Rheumatology

Electronic tools for comprehensively tracking pain are available, but will physicians and patients use them?

Researchers have found new evidence that antidepressants can reduce the severity of symptoms associated with fibromyalgia syndrome.

ABSTRACT: High ankle sprains are not as common as low anklesprains, but they are a significant injury, and the diagnosis may bechallenging. The primary role of the syndesmosis is to maintain therelationship of the talus to the tibia under physiological loads.Toaccomplish this, the distal tibiofibular joint must maintain its stability.The syndesmosis is injured most often with external rotation at theankle joint while the foot is dorsiflexed and pronated. On physicalexamination, tenderness is located in the area of the anterior syndesmosis.There are several special tests for syndesmosis injuries.Radiographic assessment is helpful. The usefulness of classificationsystems is not well defined. The optimal rehabilitation programis unknown. Rehabilitation generally is divided into phases.(J Musculoskel Med. 2008;25:564-569)

The signs and symptoms can be controlled with early diagnosis and treatment.

Links between rheumatoid arthritis (RA) and cardiovascular disease (CVD) and diabetes mellitus (DM) highlighted the research findings reported at the recent American College of Rheumatology (ACR) Annual Scientific Meeting in San Francisco.

Felson DT, Nevitt MC,Yang M, et al, Boston University School of Medicine and other centers.A new approach yields high rates of radiographic progression in knee osteoarthritis.J Rheumatol. 2008;35:2047-2054.

Molecular imaging reveals fibromyalgia symptoms related to functional brain abnormalities.

Muscle strains are most common in the hamstring, gastrocnemius, soleus, and quadriceps strains, as well as the lumbar and thigh adductor. This image-rich review covers imaging, treatment, and prevention.

This surgery is an excellent option for relieving pain and restoring function in patients with osteoarthritis.

Knee pain is a common complaint in older patients, andosteoarthritis is the leading cause.We prospectively evaluated the diagnosticpatterns of nonorthopedic physicians in 100 consecutive patientsolder than 60 years who had knee pain. Our study shows thatthere is a lack of consensus about the use radiographic studies for diagnosisof knee pain in older patients.Weight-bearing radiographs areideal for evaluating knee pain. MRI frequently is overly sensitive in detectingpathology and often underestimates joint-space narrowingand arthrosis. MRI also represents a much larger cost and burden onthe health care system. MRI is indicated when the cause of knee painis not readily apparent after careful physical and radiographic evaluation.(J Musculoskel Med. 2008;25:500-504)

The clinical presentation and outcome of heart failure differ significantly in patients who have rheumatoid arthritis (RA) and those who do not.The presentation of heart failure is more subtle in patients with RA, and mortality is significantly higher.

Pain can be intense and difficult to tolerate in the short-term, such as labor pains and kidney stone impaction, or chronic and long-term, such as low back pain.

ABSTRACT: Osteoarthritis (OA) is the leading cause of chronicdisability in older adults. A multitude of factors can contribute to thedisease process. Only a portion of patients who have radiographicevidence of OA have associated pain. Several conditions can mimicOA. Laboratory tests often contribute little to the diagnosis.Treatmentshould be tailored to individual patients. Exercises and joint protectiontechniques are the mainstays of treatment. Patient educationmay be beneficial. Acetaminophen and NSAIDs are effective in manypatients. Cyclooxygenase-2 inhibitors are associated with improvedGI tolerability. Glucosamine and chondroitin sulfate may produceimprovements in pain and function and may be associated with adecrease in the radiographic progression of OA. Corticosteroids canprovide symptomatic relief. Surgery is an option for advanceddisease. (J Musculoskel Med. 2008;25:476-480)

Complex regional pain syndrome (CRPS) can be tricky todiagnose. This review describes criteria for identifying CRPS, and gives guidance for treatment, with case studies and photographs.

Differentiation between low and high ankle sprains iscritical to delivering appropriate care.The classic mechanism for a lowankle sprain is inversion and plantar flexion. A history of ankle ligamentinjury predisposes to recurring sprains. The ankle anterior drawertest may be used to evaluate ligamentous instability. Plain radiographsof the foot and ankle may be indicated in a patient who has an acuteankle injury. Clinicians often use the Ottawa ankle rules to determinethe need for radiographs. In the acute phase, the goals of treatment areto alleviate pain, reduce swelling, and protect the ankle from furtherinjury. NSAIDs and rehabilitation are important components of management.Primary prevention may be possible with strengthening andbalance programs. (J Musculoskel Med. 2008;25:438-443)

The "logical plan" for patient care includes sparing use of medications, providingpain relief, and quick resumption of work.

This detailed review desccribes the heterogeneous idiopathic inflammatory myopathies and their mimics, with criteria for classification, an overview of cardiac, pulmonary and malignant comorbidieis, and guidance for treatment.

A 21-numbered circle visual analog scale (VAS) may be a desirable alternative to the traditional 10-cm horizontal line for pain and patient global estimate on a Multidimensional Health Assessment Questionnaire (MDHAQ).

A prediction rule for the development of rheumatoid arthritis (RA) in patients with undifferentiated arthritis (UA) has been validated. The rule accurately estimates the risk of RA in more than 75% of patients with recent-onset UA.

A study published in the Canadian Medical Association Journal reveals that PPIs for treating acid reflux elevate the risk of osteoporosis-related fractures.

ABSTRACT: If enough force is applied in a wrist ligament injury, aperilunate dislocation may occur. Physicians can readily make thediagnosis, but the injury may be missed in the initial evaluation. Withprompt recognition and intervention, the incidence of permanentdisability may be lessened. Acute carpal tunnel syndrome may accompanyperilunate injuries and frank dislocations. The scapholunateand lunotriquetral ligaments confer significant structural stabilityand help maintain the anatomical relationships of the carpal bones;when they are compromised, structural integrity is lost.Visual inspectionis critical to the physical examination. Neurovascular statusshould be determined and documented. Radiographic evaluationis recommended for all hand injuries. All perilunate dislocationsfirst need to be closed reduced, followed by surgical treatment.(J Musculoskel Med. 2008;25:390-395)

ABSTRACT: Osteopoikilosis is a rare, benign osteosclerotic dysplasiathat predominantly involves the appendicular skeleton. Radiographicfindings are diagnostic, and the disease often is discovered incidentallyon x-ray films. The importance of recognizing osteopoikilosis liesin differentiating it from osteoblastic metastases. The cause is unclear.Patients typically are asymptomatic. Diagnostic findings include theappearance of numerous small,well-defined, spheroid sclerotic foci.Because evidence suggests an association with skeletal and dermatologicalchanges, evaluation for coexisting pathological conditions maybe warranted. The differential diagnosis for a patient who has radiographiccharacteristics similar to those of osteopoikilosis includes osteoblasticmetastases, mastocytosis, tuberous sclerosis, melorheostosis,and osteopathia striata. (J Musculoskel Med. 2008;25:387-389)

ABSTRACT: Corticosteroid/anesthetic injections may be useful diagnosticand therapeutic tools for painful shoulder conditions. The currentdogma is to avoid performing more than 3 injections over a9- to 12-month period, but this rule may be broken. The volume of localanesthetic typically injected might be insufficient for assessing accuracy.Data demonstrating significant advantages of one corticosteroidover another are scarce. For patients with diabetes mellitus, considera somewhat insoluble phosphoric corticosteroid. There is no consensusabout appropriate dosages and techniques.We recommend using1.5-inch 25-gauge needles for most injections. Re-evaluating provocativemaneuvers after each injection is important. The patient's estimatedpain relief always should be documented.Two approaches toinjection may be used, an advanced/detailed method and abasic/quick method. (J Musculoskel Med. 2008;25:375-386)

I was very interested in the article "Chronic pain update: Addressing abuse and misuse of opioid analgesics" by Ross et al (The Journal of Musculoskeletal Medicine, June 2008, page 268) because pain management and addiction medicine is my specialty.The article was interesting, useful, and well written and referenced. However, it perpetuated one myth about opioid prescribing for chronic pain when the authors wrote, "Tolerance develops in most patients who receive long-term opioid therapy."

The AAPS said that many physicians have decided not to use EHRs because they fear the data will be used to control what they do and how they do it.

The fetal environment potentially preprograms the brain or endocrine system to be maladapted later in life and that patients with rheumatoid arthritis are known for having a dysregulated HPA axis, which may be affected in utero.

ABSTRACT: Inflammation of the anserine bursa occurs frequently inathletes who have tight hamstrings, obese patients, patients who haveknee joint pathology, and those who experience direct trauma to thearea. Iliotibial band syndrome results from inflammation of the iliotibialtendon and the bursa. For both injections, the patient may beinjected while lying supine with the leg extended. During anserinebursa injection, the lidocaine and corticosteroid should flow withoutresistance, although some pressure is required. An inability to depressthe syringe plunger requires repositioning of the needle to avoid injectioninto the medial collateral ligament or pes anserinus tendons.(J Musculoskel Med. 2008;25:340-341)

ABSTRACT: Hip fractures in older patients are projected to increase infrequency as the US population continues to age.

Most patients with a confirmed diagnosis of rheumatoid arthritis (RA) use nonbiologic disease-modifying antirheumatic drugs (DMARDs), and the rate of biologic DMARD use is increasing rapidly, according to the American College of Rheumatology (ACR).The organization last updated recommendations for the use of nonbiologic DMARDs in 2002 and had not developed recommendations for using biologic agents.

There is no clear consensus about which therapiesshould be used for the various underlying pathologies that lead topatellofemoral problems. The major distinction in classification isbetween patellofemoral compression syndrome and patellofemoralinstability. Patients with the former are concerned primarily withpain; those with the latter have instability or pain or both. Patellarpain may manifest in the parapatellar area or radiate to the back ofthe knee. Persons' differing activity and conditioning levels maylead to patellofemoral pain variability. Patients with patellar instabilityinclude those with recurring frank patellar dislocations andthose with symptoms of subluxation. Patients who have patellar instabilitypresent with tears of the medial patellofemoral ligament;this is the "essential lesion" for patellar dislocation. (J MusculoskelMed. 2008;25:297-300)