rheumatic pain

7/30/2019 Rheumatic Pain

http://slidepdf.com/reader/full/rheumatic-pain 1/4

159

Definition

R h e u m a t i c s y m p t o m s ( o r r h e u m a t i s m ) a r e d i s t i n g u i s h e d b y

the fol lo wing seven characteristics : (1) pain or discomfort,

usual ly perceived in the vicinity of one or more joints (in-

c l u d i n g t h e s p i n e ) ; ( 2 ) p a i n o n m o t i o n of t h e a f f e c t e d a r e a( s ) ;

( 3 ) s o r e n e s s ( t o t h e t o u c h ) o f t h e a f f e c t e d r e g i o n ( s ) ;

( 4 ) s t i f f n e s s o f t h e a f f e c t e d p a r t ( s ) , e s p e c i a l l y a f t e r a p e r i o d

o f i m m ob i l it y ; ( 5 ) s y m p t o m a t i c i m p r o v e m e n t a f t e r mild ex -

e r c i s e , b u t w o r s e n i n g a f t e r vigorous e x e r ci s e ; ( 6 ) s y m p t o -

m a t i c w o r s e n i n g i n r e s p o n s e t o c l i m a t i c f a c t o r s , e s p e c i a l l y

f a l l i n g b a r o m e t r i c p r e s s u re a n d r i s i n g h u m i d i t y ; a n d ( 7 )

s y m p t o m a t i c i m p r o v e m e n t i n r e s p o n s e t o w a r m i n g t h e a f -

f e c t e d a r e a ( s ) . N o t a l l r h e u m a t i c p a i n s y n d r o m e s h a v e a l l

seven characteristics, but most wil l at least have the first

f o u r .

Technique

A h i s t o r y o f r h e u m a t i s m i s t h e f o u n d a t i o n f o r a l l r h e u m a t i c

d i s e a s e h i s t o r i e s ; i t w i l l a t l e a s t c l a s s i f y t h e s y m pt o m c o m p l ex

a n d , f u l l y e x p l o r e d , m a y l e a d t o a p r e c i s e d i a gn o s i s . T h e

b a s i c r h e u m a t i c h i s t o r y d o e s n o t d i f f e r f u n d a m e n t a l l y f r o m

o t h e r m e d i c a l h i s t o r i e s , a n d i t c a n b e a p p r o a c h e d a c c o r d i n g

t o t h e s e v e n d i m e n s i o n s o f a s y m p t o m o u t l i n e d b y M o r g a n

a n d E n g e l ( 1 9 6 9 ) .

L o c a l i z a t i o n o f t h e P a i n

R h e u m a t i c p a i n i s a l m o s t a l w a y s l o c a l i z e d ( s e e T a b l e s 1 59 . 1

and 159 . 2 f o r s p e c i f i c s y n d r o m e s ) . I t m a y b e l o c a l i z e d to

o n e r e g i o n o f t h e b o d y ( e . g . , o n e s h o u l d e r g i r d l e ) o r t o a

s i n g l e s t r u c t u r e a t m u l t i p l e s i t e s (e . g . , t h e p e r i p h e r a l j o i n t s ) .

F r o m t h e v i e w p o i n t o f s p e c i f i c d i a g n o s i s , t h e m o s t i m p o r -

t a n t a s p e c t o f t h e m u s c u l o s k e l e t a l h i s t o r y i s t h e p r o c e s s o f

l o c a l i z i n g t h e s y m p t o m s . T h i s i s b e s t d o n e b y a s k i n g t h e

p a t i e n t t o " s h o w m e e x a c t l y w h e r e i t h u r t s ." When an un-

u s u a l l y l a r g e o r i l l - d e f i n e d a r e a i s i n d i c a t e d b y t h e p a t i e n t ,

i t i s h e l p f u l t o i n q u i r e , " W h e r e d o e s t h e p a i n s e e m t o c e n t e r ? "

A t t i m e s t h e p h y s i c i a n m i g h t h e l p t h e h e s i t a n t p a t i e n t b y

l i g h t l y p a l p a t i n g t h e r e g i o n i n q u e s t i o n . O n c e t h e s y m p t o m s

a r e a d e q u a t e l y l o c a l i z e d , p a t t e r n s o f r a d i a t i o n s h o u l d b e

determined. Be c e r t a i n t h a t a l l a r e a s o f d i s c o m f o r t h a v e

been reported .

F a c t o r s T h a t A g g r a v a t e o r A l l e v i a t e t h e P a i n

F r o m t h e v i e w p o i n t o f c l a s s i f i c a t i o n ( a s r h e u m a t i s m ) , t h e

m o s t i m p o r t a n t d i m e n s i o n o f t h e r h e u m a t i c d i s e a s e h i s t o r y

c o n c e r n s t h e f a c t o r s t h a t a g g r a v a t e o r a l l e v i a t e t h e s y m p -

HISTORYRheu matic Pain

JOE G. HARDIN

753

toms . The inf luences of motion and immobility of and across

t h e a f f e c t e d p a r t s s h o u l d b e e x p l o r e d . Gentle motion of the

a f f e c t e d p a r t w o u l d b e e x p e c t e d t o i n c r e a s e i t s d i s c o m f o r t

d u r i n g t h e m o t i o n , b u t i t m i g h t r e s u l t i n s y m p t o m a t i c i m -

p r o v e m e n t a f t e r t h e m o t i o n h a d c e a s e d ; m o r e v i g o r o u s e x -

e r c i s e s h o u l d w o r s e n t h e p a i n b o t h d u r i n g a n d a f t e r t h e

acti vity . L o n g p e r i o d s o f i m m o b i l i t y , e s p e c i a l l y d u r i n g s l e e p ,

typical ly result in the symptom of stif fness, a term readily

u n d e r s t o o d b y m o s t p a t i e n t s w i t h a r h e u m a t i c p a i n s y n -

drome . In fact, if the patient seems not to understand the

q u e s t i o n " A r e y o u s t i f f i n t h e m o r n i n g ? " i t i s p r o b a b l y n o t

w o r t h p u rs u i n g th i s l i n e of q u e s t i o n i ng . A p p r o a c h t h e i n -

f l u e n c e o f c l i m a t i c f a c t o r s w i t h a n o p e n - e n d e d q u e s t i o n ,

s u c h a s , " A r e y o u s e n s i t i v e t o c h a n g e s i n w e a t h e r ? " S p e c i f i c s

c a n t h e n b e d e t e r m i n e d . Most patients with a chronic rheu-

m a t i c p a i n s y n d r o m e h a v e l e a r n e d t h a t h e a t i s h e l p f u l , a n d

w i l l r e a d i l y r e s p o n d t o a q u e s t i o n c o n c e r n i n g t h e i n f l u e n c e

o f l o c a l h e a t a p p l i c a t i on s . " D o y o u f e e l b e t t e r a f t e r a h o t

b a t h ? " m i g h t b e a s k e d o f t h o s e w h o h a v e n o t i n t e n t i o n a l l y

a p p l i e d h e a t t o t h e p a i n f u l r e g i o n . R e s p o n s e s t o d r u g a n d

o t h e r t h e r a p i e s s h o u l d a l s o b e d e t e r m i n e d d u r i n g t h i s p a r t

o f t h e i n t e r v i e w , w h i c h m i g h t b e t e r m i n a t e d b y a n o p en -

e n d e d q u e s t i o n c o n c e r n i n g a n y o t h e r m a n e u v e r s t h a t t h e

p a t i e n t h a s n o t e d t o i n f l u e n c e t h e s y m p t o m s .

Q u a l i t y o f t h e P a i n

T h e q u a l i t y o f r h e u m a t i c p a i n i s t y p i c a l l y a d e e p a c h i n g

s e n s a t i o n , b u t t h e w o r d " s o r e n e s s " i s a l s o u s e d , p e r h a p s t o

e m p h a s i z e t h e p a i n o n m o t i on a n d t e n d e r n e s s t o t o uc h . T h e

q u e s t i o n " W h a t d o e s t h e p a i n f e e l l i k e ? " w i l l u s u a l l y s u f f i c e

t o c o v e r t h i s d i m e n s i o n , b u t s o r e n e s s t o t h e t o u c h s h o u l d

be asked about if it is not volunteered by the patient .

Q u a n t i t y o f t h e P a i n

T h e q u a n t i t y o r s e v e r i t y o f r h e u m a t i c p a i n v a r i e s w i d e l y

f r o m p a t i e n t t o p a t i e n t a n d f r o m t i m e t o t i m e i n a n y o n e

p a t i e n t . E x c e p t u n d e r e x t r e m e l y a g g r a v a t i n g c i r c u m s t a n c e s ,

i t i s g e n e r a l l y l e s s s e v e r e t h a n i s c h e m i c , n e u r o p a t h i c , o r

v i s c e r a l p a i n . U n e x p l a i n e d f l u c t u a t i o n s o v e r d a y s , w e e k s ,

o r m o n t h s a r e t y p i c a l o f r h e u m a t i c p a i n , a n d t h e p a t i e n t

s h o u l d b e a s k e d a b o u t t h i s p a t t e r n o f c h a n g i n g s e v e r i t y .

P a t i e n t s w i t h f r e q u e n t f l u c t u a t i o n s i n s e v e r i t y h a v e d i f f i c u l t y

w i t h t h e c o n c e p t s o f o v e r a l l i m p r o v e m e n t a n d o v e r a l l w o r s -

e n i n g . I t i s o f t e n h e l p f u l t o a s k t h e m t o t h i n k i n t e r m s o f

a v e r a g e s e v e r i t y ov e r t h e p e r i o d o f a m o n t h o r s o : " C o m -

p a r e d t o , s a y , D e c e m b e r , h o w b a d w a s t h e p a i n d u r i n g J u n e ? "

A m a j o r i n d i c a t o r o f t h e s e v e r i t y o f a r h e u m a t i c s y n d r o m e

i s i t s d i s a b i l i t y . P h y s i c a l , s o c i a l , a n d o c c u p a t i o n a l r e s t r i c t i o n s

i m p o s e d b y t h e p r o b l e m s h o u l d b e e x p l o r e d i n d e t a i l .



7 5 4

Table 159 . 1

Rheumatic Pain Syndromes

Chronology of the S ymptoms

The chronolo gy of a rheumati c pain s yndrome o ften helps

t o s u g g e s t a p r e c i s e d i a g n o s i s ; however, rheumatic pain in

general may begin insidiously or abruptly and p ersist for

o n l y a f e w d a y s o r i n d e f i n i t e l y . W i t h d e f i n it i v e d i a g no s i s i n

mind, the time and nature of onset and subsequent overall

disease behavior should be determined . Change in location

or character of sympto ms with time should be noted . Major

X I I . MUS CULOSKELETAL SYSTEM

medical interventions might be detailed dur ing this aspect

of the interview .

C l i n i c a l S e t t i n g

The settin g in which a rheumatic pain syndr ome deve lops

m a y a l s o p o i n t t o w a r d a s p e c i f i c d i a g n o s i s . The age and sex

of the patient are especially important . The spo ndyloa r-

Syndrome

S t ructure(s)

i n v o l v e d Causes P a t h o g e n e s i s

D i s t i n c t i v e c l i n i c a l

features Most common sites

A r th r a l g i a - J oi nt Synovitis or cartilage P a i n m o s t o f t e n r e - Pain in joint . T e n d e r - Depends on cause

a r t h r i t i s degeneration from f l e c t s s y n o v i a l i n - n e s s l o c a l i z e s t o

Bursitis Bursa

a n y c a u s e

" W e a r a n d t e a r " u s u -

f l a m m a t i on , e v e n

in osteoarthritis

B u r s a e a r e s y n o v i a l

a r e a a r o u n d j o i n t

where capsu le is ac -

cessible to surface .

S w e l l i n g i n s a m e

a r e a w i t h m o r e a d -

v a n c e d d i s e a s e

T en d er n es s l oc a li z es T ro ch an ter ic , is ch ial ,

T e n d i n i t i s - Tendon, tendon

a l l y . Less often

gout , in fection , and

o t h e r g e n e r a l i z e d

joint diseases

" W e a r a n d t e a r " f o r

t i s s u e s ; t h e y r e -

spond to irritants

as does joint syno v -

iu m . I n f l a m m a t i o n

u s u a l l y p r e s e n t

F r a y i n g , i s c h e m i a ,

t o site o f b u r s a .

S w e l l ing o f superfi -

cia l bursae

For f lat tendons ,

anserine, olecra-

n o n , a n d p r e p a t e l -

l a r

R o t a t o r c u f f ( s u p r a -

tenosyno vitis s h e a t h f l at (u n sh e at h ed ) c a lc i fi c a t i o n i n f la t tenderness loca li z es spinatus) o f shou l -

tendons. "Wear

a n d t e a r " p l u s

gout , in fection ,

r h e u m a t o i d a r t h r i -

t i s , e t c . , f o r

tendons . I n f l a m m a -

tion in the synovial

t e n d o n s h e a t h s o f

round ones

to the site o f t h e

tendon . F o r r o u n d

t e n d o n s , s w e l l i n g

a n d / o r l o c a l i z e d

t e n d e r n e s s . C o n-

d e r , l o n g h e a d o f

b i c e p s , a n d h a n d

e x t e n s o r t e n d o n s

s h e a t h e d t e n d o n s traction of the ten-

Enthesopat hy Ent hesi s ( poi nt M ul ti pl e : m os t c om - Complex structure

d o n ' s m u s c l e r e f e r s

p a i n t o s i t e o f i n -

flammation

T e n d e r n e s s l o c a l i z e s E lbo w - latera l (tennis)

o f a t t a c h m e n t

o f t e n d o n o r

t e n d o n - l i k e

structure into

bone)

m o n i s m u s c l e c o n -

traction tearing

e n t h e s i s o r c a u s i n g

i s c h e m i a ; d e ge n e r a-

t i o n w i t h a g e ; i n -

f l a m m a t i o n w i t h

with inter lin k ed

t e n d o n f i b e r s c o n -

t i n u o u s w i t h S h a r -

pey's fibers . S t r e s s

tears fibers ; s u s -

t a i n e d m u s c l e c o n -

directly to enthesis .

I sometric contrac -

tion o f its musc le

re fers pain direct ly

to enthesis

a n d m e d i a l e p i c o n -

d y l e , p l a n t a r a n d

posterior sur face o f

c a l c a n e u m , s u p e -

rior portion o f

g r e a t e r t r o c h a n t e r

Myalgia- Muscle

certain diseases

causing enthesitis

Limited number of

traction causes

e n t h e s i s i s c h e m i a

D i f fuse in fection or Diffuse m us cl e t en de r- G e ne ra l ly m or e p ro x -

myositis in fections , meta - v a s c u l i t i s ; m a s s i v e ness-not limited i m a l

M y o f a s c i a l p a i n Not known ;

b o l i c a n d i n f l a m -

m a t o r y d i s o r d e r s .

Overuse and

trauma

Unclear ; seen with

necrosis ; sustained

i s c h e m i a ; b l un t

trauma ; l e s s o f t e n ,

di f fuse musc le in -

flammation

Not known ; pathol-

t o o r e x a g g e r a t e d

n e a r i t s a t t a c h m e n t

a r e a s . Diffuse mus-

c le pain

W ide sp read ar ea of Up pe r m ed ia l b or de r

syndrome probably t r a u m a , s u s t a i n e d ogy ne v er ide nti - p a i n a r o u n d a p r e - o f t r a p ez i u s ; C 7

m u s c l e o r e n -

thesis

m u s c l e c o n t r a c t i o n ,

adjacent arthritis,

f i e d dictable small "trig-

g e r p o i n t . "

s p i n e a r e a ; m e d i a l

s c a p u l a r b o r d e r ;

n e u r o p a t h i e s , a n d S t i m u l a t i o n o f L 4 - 5 i n t e r s p i n o u s

f o r n o a p p a r e n t "trigger" causes r e g i o n ; presacral

r e a s o n pain in its region . areas ; second costo -

A nesthesia o f "trig -

ger point" re lie ves

the pain in its re-

gion

c h o n d r a l j u n c t i o n s



Table 159 .2

An Abbreviated C lassification of Arthritis

D e g e n e r a t i v e j o i n t d i s e a s e s ( o s t e o a r t h ri t i s )

C o n n e c t i v e t i s s u e d i s e a s e s

Rheumatoid arthritis

Systemic lupus erythematosus

S y s t e m i c s c l e r o s i s

Polymyositis/dermatomyositis

Sjogren's syndrome

Spondyloar thropathies

Ankylosing spondylitis

Reiter's syndrome

P s o r i a t i c a r t h r i t i s

Crystalline-induced arthropathies

Gout

Chondrocalcinosis (pseudogou t)

I n f e c t i o u s a r t h r i t i s

B a c t e r i a l

Fungal

V i r a l

Postinfectious ar thropathies ( acute rheumatic fever and others)

Juvenile arthritis of unknown etiology

A r t h r i t i s a s s o c i a t e d w i t h o t h e r s y s t e m i c d i s e a s e s

thropathies tend to occur in young m en, systemi c lupus

erythematosus occurs in young women, and rheumatoid

arthritis tends to begin in middle-aged women . The inter -

viewer s hould develop a clear picture of the patient's phys-

ical activities antedating the onset of symptoms, and patterns

that might be consider ed unusual should be fully explo red .

Antecedent musculoskeletal trau ma should not be over-

looked .

159 RHEUMATIC PAIN 755

Table 159 .3

Selected Symptomatic Extraarticular Featur es

of the Connective Tissue Diseas es and the Spondyloarthropathies

Associated Clinical Manifestation s

The final dim ension of the rheumatic pain s ymptom com-

plex is its associated manifestations . These ar e charac-

t er is ti ca ll y a b se nt whe n t he p r o b l em i s r e g io n al , b u t

characteristically protean for many of the diseases as sociat-

ed with polyarthralgia . For the latter group of disorders,

some of the most common and important as sociated man-

ifestation s are listed in Table 159.3 . For all patients with

rheumatic symptoms, however, op en-ended questions should

address this dimension . "Would you feel well or normal if

the pain and stiffness would go away?" is useful for thispurpose .

B a s i c S c i e n c e

Causes of the rheumatic pain syndromes are lis ted in Table

159 .1 . They are diverse in natu re, bu t most of the nonar-

ticular disorders seem to be indu ced by "wear and tear" or

sustai ned use of the part in question . Few scientific studies

have inquired into the origins of tendinitis, b ursitis, enthe-

sopathies, and myofascial pain, but m ost clinical observ a-

tions suggest an important role for r epetitive motionor

sustai ned muscle contraction . Repetitiv e motion can fray a

tendon as it moves ov er a bony promi nence and can produ ce

sufficient damage to result in an inflammatory focus . Bur-

sae, w hich occur at sites of friction, may be irritated in a

similar fashion . Sustained mu scle contraction may result in

ischemic foci in a mu scle belly or near its attachment, re-

sulting in tender ar eas called m y o f a s c i a l t r i g g e r p o i n t s . A num-ber of obs ervations sug gest that inflammation of an enthesis

can result from local ischemia due to sus tained contraction

of its mus cle. Rheumatic pain syndromes can be induced

or precipitated by certain patterns of mus culoskeletal usage .

Rheumatoid arthritis Polymyositis/dermatomyositis

Subcutaneous nodules Muscle weakness

Peripheral neurop athies Rashes

Cutaneous vasculitis Pulmonary fibrosis

P l e u r i t i s - p e r i c a r d i t i sSjogren's syndrome

Pulmonary fibrosisD r y ( i r r i t a t e d ) e y e s

S c le r i t i s -e p i s c le r i t i sDry mouth

Sjogren's syndromeA c c e l e r a t e d d e n t a l c a r i e s

Systemic lupu s erythematosus Dyspareunia

Fever

RashesAnkylosing spondylitis

P h o t o s e n s i t i v i t y

I r i t i s

Oral and nasal ulcersEnthesopathies

Alopecia Reiter's syndrome

Raynaud's p henomenon Fever

P l e u r i t i s - p e r i c a r d i t i s U r e t h r i t i s

Symptomatic anemia-thrombocytopenia C o n j u n c t i v i t i s

Nephrotic syndrome Heel enthesopathies

Seizures Keratoderma blennorrhagicum

Psychoses B a l a n i t i s c i r c i n a t a

Systemic sclerosis (scleroderma)Onycholysis

S k i n t i g h t n e s s P s o r i a t i c a r t h r i t i s

Raynaud's p henomenon Cutaneous and nail p soriasis

Esophageal dysfunction Heel enthesopathies

Pulmonary fibrosis

Cutaneous calcinosis



756

The pathogenesis of each of the rheumatic pain syn-

dromes is addre ssed bri efly in Table 159 .1 . There is no

scientific evidence to associate myofascial pain with an in-

flammatory respons e ; otherwise an acute or chronic inflam-

matory process plays an important p athogenetic role in the

remainder. Inflammation, whether initiated by known or

unknown causes, is the primar y event in all the arthropa-

thies except osteoarthritis . Even in osteoarthritis there is a

secondary inflammatory pr ocess that is import ant in the

production of many of its s ymptoms . Especially in the case

of inflamed synovial structures (joints, b ursae, and tendon

sheaths), the patient is likely to be aware of the inflammato ry

process . Consequently, it may be possible to obtain a history

of local swelling, warmth and redness, as well as pain and

tenderness .

C l i n i c a l S i g n i f i c a n c e

The clinical sig nificance of rheumatism trav erses a sp ec-

trum from trivial or expected discomfort to serious, dis a-

bling, and life-threatening disease . Most p atients w ho seek

XII . MUSCULOSKELETAL SYSTEM

medical attention for local or regional nonarticular rheu-

matic symptoms have a b enign and self-limited disorder,

whereas a significant number, p erhaps the majori ty, who

see a physician for general ized joint symp toms have a po-

tentially serious and disabling disease .

References

American Rheumatism Association . Dictionary of the rheumatic

d i s e a s e s , v o l . 1 . New York : C o n t a c t A s s o c i a t e s I n t e r n a t i o n a l ,

1982 .

Kelley WN, Harris ED Jr, Ruddy S, et al ., eds. Textbook of rheu-

matology, 3rd ed . P h i l a d e l p h i a : W .B . Saunders, 1989;Chaps .

24, 25 .

McCarty DJ, ed . A r t h r i t i s a nd a l l i e d c o n d i ti o n s . A t e x t b o o k o f r h e u -

matol ogy, 11th ed . P h i l a d e l p h i a : Lea & Febiger, 1989 ;55-68 .

M o r g an WL J r ., Engel GL . T h e c l i n i c a l a p p r o a c h t o t h e p a t i e n t .

Philadelphia : W . B . Saunders, 1969 .

Polley HF, Hunder GG. Rheumatologic interviewing and physical

e x a m i n a t i o n o f t h e j o i n t s . 2 d ed . P h i l a d e l p h i a : W . B . S a u n d e r s,

1978 .

rheumatic pain

Documents