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Peripheral musculoskeletal manifestations in polymyalgia rheumatica.

OBJECTIVES: The objectives of this study were to evaluate the frequency and characteristics of the peripheral musculoskeletal manifestations in polymyalgia rheumatica (PMR), evaluate if PMR with peripheral synovitis represents a subset with a more severe disease, and examine for clinical and laboratory characteristics at onset of PMR that might later predict rheumatoid arthritis (RA). PATIENTS AND METHODS: Patients were diagnosed with PMR according to the 1982 Chuang criteria. Patients were followed up between 1990 and 2002. The following musculoskeletal manifestations at onset and during the follow up were considered: peripheral synovitis, distal extremity swelling with pitting edema, carpal tunnel syndrome, and distal tenosynovitis. RESULTS: Thirty-eight of the 74 patients (51%) showed distal musculoskeletal symptoms: 29 (39%) had peripheral synovitis, 4 (5%) presented pitting edema, 4 (5%) experienced carpal tunnel syndrome, and one (1.3%) had distal tenosynovitis. These manifestations resolved completely after corticosteroid therapy was initiated. Peripheral synovitis was oligoarticular and often transient. The joints most frequently involved were the wrist, metacarpophalangeal, and knee. Erythrocyte sedimentation rate (ESR) was normal in 7 patients. When comparing patients with PMR with and without peripheral synovitis, no statistically significant differences were found in the studied variables. Through the first year of follow up, 7 patients fulfilled the American College of Rheumatology 1987 criteria for RA, 2 patients developed giant cell arteritis, and 3 had associated malignancy. Patients who developed RA had statistically significantly increased presence of persistent synovitis and a smaller decrease in mean ESR after treatment with corticosteroids. CONCLUSION: Fifty-one percent of the patients with PMR presented distal musculoskeletal manifestations, with peripheral synovitis being the most frequent one. Patients with PMR with peripheral synovitis did not represent a high-risk subgroup with more severe disease. Seven patients who developed criteria for seronegative RA within the first year of follow up had presented statistically significant persistent synovitis compared with those who continued as PMR and also showed a smaller initial decrease in mean ESR after steroid treatment was initiated. The absence of persistent arthritis and the benign course of the arthritis permit the distinction of PMR from other inflammatory arthropathies.

Aged↗

Prevalence of reoviruses in commercial chickens.

The prevalence of reoviruses in commercial chickens with the runting/stunting syndrome, tenosynovitis, and normal chickens was investigated. Reoviruses were isolated from 3-week-old chickens affected with the runting/stunting syndrome and from older chickens with tenosynovitis; viruses were isolated from tissues with and without lesions. Reoviruses were also frequently isolated from rectal contents of normal 3-week-old chickens, and there was serological evidence of previous reovirus infection in all flocks of adult meat breeder chickens examined. The widespread occurrence of reoviruses in both normal and diseased chickens indicates that the isolation of reoviruses from tissues of chickens with lesions does not necessarily imply any aetiological relationship of reovirus with disease, even in the absence of other known causes. However, the occurrence of reovirus in normal chickens does not preclude an aetiological relationship with disease and further investigation of strain variation and possible virulence factors in avian reoviruses is required.

Animals↗

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome: a prospective follow up and magnetic resonance imaging study.

OBJECTIVE: To determine the clinical characteristics of patients with "pure" remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome, and to investigate its relation with polymyalgia rheumatica (PMR). Magnetic resonance imaging (MRI) was used to describe the anatomical structures affected by inflammation in pure RS3PE syndrome. METHODS: A prospective follow up study of 23 consecutive patients with pure RS3PE syndrome and 177 consecutive patients with PMR diagnosed over a five year period in two Italian secondary referral centres of rheumatology. Hands or feet MRI, or both, was performed at diagnosis in 7 of 23 patients. RESULTS: At inspection evidence of hand and/or foot tenosynovitis was present in all the 23 patients with pure RS3PE syndrome. Twenty one (12%) patients with PMR associated distal extremity swelling with pitting oedema. No significant differences in the sex, age at onset of disease, acute phase reactant values at diagnosis, frequency of peripheral synovitis and carpal tunnel syndrome and frequency of HLA-B7 antigen were present between patients with pure RS3PE and PMR. In both conditions no patient under 50 was observed, the disease frequency increased significantly with age and the highest frequency was present in the age group 70-79 years. Clinical symptoms for both conditions responded promptly to corticosteroids and no patient developed rheumatoid arthritis during the follow up. However, the patients with pure RS3PE syndrome were characterised by shorter duration of treatment, lower cumulative corticosteroid dose and lower frequency of systemic signs/symptoms and relapse/recurrence. Hands and feet MRI showed evidence of tenosynovitis in five patients and joint synovitis in three patients. CONCLUSION: The similarities of demographic, clinical, and MRI findings between RS3PE syndrome and PMR and the concurrence of the two syndromes suggest that these conditions may be part of the same disease and that the diagnostic labels of PMR and RS3PE syndrome may not indicate a real difference. The presence of distal oedema seems to indicate a better prognosis.

Age Distribution↗

Disseminated gonococcal infection presenting as vasculitis: a case report.

A 50-year-old man with alcoholic liver disease presented with fever, tenosynovitis, polyarthritis and a vasculitic rash on the hands and feet for 4 days. He had neutrophilia and raised inflammatory markers. He had no history of sore throat, urethral discharge or travel abroad. His initial blood cultures were negative, and he was treated for vasculitis with steroids. The rash and arthritis seemed to improve initially, but he had another episode of fever. Repeat blood cultures grew Neisseria gonorrhoeae,and he received intravenous ceftriaxone followed by oral ciprofloxacin. He had marked improvement in rash, tenosynovitis and arthritis, and the fever dropped. He also had chlamydial urethritis and received azithromycin. The presentation of disseminated gonococcal infection after a presumptive episode of asymptomatic urethral gonorrhoea is highlighted.

Arthritis, Infectious↗

Normal anatomy and pathologic conditions of ankle tendons: current imaging techniques.

Radiologic assessment of tendon injuries requires familiarity with normal anatomy and the capabilities of available imaging modalities. Tenography, less commonly used nowadays, does not allow direct visualization of tendons, so that partial ruptures and longitudinal splits may go undetected. Ultrasonography can depict tenosynovitis, tendinitis, and complete tendon rupture of the Achilles tendon, but the other tendons are difficult to visualize with this technique. Magnetic resonance (MR) imaging is superior to computed tomography (CT) in the depiction of tenosynovitis and peritendinitis, tendinitis, tendon rupture, and tendon dislocation and subluxation. CT can demonstrate these abnormalities, but accompanying scar tissue or edema, early changes of tendon degeneration, and small amounts of inflammatory fluid are difficult to differentiate with this technique. CT is superior for demonstrating calcifications, convex retromalleolar groove, bone fragments, or spurs that complicate tendon dislocation and rupture. Although the authors prefer MR imaging, they caution that all of the modalities are not always specific and that differentiation between closely related processes such as tendinitis and early tendon rupture is difficult.

Ankle Joint↗

Carpal tunnel: MR imaging. Part II. Carpal tunnel syndrome.

The magnetic resonance (MR) images of 14 wrists of patients with carpal tunnel syndrome (CTS) were studied. Four general findings visible regardless of the cause of CTS included swelling of the median nerve, best evaluated at the level of the pisiform bone; flattening of the median nerve, most reliably judged at the hamate level; palmar bowing of the flexor retinaculum, best visualized at the level of the hamate bone; and increased signal intensity of the median nerve on T2-weighted images. Findings related to cause were tendon sheath edema in traumatic tenosynovitis, synovial hypertrophy in rheumatoid tenosynovitis, a ganglion cyst, and excessive amount of fat within the carpal tunnel, a persistent median artery, and a large adductor pollicis muscle. Knowledge of these findings may permit more rational choice of treatment. In four cases in which symptoms persisted after surgery, findings valuable in explaining or predicting the failure included incomplete incision of the flexor retinaculum, excessive fat within the carpal tunnel, persistent neuritis of the median nerve, and development of neuromas.

Adult↗

De Quervain disease in volleyball players.

BACKGROUND: Chronic inflammatory tendon diseases in athletes are frequent, and they often result from modifications in normal kinematics of a tendon associated with a patient's anatomical determinants. De Quervain stenosing tenosynovitis is an inflammatory disease of tendons of the first dorsal compartment of the wrist. There is no literature about this disease concerning professional volleyball players. HYPOTHESIS: Limited, multiple trauma on the dorsal radial portion of the wrist, associated with long training times, can be involved in the pathogenetic process of de Quervain disease in professional volleyball players. STUDY DESIGN: Case series; Level of evidence, 4. MATERIALS AND METHODS: The authors studied 45 consecutively enrolled volleyball players (27 professional, 18 nonprofessional) satisfying clinical criteria for the diagnosis of de Quervain stenosing tenosynovitis. All patients were evaluated by questionnaire and physical examination. They were divided into group A (mild) and group B (severe) based on the severity of the symptoms and physical findings; they were followed for a mean of 37 months. RESULTS: Total training quantity (mean weekly training time multiplied by mean sports activity duration) in group A was 74, whereas it was 155 in group B (P < .01). No neuropathies were found in group A, whereas they were found in 3 patients in group B. Fifty percent of surgical patients had a longitudinal fibrous septum, whereas 54% showed multiple tendon sheaths making up the abductor pollicis longus tendon. CONCLUSIONS: This study shows that increased training time and consequent microtrauma associated with professional volleyball activity can increase the likelihood of de Quervain disease.

Adolescent↗

Spectrum of lesions of the anterior capsular mechanism of the shoulder.

The anterior capsular mechanism appears to be the common denominator in a number of shoulder problems ranging from the recurrent dislocation ("too loose") to the frozen shoulder ("too tight"). The shoulder region and the anterior capsular mechanism can be carefully and accurately assessed by arthrography and cineradiography. Bicipital tenosynovitis has been held accountable for shoulder problems at each extreme of the spectrum. Bicipital tenosynovitis may exist in many shoulders; however, in corrective procedures for the unstable shoulder, the biceps becomes a dynamic reinforcement of the anterior capsule. In the frozen shoulder, the biceps tendon frequently is seen as normal at surgery and the anterior capsular mechanism is identified as the site of the essential lesion. Surgery may switch the patient's problem from one side of the spectrum to the other. Shoulder problems should be investigated thoroughly and evaluated in terms of the patient's requirements for shoulder motion as well as in terms of the orthopaedic surgeon's usual criteria for recommending corrective procedures.

Adolescent↗

Associated injuries found in chronic lateral ankle instability.

Sixty-one patients underwent a primary ankle lateral ligament reconstruction for chronic instability between 1989 and 1996. In addition to the ligament reconstruction, all patients had evaluation of the peroneal retinaculum, peroneal tendon inspection by routine opening of the tendon sheath, and ankle joint inspection by arthrotomy. A retrospective review of the clinical history, physical exam, MRI examination, and intraoperative findings was conducted on these 61 patients. The purpose was to determine the type and frequency of associated injuries found at surgery and during the preoperative evaluation. At surgery no patients were found to have isolated lateral ligament injury. Fifteen different associated injuries were noted. The injuries found most often by direct inspection included: peroneal tenosynovitis, 47/61 patients (77%); anterolateral impingement lesion, 41/61 (67%); attenuated peroneal retinaculum, 33/61 (54%); and ankle synovitis, 30/61 (49%). Other less common but significant associated injuries included: intra-articular loose body, 16/61 (26%); peroneus brevis tear, 15/61 (25%); talus osteochondral lesion, 14/61 (23%); medial ankle tendon tenosynovitis, 3/61 (5%). The findings of this study indicate there is a high frequency of associated injuries in patients with chronic lateral ankle instability. Peroneal tendon and retinacular pathology, as well as anterolateral impingement lesions, occur most often. A high index of suspicion for possible associated injuries may result in more consistent outcomes with nonoperative and operative treatment of patients with chronic lateral ankle instability.

Adolescent↗

Ankle extensor tendon synovitis due to a date palm thorn.

Palm thorn injury to tendons and joints is characterized in most patients by an acute inflammatory stage followed by a relatively asymptomatic period and finally by chronic synovitis or tenosynovitis. Once the inflammatory process has begun, detection and localization of the thorn can be very difficult. We present an unusual case of palm thorn tenosynovitis of the ankle extensor tendon which was detected and localized preoperatively by ultrasound. Removal of the thorn and synovectomy were curative.

Adult↗

Chronic disorders of the Achilles tendon: results of conservative and surgical treatments.

We reviewed our results of nonoperative and operative treatment of chronic Achilles tenosynovitis to further define outcomes and treatment parameters. Forty-one patients presented with an average of 14 weeks of Achilles tendon symptoms. All patients received nonsurgical treatment initially, and 21 patients (51%) recovered after an average of 18 weeks of therapy. Three additional patients improved after brisement of the tendon/peritenon interspace. Seventeen of 41 patients eventually underwent soft tissue tenolysis and/or excision of degenerative tendon cysts. Those patients who responded to nonoperative therapy tended to be younger (average age, 33 years) than those who had degenerative tendon changes requiring surgery (average age, 48 years). All surgical patients were able to return to unrestricted activity after 31 weeks (range, 27-48 weeks). We believe 4 to 6 months of nonsurgical therapy is appropriate for middle aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon.

Achilles Tendon↗

Computed tomographic assessment of old calcaneal fractures.

Prolonged pain and disability are common complications of calcaneal fractures. A prospective study was conducted on the value of computed tomography (CT) in 63 patients with 73 calcaneal fractures sustained more than 6 months before. The fractures were classified from the initial plain radiographs, and the patients' current clinical condition assessed in terms of a "disability score". The mean disability scores (MDS) associated with the different types of fracture were correlated with the CT findings. The highest MDS was found in the intra-articular fracture group which comprised 71% of the series. In this group the MDS was increased in the presence of post-traumatic osteoarthrosis of the subtalar joint (61% of cases), involvement of the calcaneocuboid joint (39% of cases) and subluxation/dislocation of the peroneal tendons (47% of cases). Structural abnormalities of the peroneal tendons were associated with a higher MDS including chronic tenosynovitis (eight cases), chronic partial tendon rupture (eight cases), complete peroneus brevis tendon rupture (two cases) and scarring indicating stenosing tenosynovitis (14 cases). A similar spectrum of appearances affecting the medial tendons of the hindfoot was identified in eight cases. Direct CT measurements of the degree of comminution did not correlate well with the patients' MDS. In the patient with persistent symptoms, CT is of value in the later assessment of long-term complications by revealing abnormalities of the subtalar joints and adjacent tendons.

Adolescent↗

Heterophil function and resistance to staphylococcal challenge in broiler chickens naturally infected with avian leukosis virus subgroup J.

Avian leukosis virus subgroup J has a high tropism for myeloid lineage cells and frequently induces neoplastic transformation of myelocytes. The impact of congenital avian leukosis virus subgroup J infection on the function of circulating heterophils and susceptibility to staphylococcal infection was investigated. Six-week-old broiler chickens negative for exogenous avian leukosis viruses or congenitally infected with avian leukosis virus subgroup J were inoculated intravenously with 10(6) colony-forming units of Staphylococcus aureus, and pre- and postinoculation heterophil function was assessed. All chickens developed a leukocytosis with heterophilia after inoculation, but total leukocyte and heterophil counts were significantly higher in leukosis-negative chickens than in virus-infected chickens. Tenosynovitis was more severe in leukosis-negative chickens, and 2/10 (20%) of the virus-infected chickens had no histologic evidence of tenosynovitis. Osteomyelitis in the tibiotarsus or tarsometatarsus developed in 5/10 (50%) of the chickens in each group. S. aureus was recovered from the hock joint of 6/10 (60%) of the chickens in each group. Heterophils from all chickens exhibited similar phagocytic ability pre- and postinoculation. Heterophils from virus-infected chickens exhibited less bactericidal ability preinoculation than did heterophils from leukosis-negative chickens. However, postinoculation bactericidal ability was similar in both groups. Avian leukosis virus subgroup J provirus was present in heterophils isolated from congenitally infected chickens. Heterophils isolated from broiler chickens congenitally infected with avian leukosis virus subgroup J exhibit no significant functional deficits, and infected and uninfected chickens exhibit similar susceptibility to staphylococcal infection.

Animals↗

Extensor retinaculum of the wrist: sonographic characterization and pseudotenosynovitis appearance.

OBJECTIVE: We have found in our practice that the normal extensor retinaculum of the wrist may appear hypoechoic on sonography and, because it is closely applied to the extensor tendons, may simulate tenosynovitis. This study prospectively evaluates the extensor retinaculum in 50 healthy adult volunteers, characterizing its sonographic appearance. CONCLUSION: The extensor retinaculum has a characteristic appearance on sonography. A hypoechoic appearance from anisotropy should not be confused with tenosynovitis.

Adult↗

MR imaging of posterior tibial tendon dysfunction.

OBJECTIVE: The purpose of this study was to describe the MR findings of posterior tibial tendon dysfunction. MATERIALS AND METHODS: MR images and medical records were reviewed for 11 patients with surgically proven posterior tibial tendon abnormalities (i.e., tears or tenosynovitis) and for six patients with clinical evidence of posterior tibial tendon dysfunction. Our study group included 16 women and one man from 37 to 70 years old (mean, 53.5 years old). MR examinations used T1-weighted and T2-weighted spin-echo sequences in the oblique axial and sagittal planes. RESULTS: Abnormal MR findings were observed in all 17 patients. The spectrum of MR abnormalities included fluid in the tendon sheath of a normal tendon interpreted as isolated paratenonitis (tenosynovitis, n = 3); tendon thickening and surrounding fluid with normal tendon signal interpreted as tendinosis (degeneration, n = 1); tendon thickening with increased linear or heterogeneous intrasubstance signal interpreted as partial tear (n = 11); tendon discontinuity with fluid-filled tendon sheath interpreted as complete rupture (n = 2). In 11 patients, the posterior tibial tendon was explored at surgery. In these patients, MR imaging accurately showed two cases of isolated paratenonitis, one case of tendinosis, four partial tears, and two complete ruptures. In the remaining two patients, the presumed MR diagnosis did not correlate very closely with the surgical findings: one patient with isolated paratenonitis shown by MR imaging had tendinosis found at surgery; however, the surgery in this patient followed the MR examination by 10 months, a time during which degeneration might have occurred. The other patient had an MR diagnosis of partial tear, which was not found at surgery; however, tendon degeneration was severe and a small tear not reaching the tendon surface could have been missed at inspection. MR imaging characteristics of severe tendinosis and partial tear may overlap. CONCLUSION: MR imaging is effective for detecting abnormalities related to posterior tibial tendon dysfunction. Familiarity with the appearance of these changes facilitates accurate characterization.

Ankle↗

The rope ladder: an uncommon artifact and potential pitfall in MR arthrography of the shoulder.

OBJECTIVE: MR arthrograms were retrospectively reviewed for susceptibility artifacts induced by accidental injection of a small amount of gas when paramagnetic contrast solution was injected. A pitfall to interpretation, an unusual distribution of intraarticular gas into the sheath of the long biceps tendon that resembled a rope ladder, was observed and compared with findings of bicipital tenosynovitis. CONCLUSION: Intraarticular gas contamination during MR arthrography must be differentiated from intraarticular loose bodies and findings of bicipital tenosynovitis. Most reliable for the differential diagnosis are the different shapes and sizes of the gas-induced susceptibility artifacts on spin-echo and gradient-recalled echo images.

Adult↗

Diagnostic and therapeutic ankle tenography: outcomes and complications.

OBJECTIVE: The purpose of our study was to evaluate tenography complications and outcomes in a large series. MATERIALS AND METHODS: Of 144 tenograms obtained consecutively from May 5, 1995, to March 17, 1997, 111 were located for at least a 6-month follow-up; 65 were posterior tibial, 39 peroneal, two anterior tibial, three flexor digitorum longus, and two flexor hallucis longus tenograms. Tenography was performed fluoroscopically with contrast material and anesthetic followed by steroid placement into tendon sheaths. RESULTS: Of 65 patients undergoing posterior tibial tenography, 31 (48%) had complete or near-complete symptom resolution; 17 (26%) had no relief. Seventeen patients (26%) had initial relief with the subsequent return of pain to the pretenography level. Of 39 patients undergoing peroneal tenography, 18 (46%) had complete or near-complete symptom resolution; 10 (26%) had no and 11 (28%) had initial relief with subsequent pretenography pain return. Of three patients undergoing flexor digitorum longus tenography, one had complete, one had no, and one had initial relief with complete pretenography pain return. One of two patients who underwent flexor hallucis longus tenography had no relief; the other had initial relief with complete pain return. Two patients who underwent anterior tibial tenography had complete pain relief. We found no correlation between degree of tenosynovitis shown radiographically and therapeutic improvement with anesthetic and steroid injection. Tenography complications included one posterior tibial tendon rupture (0.89%) and 14 patients with skin discoloration at the tendon sheath injection site. CONCLUSION: Forty-seven percent of surgical candidates whose condition was refractory to conservative therapy had complete or near-complete prolonged symptom relief after tenography. In appropriate patients, tenography is excellent therapy for tenosynovitis. Certain precautions make complications rare.

Ankle Joint↗