Clinical manifestation: pain and tenderness, Clinical manifestation: pain and tenderness, swelling over the radial styloid, Finkelstein swelling over the radial styloid, Finkelstein testtest

Treatment: rest, physical therapy, NSAID’s, Treatment: rest, physical therapy, NSAID’s, local steroid injection, surgery in refractory local steroid injection, surgery in refractory casescases

Soft Tissue RheumatismSoft Tissue RheumatismDe Quervain’s TenosynovitisDe Quervain’s Tenosynovitis

Soft Tissue RheumatismSoft Tissue RheumatismFinkelstein TestFinkelstein Test

Soft Tissue RheumatismSoft Tissue RheumatismFlexor Tendon Sheaths Of The HandFlexor Tendon Sheaths Of The Hand

Soft Tissue Rheumatism Soft Tissue Rheumatism Dupuytren’s ContractureDupuytren’s Contracture

Epidemiology: F/M 1/5, white manEpidemiology: F/M 1/5, white man Etiology: shortening and thickening of Etiology: shortening and thickening of

palmar fascia, hereditary, alcoholism, palmar fascia, hereditary, alcoholism, epilepsy, DM, any chronic diseaseepilepsy, DM, any chronic disease

Clinical manifestation: dimpling or puckering Clinical manifestation: dimpling or puckering of skin palmar fascia, flexion contracture of of skin palmar fascia, flexion contracture of one or more digits, in decreasing order (5one or more digits, in decreasing order (5thth 3th, 2th fingers)3th, 2th fingers)

Treatment: physical therapy, steroid Treatment: physical therapy, steroid injection, colchicin, vitamin E, surgeryinjection, colchicin, vitamin E, surgery

Soft Tissue RheumatismSoft Tissue RheumatismDupuytren’s ContractureDupuytren’s Contracture

Soft Tissue RheumatismSoft Tissue RheumatismVolar Flexor Tenosynovitis (Trigger Volar Flexor Tenosynovitis (Trigger

Fingers)Fingers)

Etiology: inflammation of tendon sheaths of Etiology: inflammation of tendon sheaths of flexor digitorum, trauma, inflammatory flexor digitorum, trauma, inflammatory disease (RA, psoriatic arthritis, crystal disease (RA, psoriatic arthritis, crystal arthropathy, overused, osteoarthritisarthropathy, overused, osteoarthritis

Clinical manifestation: painful finger flexion Clinical manifestation: painful finger flexion (middle and index fingers), swelling, (middle and index fingers), swelling, tenderness and nodule proximal to MCP joint tenderness and nodule proximal to MCP joint in the volar side, in the volar side,

treatment: rest, physical therapy, NSAID’s, treatment: rest, physical therapy, NSAID’s, steroid injection, surgerysteroid injection, surgery

Soft Tissue RheumatismSoft Tissue RheumatismGanglionGanglion

Epidemiology: ages 20-40, F=MEpidemiology: ages 20-40, F=M Etiology: cystic swelling arising from a joint Etiology: cystic swelling arising from a joint

or tendon sheath, trauma, prolonged wrist or tendon sheath, trauma, prolonged wrist extensionextension

Clinical manifestation: swelling and Clinical manifestation: swelling and discomfort on wrist extensiondiscomfort on wrist extension

Treatment: splint, rest, physical therapy, Treatment: splint, rest, physical therapy, NSAID’s, steroid injection, surgeryNSAID’s, steroid injection, surgery

Soft Tissue SyndromeSoft Tissue SyndromeCostochondritis-teitze’s syndromeCostochondritis-teitze’s syndrome

Epidemiology: costochondritis (age >40, F>M), Epidemiology: costochondritis (age >40, F>M), tietz’s syndrome (age <40, M=F)tietz’s syndrome (age <40, M=F)

Pain and tenderness without swelling over more Pain and tenderness without swelling over more than one costochondral junction than one costochondral junction (costochondritis), with swelling in second and (costochondritis), with swelling in second and third costal cartilage (tietz’s syndrom)third costal cartilage (tietz’s syndrom)

Etiology: trauma, sever cough, mechanical Etiology: trauma, sever cough, mechanical stress, spondyloarthropathystress, spondyloarthropathy

Differential diagnosis: cardiac pain, fibromyalgiaDifferential diagnosis: cardiac pain, fibromyalgia Treatment: NSAID’s, steroid injectionTreatment: NSAID’s, steroid injection

SOFT TISSUE RHEUMATISMSOFT TISSUE RHEUMATISMLOWER EXTREMITYLOWER EXTREMITY

Mohsen Akhiani M.D.Mohsen Akhiani M.D.

Soft Tissue RheumatismSoft Tissue RheumatismHip RegionHip Region

Trochantric bursitisTrochantric bursitisIliopsoas bursitisIliopsoas bursitisIschial bursitisIschial bursitisMeralgia parestheticaMeralgia parestheticaPiriformis syndromePiriformis syndrome

Soft Tissue RheumatismSoft Tissue RheumatismThe Bursa Of The Hip JointThe Bursa Of The Hip Joint

Soft Tissue RheumatismSoft Tissue RheumatismTrochantric BursitisTrochantric Bursitis

Epidemiology: age 30-70, F>MEpidemiology: age 30-70, F>M Etiology: local trauma, osteoarthritis of hip Etiology: local trauma, osteoarthritis of hip

and lumbar spine, scoliosis, leg-length and lumbar spine, scoliosis, leg-length discrepancy, inflammatory conditionsdiscrepancy, inflammatory conditions

Clinical manifestation: pain on moving and Clinical manifestation: pain on moving and lying on the involved side, pain in external lying on the involved side, pain in external rotation and abduction against resistance, rotation and abduction against resistance, calcification in X-Raycalcification in X-Ray

Treatment: NSAID’s, strengthening of Treatment: NSAID’s, strengthening of gluteus medius muscles, steroid injectiongluteus medius muscles, steroid injection

Soft Tissue RheumatismSoft Tissue RheumatismIliopsoas BursitisIliopsoas Bursitis

Etiology: trauma, inflammatory conditions, Etiology: trauma, inflammatory conditions, septic, communication with hip joint (15%)septic, communication with hip joint (15%)

Clinical manifestation: groin and anterior Clinical manifestation: groin and anterior thigh pain, exacerbation of pain with thigh pain, exacerbation of pain with hyperextension of hip, cystic mass (30%), hyperextension of hip, cystic mass (30%), femoral venous obstructionfemoral venous obstruction

Diagnosis: X-Ray with contrast media, MRIDiagnosis: X-Ray with contrast media, MRI Treatment: NSAID’s, physical therapy, Treatment: NSAID’s, physical therapy,

steroid injection, surgerysteroid injection, surgery

Soft Tissue RheumatismSoft Tissue Rheumatism CT Scan Of Iliopsoas BursitisCT Scan Of Iliopsoas Bursitis

Soft Tissue RheumatismSoft Tissue RheumatismIschial BursitisIschial Bursitis

Etiology: trauma, prolonged sitting on hard Etiology: trauma, prolonged sitting on hard surface, weaver’s bottom surface, weaver’s bottom

Clinical Manifestation: radiation of pain to Clinical Manifestation: radiation of pain to back of the thigh, local tendernessback of the thigh, local tenderness

Treatment: modified activity, cushion’s, Treatment: modified activity, cushion’s, NSAID’s, steroid injection with cautionNSAID’s, steroid injection with caution

Soft Tissue RheumatismSoft Tissue RheumatismMeralgia ParestheticaMeralgia Paresthetica

Etiology: obesity, pregnancy, diabetes, direct Etiology: obesity, pregnancy, diabetes, direct trauma, compression from corset, leg-length trauma, compression from corset, leg-length discrepancydiscrepancy

Clinical manifestation: hyperesthesia and numbness Clinical manifestation: hyperesthesia and numbness of anterolateral thigh,exacerbation of pain of anterolateral thigh,exacerbation of pain with ,extension and abduction of thigh, prolonged with ,extension and abduction of thigh, prolonged standing and walking, standing and walking,

Decreased touch and pinprik sensationDecreased touch and pinprik sensation Diagnosis: NCVDiagnosis: NCV Treatment: weight loss, steroid injection (medial to Treatment: weight loss, steroid injection (medial to

anterior superior iliac spineanterior superior iliac spine

Soft Tissue RheumatismSoft Tissue RheumatismMeralgia ParestheticaMeralgia Paresthetica

Soft Tissue RheumatismSoft Tissue RheumatismPiriformis SyndromePiriformis Syndrome

Etiology: trauma, abnormal piriformis Etiology: trauma, abnormal piriformis musclemuscle

Clinical manifestation: F>M, pain over Clinical manifestation: F>M, pain over buttocks with radiation to down and back of buttocks with radiation to down and back of thigh (similar to siatica), tenderness of thigh (similar to siatica), tenderness of piriformis muscle on rectal or vaginal piriformis muscle on rectal or vaginal examination, pain on internal rotation of hip examination, pain on internal rotation of hip against resistanceagainst resistance

Treatment: NSAID’s, local injection of Treatment: NSAID’s, local injection of lidocaine and steroid (carefully)lidocaine and steroid (carefully)

Soft Tissue RheumatismSoft Tissue RheumatismPiriformis SyndromePiriformis Syndrome

Soft Tissue RheumatismSoft Tissue Rheumatismknee Regionknee Region

Popliteal cystPopliteal cystPrepatellar and infrapatellar bursitisPrepatellar and infrapatellar bursitisAnserine bursitisAnserine bursitisPatellar tendinitisPatellar tendinitisOsgood-schalatter’s diseaseOsgood-schalatter’s diseasePellegrini-stiedia syndromPellegrini-stiedia syndrom

Soft Tissue RheumatismSoft Tissue RheumatismPopliteal Cyst (Baker’s Cyst)Popliteal Cyst (Baker’s Cyst)

Etiology: any knee disease with synovial effusion Etiology: any knee disease with synovial effusion (mechanical and inflammatory), naturally (mechanical and inflammatory), naturally occurring communication between knee joint and occurring communication between knee joint and semimembranosus-gastrocnemius bursa (40%)semimembranosus-gastrocnemius bursa (40%)

Clinical manifestation: diffuse swelling and pain of Clinical manifestation: diffuse swelling and pain of calf, erythema and edema of ankle (ceresent calf, erythema and edema of ankle (ceresent sign), mimiking thrombophlebitissign), mimiking thrombophlebitis

Diagnosis: ultrasound, arthrography, MRIDiagnosis: ultrasound, arthrography, MRI Treatment: rest, aspiration and steroid injection, Treatment: rest, aspiration and steroid injection,

surgery surgery

Soft Tissue SyndromeSoft Tissue SyndromePrepatellar and Infrapatellar Prepatellar and Infrapatellar

BursitisBursitis Etiology: trauma, frequent kneeling Etiology: trauma, frequent kneeling

(housemaid’s knee), inflammatory (gout, (housemaid’s knee), inflammatory (gout, septic)septic)

Clinical manifestation: pain, tenderness, Clinical manifestation: pain, tenderness, swelling, hotness and redness (septic)swelling, hotness and redness (septic)

Treatment: aspiration and culture, steroid Treatment: aspiration and culture, steroid injection, modified activityinjection, modified activity

Soft Tissue RheumatismSoft Tissue RheumatismBursa Around The Knee JointBursa Around The Knee Joint

Soft Tissue RheumatismSoft Tissue RheumatismAnserine BursitisAnserine Bursitis

Epidemiology: age 30-50, F>MEpidemiology: age 30-50, F>M Etiology: inflammation of pes anserinus Etiology: inflammation of pes anserinus

(goose foot) include, tendons of gracilis, (goose foot) include, tendons of gracilis, sartorius, semitendinosus,osteoarthritis of sartorius, semitendinosus,osteoarthritis of knee, obese and long legknee, obese and long leg

Clinical manifestation: pain and tenderness Clinical manifestation: pain and tenderness over the medial aspect of the knee (2 inch over the medial aspect of the knee (2 inch below the joint marginbelow the joint margin

Treatment: rest, stretching of adductor and Treatment: rest, stretching of adductor and quadriceps muscles, NSAID’s, steroid quadriceps muscles, NSAID’s, steroid injectioninjection

Soft tissue RheumatismSoft tissue RheumatismPatellar Tendinitis (Jumper’s Patellar Tendinitis (Jumper’s

Knee)Knee)

Etiology: repetitive running, jumpingEtiology: repetitive running, jumping Clinical manifestation: local pain and Clinical manifestation: local pain and

tendernesstenderness Treatment: stretching and strengthening of Treatment: stretching and strengthening of

quadriceps and hamstring muscles, knee quadriceps and hamstring muscles, knee bracing, rest, avid steroid injection, NSAID’sbracing, rest, avid steroid injection, NSAID’s

Soft Tissue RheumatismSoft Tissue RheumatismOsgood-Schlatter’s DiseaseOsgood-Schlatter’s Disease

Etiology: traction apophysitis of tibial Etiology: traction apophysitis of tibial tuberosity, overusetuberosity, overuse

Clinical manifestation: age (10-14), localized Clinical manifestation: age (10-14), localized pain, tenderness and swellingpain, tenderness and swelling

Diagnosis: characteristic fragmentation of Diagnosis: characteristic fragmentation of tibial tubercle in lateral X-Raytibial tubercle in lateral X-Ray

Treatment: rest, remission with fusion of Treatment: rest, remission with fusion of tibial tuberositytibial tuberosity

Soft Tissue RheumatismSoft Tissue RheumatismOsgood-Schlatter’s DiseaseOsgood-Schlatter’s Disease

Soft Tissue RheumatismSoft Tissue RheumatismPellegrini-Stiedia SyndromePellegrini-Stiedia Syndrome

Etiology:trauma, calcification of medial Etiology:trauma, calcification of medial collateral ligamentcollateral ligament

Clinical manifestation:men,asymptomatic Clinical manifestation:men,asymptomatic period, later symptom of medial knee pain period, later symptom of medial knee pain and progressive restriction of knee and progressive restriction of knee movementmovement

Diagnosis: calcification in X-RayDiagnosis: calcification in X-Ray Treatment: pain is self limited, improvement Treatment: pain is self limited, improvement

usually within several months usually within several months

Soft Tissue RheumatismSoft Tissue RheumatismPellegrini-Stiedia SyndromePellegrini-Stiedia Syndrome

Soft Tissue RheumatismSoft Tissue RheumatismAnkle And Foot RegionAnkle And Foot Region

Retrocalcaneal bursitisRetrocalcaneal bursitis Subcutaneous achilles bursitisSubcutaneous achilles bursitis Achilles tendinitisAchilles tendinitis Achilles tendon ruptureAchilles tendon rupture Plantar fasciitisPlantar fasciitis Tarsal tunnel syndromeTarsal tunnel syndrome Halux valgus and bunionHalux valgus and bunion Morton’s neuromaMorton’s neuroma Pes planusPes planus Pes cavusPes cavus

Soft Tissue RheumatismSoft Tissue RheumatismRetrocalcaneal BursitisRetrocalcaneal Bursitis

Etiology: inflammation of the bursa between Etiology: inflammation of the bursa between the posterior surface of the achille tendon the posterior surface of the achille tendon and the calcaneous, trauma, inflammatory and the calcaneous, trauma, inflammatory arthritis (especially spondyloarthropathy)arthritis (especially spondyloarthropathy)

Clinical manifestation: pain on dorsiflexion, Clinical manifestation: pain on dorsiflexion, tenderness, local swelling and bulgingtenderness, local swelling and bulging

Diagnosis: physical diagnosis, MRI, Diagnosis: physical diagnosis, MRI, ultrasoundultrasound

Treatment: rest, splint, NSAID’s, steroid Treatment: rest, splint, NSAID’s, steroid injection (attention to achille tendon)injection (attention to achille tendon)

Soft Tissue RheumatismSoft Tissue RheumatismBursa Around the FootBursa Around the Foot

Soft Tissue RheumatismSoft Tissue RheumatismSubcutaneous Achilles Subcutaneous Achilles

BursitisBursitisEtiology: pressure of shoes, bony Etiology: pressure of shoes, bony

exostoses; sondyloarthropathyexostoses; sondyloarthropathyClinical manifestation: pain, swelling and Clinical manifestation: pain, swelling and

rednessrednessTreatment: relief from shoe pressure, Treatment: relief from shoe pressure,

treatment of underlying diseasetreatment of underlying disease

Soft Tissue RheumatismSoft Tissue RheumatismAchilles tendinitisAchilles tendinitis

Etiology: trauma, athletic injury, fitting Etiology: trauma, athletic injury, fitting shoes, inflammatory conditions (especially shoes, inflammatory conditions (especially spondyloarthropathy)spondyloarthropathy)

Clinical manifestation: pain on dorsiflexion, Clinical manifestation: pain on dorsiflexion, swelling, crepitus on motionswelling, crepitus on motion

Diagnosis: MRI, ultrasoundDiagnosis: MRI, ultrasound Treatment: rest, splint (slight plantar Treatment: rest, splint (slight plantar

flexion), NSAID’s, steroid injection (risk of flexion), NSAID’s, steroid injection (risk of tendon rupture)tendon rupture)

Soft Tissue RheumatismSoft Tissue RheumatismAchilles Tendon RuptureAchilles Tendon Rupture

Etiology: athletic trauma (jumping, falling), Etiology: athletic trauma (jumping, falling), achilles tendinitis, steroid injectionachilles tendinitis, steroid injection

Clinical manifestation: sudden onset of pain Clinical manifestation: sudden onset of pain during forced dorsiflexion, swelling and during forced dorsiflexion, swelling and edema, audible snapedema, audible snap

Diagnosis: thompson test, MRI, ultrasoundDiagnosis: thompson test, MRI, ultrasound Treatment: immobilization (cast), surgery Treatment: immobilization (cast), surgery

(young patient) (young patient)

Soft Tissue RheumatismSoft Tissue RheumatismPlantar FasciaPlantar Fascia

Soft Tissue RheumatismSoft Tissue RheumatismPlantar FasciitisPlantar Fasciitis

Etiology: athletic over activity, prolonged Etiology: athletic over activity, prolonged walking, improper shoes, walking, improper shoes, spondyloarthropathyspondyloarthropathy

Clinical manifestation: pain (morning upon Clinical manifestation: pain (morning upon arising, initial improvement, worsen later in arising, initial improvement, worsen later in the day), burning, aching, tenderness on the day), burning, aching, tenderness on palpation of medial calcaneal tuberclepalpation of medial calcaneal tubercle

Diagnosis: rest, heel pad, NSAID’s, orthoses, Diagnosis: rest, heel pad, NSAID’s, orthoses, steroid injectionsteroid injection

Soft Tissue RheumatismSoft Tissue RheumatismPlantar FasciitisPlantar Fasciitis

Soft Tissue RheumatismSoft Tissue RheumatismTarsal Tunnel SyndromeTarsal Tunnel Syndrome

Etiology: compression of posterior tibial nerve Etiology: compression of posterior tibial nerve at or near flexor retinaculum, trauma, at or near flexor retinaculum, trauma, fracture, valgus deformity, hypermobility, fracture, valgus deformity, hypermobility, inflammatory arthritisinflammatory arthritis

Clinical manifestation: numbness, burning Clinical manifestation: numbness, burning pain, paresthesia of the toes and sole, pain, paresthesia of the toes and sole, nocturnal exacerbationnocturnal exacerbation

Diagnosis: tinel’s sign, loss of pinprick, NCVDiagnosis: tinel’s sign, loss of pinprick, NCV Treatment: shoe correction, steroid injection, Treatment: shoe correction, steroid injection,

surgerysurgery

Soft Tissue SyndromeSoft Tissue SyndromeThe Tarsal TunnelThe Tarsal Tunnel

Soft Tissue RheumatismSoft Tissue RheumatismHallux Valgus-BunionHallux Valgus-Bunion

Etiology: deviation of the large toe, genetic Etiology: deviation of the large toe, genetic tendency, improper shoes, inflammatory tendency, improper shoes, inflammatory arthritis, osteoarthritisarthritis, osteoarthritis

Clinical manifestation: deformity, local Clinical manifestation: deformity, local tenderness and redness (bunion), X-Ray tenderness and redness (bunion), X-Ray (osteoarthritis of first MTP)(osteoarthritis of first MTP)

Treatment: orthoses and bunion pads, Treatment: orthoses and bunion pads, NSAID’s, surgeryNSAID’s, surgery

Soft Tissue RheumatismSoft Tissue RheumatismHallux Valgus Deformity And BunionHallux Valgus Deformity And Bunion

Soft Tissue RheumatismSoft Tissue RheumatismMorton’s NeuromaMorton’s Neuroma

Epidemiology: middle ages, F>MEpidemiology: middle ages, F>M Etiology: compression of interdigital nerve Etiology: compression of interdigital nerve

by transverse metatarsal ligament,synovial by transverse metatarsal ligament,synovial cyst or intermetatarsophalengial bursa cyst or intermetatarsophalengial bursa Clinical manifestation: paresthesia and Clinical manifestation: paresthesia and burning, aching pain in forth toe, tenderness burning, aching pain in forth toe, tenderness by palpation between the third and fourth by palpation between the third and fourth metatarsal headsmetatarsal heads

Diagnosis: MRI, NCV studyDiagnosis: MRI, NCV study Treatment: metatarsal bar, steroid injection, Treatment: metatarsal bar, steroid injection,

surgery surgery

Soft Tissue RheumatismSoft Tissue RheumatismMorton’s NeuromaMorton’s Neuroma

Soft Tissue RheumatismSoft Tissue RheumatismPes Planus (Flat Foot)Pes Planus (Flat Foot)

Etiology: loss of longitudinal arch on the Etiology: loss of longitudinal arch on the medial side , prominence of the navicular medial side , prominence of the navicular and head of the talus, generalized and head of the talus, generalized hypermobility, inherited, rheumatoid hypermobility, inherited, rheumatoid arthritisarthritis

Clinical manifestation: asymptomatic Clinical manifestation: asymptomatic (often), fatigue of foot muscles and aching, (often), fatigue of foot muscles and aching, intolerance to prolonged walking or standingintolerance to prolonged walking or standing

Treatment: thomas heel, firm shoes, Treatment: thomas heel, firm shoes, grasping exercises, shoe orthosesgrasping exercises, shoe orthoses

Soft Tissue RheumatismSoft Tissue RheumatismPes PlanusPes Planus

Soft Tissue RheumatismSoft Tissue RheumatismPes PlanusPes Planus

Soft Tissue RheumatismSoft Tissue RheumatismPes cavus (Claw Foot)Pes cavus (Claw Foot)

Etiology: high medical arch , high Etiology: high medical arch , high longitudinal arch, shortening of extensor longitudinal arch, shortening of extensor ligaments, neurologic disorder, inheritedligaments, neurologic disorder, inherited

Clinical manifestation: foot fatigue, pain, Clinical manifestation: foot fatigue, pain, tenderness over the metatarsal heads, tenderness over the metatarsal heads, callus formation, dorsiflexion of PIP and callus formation, dorsiflexion of PIP and plantar flexion of DIP, claw like toesplantar flexion of DIP, claw like toes

Treatment: metatarsal pad and bar, Treatment: metatarsal pad and bar, stretching of the toe extensor, surgerystretching of the toe extensor, surgery

Soft Tissue RheumatismSoft Tissue RheumatismPes CavusPes Cavus

Soft Tissue RheumatismSoft Tissue RheumatismPes CavusPes Cavus

Soft Tissue RheumatismSoft Tissue RheumatismMetatarsalgiaMetatarsalgia

Etiology: foot strain, high-heelded shoes, Etiology: foot strain, high-heelded shoes, everted foot, trauma, sesamoiditis, hallux everted foot, trauma, sesamoiditis, hallux valgus, inflammatory arthritis, high valgus, inflammatory arthritis, high longitudinal archlongitudinal arch

Clinical manifestation: pain on standing, Clinical manifestation: pain on standing, tenderness on transverse arch, weakness of tenderness on transverse arch, weakness of the intrinsic musclesthe intrinsic muscles

Treatment: orthose, strengthening the Treatment: orthose, strengthening the intrinsic muscles, weight reduction, intrinsic muscles, weight reduction, metatarsal pad or barmetatarsal pad or bar