The author provides an extensive diagnostic overview of various conditions ranging from fibromyalgia and olecranon bursitis to pre-patellar bursitis and Achilles tendonitis.

Soft tissue rheumatism is a collection of nonarticular pain generators that result from pathology of extraarticular and extraosseous periarticular structures. These soft tissue structures include bursae, tendons and their synovial sheaths, entheses, muscles and fasciae. The focal point to soft tissue rheumatism is that pain is not due to pathology of structures within the true joint (i.e., arthritis). Soft tissue rheumatism may manifest itself as well defined pathology of a single periarticular site or a regional myofascial pain syndrome.

Examples of single site periarticular pain generators include bursitis, tendonitis or enthesopathy (e.g., plantar fasciitis). Finding a few of these pain generators in the absence of articular involvement suggests a chronic, low-grade, repetitive trauma disorder or an acute overexertion syndrome that one may find in “weekend warrior” athletes.

Although fibromyalgia syndrome is considered a form of soft tissue rheumatism in that patients experience soft tissue pain in the absence of articular disease, the underlying pathology may be within the central nervous system.

What You Should Know About Fibromyalgia
Fibromyalgia is a regional myofascial pain syndrome with multiple “trigger points” in a very specific pattern. Patients also experience a varying presentation of chronic fatigue, irritable bowel, anxiety, headaches, morning stiffness and depression.

Laboratory tests in fibromyalgia syndrome are generally unremarkable for any markers of an inflammatory disease. ANA, RA, CRP, ESR, pANCA, cANCA, SPE, T4, TSH, hepatitis panel and anti-CCP antibody tests are all either negative or clinically insignificant in the majority of fibromyalgia syndrome cases. In the few cases in which there are lab abnormalities, one should emphasize clinical observation and occasionally repeat the lab work to ensure the patient’s condition has not evolved into a different diagnosis.

One pathologic process that one should keep at the top of the list of differential diagnoses is obstructive sleep apnea. If symptoms warrant, you should order sleep studies early during treatment to rule out or confirm sleep apnea.

Fibromyalgia syndrome is an organic disorder as opposed to a psychiatric disorder. It still remains unclear why patients experience hyperalgesia but evidence points to aberrations in central nervous system processing of stimuli. Abnormal cerebral blood flow to the thalamus and caudate nucleus is noted in fibromyalgia syndrome. Treatment for fibromyalgia syndrome is directed at improving restorative sleep and emphasizing reconditioning efforts with aerobic exercises.

How To Recognize And Differentiate Between Bursitis, Tendonitis, Enthesitis And Fasciitis
Bursitis is another example of single or multiple-site soft tissue rheumatism. A bursa is defined as a “potential space.” Bursae form between soft tissue planes and facilitate easy gliding of soft tissues over one another. When there is inflammation or infection within a bursa, patients will experience pain. While one will rarely see swelling in cases of bursitis, there are exceptions depending upon the location of the bursitis. When patients have bursitis of the olecranon, Achilles or pre-patellar regions, one will note impressively swollen regions.

One would diagnose bursitis primarily through clinical observation as early imaging techniques are of limited value. If the physical exam reveals normal strength of an extremity but a painful stimulus in an appropriate, nonarticular soft tissue area, then you should be able to make the diagnosis without plain radiographs or other unnecessary and more expensive imaging techniques.

Tendonitis is another type of single- or multiple-site soft tissue rheumatism. The etiology of tendonitis varies and includes: inflammation of the tendon sheath; trauma-induced ischemia with subsequent inflammation (trigger fingers); crystal-induced inflammation (calcific tendonitis); and overuse syndromes.

The diagnosis of tendonitis is also clinically driven. Early imaging techniques have minimal benefit. The clinician should take a good patient history (including a work and extracurricular activity history). One should also perform a thorough physical exam that includes palpating any tender areas and ruling out any articular involvement of pain. One may see minimal swelling in tendonitis cases but keep in mind that it can be impressive in cases of infection or with inflammatory causes of tenosynovitis.

Enthesitis is defined as inflammation of the ligament, tendon, joint capsule or fascia insertion into bone (enthesis).1 One most commonly finds sites of enthesitis at the hip, elbow, wrist, shoulder, low back, knee, heel and foot. The site will be at the insertion of the soft tissue into the bone and will be tender to palpation. In cases of a single or a few periarticular sites of tenderness without any joint involvement, practitioners should first consider overuse. In cases in which there is multiple site tenderness and articular (joint) involvement, one must first consider a diffuse connective tissue disorder.

When it comes to fasciitis, plantar fasciitis and palmar fasciitis are both fairly common with plantar fasciitis being the most frequent. One may consider plantar fasciitis as an enthesopathy as it can be tender where the plantar fascia inserts into the calcaneus. However, MRI scans show there is true inflammation of the plantar fascia and not the entheses that seems to be the root cause of the pain.

Identifying Soft Tissue Rheumatism In The Shoulder
There is a lot of overlap between the different pain causes in soft tissue rheumatism of the shoulder. The shoulder pain may be caused by either bursitis, tendonitis and/or impingement syndrome.

Bursitis of the shoulder is a painful inflammation of the subacromial bursa that rarely occurs in the absence of impingement syndrome. The clinical signs and symptoms of bursitis are also very similar to impingement syndrome. When patients have these conditions, they will experience pain with range of motion, especially with elevation, and abduction with internal rotation of the shoulder. Tenderness to palpation over the subacromial space, increased pain with pressure on the affected shoulder (“I can’t sleep on my shoulder”) and normal strength of the affected shoulder muscles support the diagnosis of bursitis.

Tendonitis of the shoulder includes the biceps tendon as well as the tendons of the rotator cuff. Again, this is similar to impingement syndrome. When patients have shoulder tendonitis, one will note tenderness with palpation of the subacromial space. These patients will also have tenderness when one palpates the long head of biceps tendon in the bicepital notch. In order to do this, have patients keep their elbow at their affected side and externally rotate the shoulder to palpate the bicepital notch anteriorly and medially in the humeral head. When examining these patients, one can also elicit pain with resisted supination or flexion of the forearm. Again, keep in mind there is often an overlap of impingement syndrome with tendonitis of the shoulder.

Impingement of the shoulder is caused by a narrowing of the space between the humeral head and the acromion process. This may result from overuse injuries, whether they are sports- or job-related, a downsloping acromion (type II acromion), swelling within the tendon or idiopathic causes.

This is a chronic painful condition. These patients will complain of pain with abduction, flexion and/or internal rotation of the affected shoulder. Patients will have trouble reaching above their shoulder to do normal activities of daily living. For example, a patient may have trouble fastening her bra behind her back. Other patients may have pain at night attempting to lie on their affected shoulder.

Impingement of the shoulder is a chronic painful condition. Conservative treatment modalities include a regular exercise program, NSAIDs, physical therapy and judicious use of corticosteroid injections as shown at the left.

It is common knowledge that approximately 60 percent of the rotator cuff tears and the majority of the cases of adhesive capsulitis (frozen shoulder) are caused by chronic impingement syndrome. Treatment for impingement syndrome includes NSAIDS, a regular exercise program, physical therapy, judicious use of corticosteroid injections and, in refractory cases, surgical decompression.

When Rheumatologic Conditions Affect The Elbow
The causes of soft tissue rheumatism around the elbow include medial and lateral epicondylitis (enthesitis), distal biceps tendonitis and olecranon bursitis. The epicondylitis is generally chronic and painful but the bursitis is commonly impressive in its presentation but not particularly painful. Delineating these entities is not as difficult as differentiating the conditions that affect the shoulder. The pain is medial, lateral or anterior. The muscle origins or insertions are very different in their functions and one can easily differentiate the bursitis from the epicondylitis or tendonitis.

When it comes to medial epicondylitis, one can diagnose it by eliciting pain via palpation over and just distal to the medial epicondyle at the elbow. There is increased pain with attempted flexion and/or pronation of the forearm against resistance. There may also be increased pain with volar flexion of the wrist against resistance.

Knowing The Difference Between Sprains, Strains and Overuse Injuries

-Don Flinn, PA-C A sprain is a traumatic acute injury to a ligament. There is an acute stretch or tearing of a ligament. These injuries may occur when a football helmet collides with a knee or when someone suffers whiplash in a motor vehicle accident. One would grade ligament sprains on a 1 to 3 scale with grade 1 being a minimal sprain and grade 3 being a complete tear of the ligament. Strains on the other hand are injuries to the musculotendinous junction. These are acute injuries to the muscles due to sudden overstretching of the muscle or trauma. One of the most common strains is the strain of the iliolumbar region, which causes acute low back pain. There are three grades of strain as well. Grade 1 is minimal and grade 3 causes an inability to flex the affected muscle(s). Overuse syndromes are caused by non-acute injuries to tendons, muscles or ligaments. With overuse syndromes, one may see scarring of these tissues microscopically. It is estimated that 30 to 50 percent of athletes suffer from overuse syndrome at one point or another.1

To diagnose lateral epicondylitis, you should be able to elicit pain by palpating over the lateral epicondyle. There should also be increased pain with attempted extension or supination of the forearm against resistance or with dorsiflexion of the wrist against resistance.

The distal biceps tendon inserts into the proximal ulna just distal to the elbow. This insertion site can become inflamed, be tender to palpation and the tendon can even rupture with overuse. Palpating the tendon at the insertion into the ulna is simple and will reproduce the patient’s tenderness. Another confirmatory test is if the patient experiences pain with flexion and supination of the forearm against resistance.

Olecranon bursitis is a common reason for patients to present for care. Pain, warmth and swelling over the olecranon process with palpable fluid in the bursa make this diagnosis fairly easy. What is somewhat confusing is the cause of the bursitis. Trauma, infection or inflammatory causes (gout, rheumatoid arthritis, and pseudogout) are all etiologies of olecranon bursitis.

If the bursa is not particularly painful or erythematous, aspiration of the bursa is not mandated. When informing the patient of the diagnosis, one should note that while aspiration is possible, the reoccurrence rate is very high and there is also a risk of inducing infection when one breaks the skin with the needle.

It is also important to educate the patient about the need to avoid trauma to the elbow. He or she should use pads to protect the elbow, watch for signs and symptoms of infection (and report them immediately to a health care provider if symptoms of infection show), and live with the small water balloon over the point of his or her elbow.

If the bursa seems infected or becomes secondarily infected, then surgical incision and drainage or excision of the bursa with intravenous antibiotics is mandated for the infection.

Diagnosing Painful Conditions In The Wrist
De Quervain’s tenosynovitis is a painful stenosis of the first dorsal interosseous compartment of the wrist and involves the abductor pollicus longus and extensor pollicus brevis tendons. These patients will have acute pain at the wrist near the radial styloid.

Using the Finklestein test, one can see if patient have increased pain when they place their thumb into the palm of the hand, wrap their fingers around the thumb and then ulnar deviate the wrist. Treatment includes rest, ice, heat, corticosteroid injection or a surgical release.

There are also many other causes of tenosynovitis of the wrist, dorsally or volarly. These possible etiologies include trauma, overuse, infection (Staph, Strep, fungi and mycobacterium, etc.) and crystal deposition diseases. Depending upon the etiology of the tendonitis, one must direct the treatment regimen at relieving the pain and inflammation.

If you suspect a non-infectious etiology, you should emphasize splinting for rest, NSAIDs and have the patient apply intermittent heat or ice therapy to the affected area. If there is no response to treatment, giving a local corticosteroid injection often provides relief. However, keep in mind there may be an ongoing indolent infection causing the tenosynovitis and corticosteroids may exacerbate the problem. If there is any question of infection, surgical synovectomy and cultures are mandated.

Stenosing tenosynovitis (trigger finger) is a common and easily diagnosed malady that we see on a daily basis. The problem is swelling in the tendon itself as well as stenosis at the site of the A-1 pulley in the palm of the hand. The tendon becomes trapped on the proximal side of the pulley with the finger flexed. The patient must manually extend the finger and pull the swollen tendon through the pulley. This does cause some amount of pain. Conservative treatment include rest, NSAIDs, restriction of activities and performing corticosteroid injections into the tendon sheath. One would reserve surgical release of the A-1 pulley for refractory cases.

Addressing Possible Causes Of Hip Pain
Trochanteric bursitis is an acute or chronic pain caused by inflammation of the tissues overlying the greater trochanter. One can diagnose the condition by recreating the patient’s pain via palpation of the area over the greater trochanter of the femur. The patient will often present with “hip pain” and have an inability to sleep on the affected hip at night.

One can easily eliminate true hip joint disease via simple internal and external rotation of the hip and by watching the patient walk. A patient with arthritis of the hip will have limited hip rotation in at least internal rotation and will have a short, antalgic gait with the affected leg. A patient with trochanteric bursitis will have normal gait and normal range of motion of the hip. The cause of trochanteric bursitis is inflammation of the bursa between the greater trochanter and the iliotibial band. Treatment includes physical therapy, stretching exercises, NSAIDS, ice, heat and judicious use of corticosteroid injections. Surgical lengthening of the iliotibial band is rarely necessary.

Ischial bursitis is caused by inflammation of the bursa overlying the ischial tuberosity superficially. This has been commonly called “weavers bottom.”1 The prevailing thinking is this condition is generally caused by prolonged sitting on hard surfaces especially by thin people. Palpating the ischial tuberosity and recreating the painful stimulus makes the diagnosis. Treatment consists of protection, avoidance of prolonged sitting, NSAIDS, and corticosteroid injections.

Obtaining X-rays of the pelvis is justified when you find tender points overlying bony prominences. One must consider fragility fractures of the inferior and superior pubic rami, sacrum or ischium in the differential diagnosis.

Differentiating Between The Various Conditions That Can Cause Nonarticular Knee Pain
Common causes of non-articular knee pain (soft tissue rheumatism) are pre-patellar bursitis, anserine bursitis and popliteal cysts. When patients have bursitis, there is a potential space above the bursae that becomes inflamed. The pre-patellar bursa is located outside of the knee joint (extraarticular) and anterior to the patella. As with olecranon bursitis, swelling heat and pain are hallmarks of pre-patellar bursitis. While the usual cause is trauma, idiopathic, gout and pseudogout (crystal induced) etiologies as well as infection may be implicated. People like housemaids or bricklayers who chronically kneel on their knees are prone to pre-patellar bursitis. One should emphasize the use of knee pads for people with these occupations.

De Quervain’s tenosynvoitis is a painful stenosis of the first dorsal interosseous compartment of the wrist. If there is a non-infectious etiology and no response to treatments such as NSAIDs, splinting and intermittent heat and icing, employing a local corticosteroid injection often provides relief, according to the author.

Treatment for pre-patellar bursitis is the same as treatment for olecranon bursitis as one should emphasize rest, NSAIDS and protection from pressure on the knee, and have patients avoid trauma to the affected knee. For this condition, one should avoid aspiration unless you suspect infection and deem a culture is necessary. Reserve excision for recalcitrant cases or if infection is confirmed or occurs secondarily.

Anserine bursitis has a more tendonitis etiology involving the pes anserine area of the anterior medial knee overlying the proximal tibia. The patient will be especially tender over the proximal medial tibia, just distal to the knee joint and at times, you can palpate tenderness in the conjoined tendons where they pass around the medial side of the knee. The pes anserine is made up of the conjoined tendons of the sartorius, gracilis and semitendonosis muscles as they pass around from posterior medial to anterior medial tibia. The bursa lies just posterior and medial to the pes anserinus, and anterior to the medial collateral ligament.

There is usually less swelling and more extraarticular pain with this condition than one would see in patients with pre-patellar bursitis. These patients often have osteoarthritis (OA) of the knee and this can confuse the issue somewhat. The tenderness of OA of the knee will be overlying the knee joint and bursitis will be distal and medial over the tibia.

The severity of the symptoms will guide your treatment plan. Treatment modalities include rest, ice, heat, NSAIDS, avoidance of aggravating activity and judicious use of corticosteroid injections. Other possible treatment options include physical therapy, ultrasound, iontophoresis and controlled exercises to stretch the hamstring muscles.

A popliteal cyst (Baker’s Cyst) is fullness in the popliteal space which is located between the semimembranosus, gastrocnemius muscle and the knee joint. Generally, these cysts are minimally tender. A popliteal cyst is caused by any etiology that induces increased synovial fluid within the joint (osteoarthritis, rheumatoid arthritis and trauma). Some authors have even postulated a one-way valve between the knee joint and the cyst. A popliteal cyst can become large and even dissect down the calf musculature. One may confuse this with a deep venous thrombosis (DVT). Obtaining an ultrasound will help distinguish between DVT and a ruptured popliteal cyst.

Depending upon the symptoms, one should emphasize rest, avoidance of traumatic activities to the knee, NSAIDS and judicious use of corticosteroid injections to the knee joint. Excision of large popliteal cysts is an option in very select instances.

Heel Pain: How To Pinpoint The True Etiology
The heel is often affected by soft tissue rheumatism. There are five main causes of extraarticular pain around the heel. These causes include Achilles enthesitis, Achilles tendonitis, Achilles bursitis, plantar fasciitis and heel fat pad atrophy.

The Achilles enthesopathy is the area where the tendon inserts into the calcaneus. Achilles bursitis occurs in an area just proximal and anterior to the Achilles tendon insertion. With both of these entities, there is heel pain, erythema and fullness or swelling.

Achilles tendonitis usually occurs about 2 to 3 cm proximal to the insertion site. These patients may have heel pain or even posterior leg pain. Dorsiflexion of the foot often causes an increase in the symptoms. The tendon can become hypertrophied, weak and possibly rupture. The “Thompson Test” is a diagnostic test for Achilles tendon ruptures.1 Have the patient kneel on a chair with his or her affected foot hanging off the edge. Squeeze the calf muscle. The patient should plantarflex the foot in response. If this does not occur, the patient has an Achilles tendon rupture.

Plantar fasciitis is a painful extraarticular pain syndrome that can cause heel pain but also causes pain along the plantar surface of the foot. There is increased pain with palpation of the fascia where it inserts into the calcaneus. X-rays will frequently reveal heel spurs anteriorly on the calcaneus where the plantar fascia originates but no pathologic basis for pain can be proven from the bone. These patients will report having worse pain with the first few steps in the morning and after rest. They will also note the pain is worse when they place pressure on the plantar surface of the foot such as with jogging, walking, etc.

Heel fat pad atrophy syndrome is very similar to plantar fasciitis. There is pain over the heel with the pressure of walking or jogging. These patients also have increased pain with the first few steps in the morning. The position of the pain is a little different in that it occurs centrally over the heel instead of at the insertion of the fascia into the calcaneus.

Treatment for all of the heel pain syndromes involves rest, heat or ice. For the ice, have patients partially fill a plastic bottle with water and freeze it. Have them roll that under the affected foot for 15 minutes. Other treatment approaches include NSAIDs, local corticosteroid injections and the avoidance of painful activities.
In tendonitis cases, one may employ splinting to avoid a tendon rupture and surgery may be necessary if tendon rupture occurs. In cases of plantar fasciitis, one should emphasize stretching exercises for two to three months. If that fails, one may consider corticosteroid injections for over a two to three-month period. Surgery may be necessary in refractory cases of plantar fasciitis.

Final Notes
As with any disease process, we must obtain a good history and perform a thorough physical exam. We have to establish a working differential diagnosis and accordingly order appropriate laboratory tests, X-rays or special studies to narrow down our diagnosis. We will have to know our limitations and when to ask for assistance from other professionals (such as physical therapists, psychologists, orthotists, etc.) and when to refer to other specialists. We must always remember that the patient comes first.

Don Flinn, PA-C, has been in practice for 24 years at the McBride Clinic in Oklahoma City. He is on the Board of Directors for the Oklahoma Academy of Physician Assistants and the Society of Physician Assistants in Rheumatology. He is also a member of the Conference Education Planning Committee for the American Academy of Physician Assistants.