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Soft tissue rheumatism

            Soft tissue rheumatism encompasses a wide spectrum of musculoskeletal disorders that result from pathology of extra-articular periarticular structures. It includes disorders of tendons and their sheaths, ligaments, bursae, joint capsules, muscles, fascia. Soft tissue rheumatism may manifest as well-defined pathology of a single periarticular site or as a regional myofascial pain syndrome.


            Fibromyalgia is also a form of soft tissue rheumatism but here the underlying pathology is thought to be within the central nervous system. Fibromyalgia is characterized by diffuse chronic (>3 months) noninflammatory pain and presence of specific tender points at pressure on physician’s examination. The pain is considered to be widespread when there is pain in the left side of the body, pain in the right side of the body, pain above and below the waist. In addition, axial skeletal pain (cervical, thoracic spine or low back) must be present. Other characteristic features of the disease are presence of fatigue, nonrestorative sleep, cognitive symptoms (difficulty concentrating, forgetfulness, etc.), depression, headache, Raynaud’s phenomenon, dry eyes and mouth, subjective soft tissue swelling, paresthesias, irritable bowel syndrome, dysmenorrhea, etc. The prevalence of the disease is over 3.4% in women and 0.5% in men. Fibromyalgia affects more commonly women who account for 79-90% of patients. The age of onset is usually between 30 and 55 years. Fibromyalgia may be primary or secondary in the context of other rheumatic disorder e. g., rheumatoid arthritis, systemic lupus erythematosus, etc. Diagnosing the coexistence of fibromyalgia in these patients is of crucial importance in order to avoid overtreatment with toxic antirheumatic drugs.


            Laboratory and instrumental investigations

            Laboratory and instrumental investigations in fibromyalgia patients aim to exclude diseases that may mimick fibromyalgia. The interpretation of the findings, diagnosis and treatment of these cases is performed by trained rheumatologist. 


            The treatment of fibromyalgia includes patient education, exercise programmes, physical therapy, analgetics, antidepressants and other drug classes in physician’s judgement.


            Regional myofascial pain syndrome is a localized soft tissue pain syndrome characterized by the presence of a trigger point within a muscle that results in severe local tenderness after palpation. Although pain in regional myofascial pain syndrome is regiоnal it is more widespread than soft tissue pathology of a single periarticular site. Its common locations are unilateral lower back, neck, shoulder and hip.


            Examples of involvement of single periarticular sites include tendinitis, tenosynovitis, bursitis, enthesitis or enthesopathy (inflammataion or pathological abnormalities at tendon, ligament or joint capsule insertions). These areas may be also involved in inflammatory arthritides, enthesitis being a characteristic feature of seronegative spondyloarthropathies, but involvement of a single site in the absence of articular disease in soft tissue rheumatism suggests low-grade repetitive trauma or overexertion. Local soft tissue disorders represent a significant part of  both primary and specialized rheumatologic care. They are considered to reach one-third of all rheumatic diseases seen by the general practitioners and are thought to be one of the most common rheumatic causes for absences from work.


            A number of clinical conditions are known in the different anatomical areas. Soft tissue rheumatism in the shoulder region is one of the most common seen in clinical practice. The structure of the shoulder joint permits a great range of motion due to the incongruity of the joint surfaces, and complex periarticular structure, which is associated with frequent mechanical damage of the joints and periarticular components. Shoulder periarticular pathology includes rotator cuff tendinitis, adhesive capsulitis, subacromial bursitis, bicipital tendinitis, etc. In the elbow region the main forms of periarticular disorders are lateral epicondylitis (tennis elbow), medial epicondylitis (golfer’s elbow), olecranon bursitis. In the wrist and hand region, common forms of soft tissue rheumatism are de Quervain’s tenosynovitis, ganglions, Dupuytren’s contracture, carpal tunnel syndrome, etc. 


            The main pathologic conditions of periarticular tissues around the hip are trochanteric bursitis, iliopectineal bursitis, ischiogluteal bursitis. Other forms of soft tissue rheumatism of the lower extremity are located around the knee joint (prepatellar bursitis, anserine bursitis, popliteal cysts (Baker’s cyst), etc.) and around the ankle joint (Achilles tendinitis, retrocalcaneal  bursitis, retroachilles bursitis, plantar fasciitis, etc.).


            Musculoskeletal ultrasonography plays a key role for diagnosis and differential diagnosis of local periarticular pathology, at physician’s discretion other techniques that are applied are magnetic resonance imaging, computed tomography, conventional radiography.


            The management of local soft tissue pathology includes nonsteroidal anti-inflammatory drugs, local corticosteroids, physiotherapy.


                                                                                  Dr Sevdalina Lambova, MD, PhD