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Rheumatology & Soft Tissue Disorders

Links

• Local: orthopedics, Osteoporosis, Osteomalacia and Paget's, vasculitides
• Radiographic Anatomy of the Skeleton (Wash Radiology)
• Joint Injection (images and directions)

Foot Pain and Strain

anatomy

• forefoot: metatarsals and phalanges
• midfoot: navicular, cuneiform, cuboid
• hindfoot: talus and calcaneous

heel pain therapy

• stretching exercises for foot
• silicone heel pad (best), heel cup (2nd), felt arch support (3rd)

Injectable steroids

1. aristospan (triamcinolone): 5 mg/ml or 20 mg/ml. Dilute with 1% xylocaine. intra-artic. 5-15 mg (3/4 ml), intra-lesion. .5-1.0 mg.
2. dalalone (dexomethasone): "less tissue necrosis", 8 mg/dl or 16 mg/dl. Usual 1 mg/site.
3. Celestone soluspan (betamethosone): 6 mg/ml. shoulder/knee @ 6-12 mg, bursae 6 mg, ganglion 3 mg. Dilute with 2 ml .5% marcaine. (Typically 1.5 ml celestone and 1.5 ml .5% marcaine.)

Migratory Polyarthritis

• CBC, ESR, ASO, UA (protein), Parvovirus B19 antibody
• history of strep?
• usually viral, may last weeks

Miscellaneous

• anserine bursitis: night pain over upper medial tibia 1.5" below joint line with a negative valgus stress maneuver. If pain is severe, consider stress fracture. Ice massage, hamstring stretch, avoid inducing activities.

Osteoarthritis

• <30 minutes of morning stiffness is typical
• bone demineralization is atypical, consider RA
• ESR < 20

Sore shoulder

ref: Mgt of Shoulder Impingement Syndrome and Rotator Cuff Tears - 2/15/98 AFP

• in athlete main d/dx tendinitis vs. rotator cuff tear. "Night Pain" --> rotator tear. Test by arm frwrd 30 deg., thumb down, pt unable to resist force down when abducted 90 deg --> rot. tear. If pain can injct xylocaine in subacroml space and test when numbed.
• "persistent bursitis: suspect rotator cuff tear. Do arthrogram.
• swimmer's shoulder: coraco-acromion bursitis and rotator cuff tendinitis.
• impingement sign: arm flexed to 90 deg. then internally rotated (humoral head hits lig).
• calcific tendinitis: ultrasound helps in short term. To detect calcium may need AP shoulder in neutral position and internal/external rotation. Once calcium extravasates have severe inflammatory response lasting @ 2 weeks.
• AC seperation: no good operation, little bad effect. Sling for comfort for 2 weeks.