What is Extraarticular Rheumatism?
Rheumatic processes in the periarticular tissues are extra-articular diseases of the soft tissues of the musculoskeletal system, often referred to as “extra-articular rheumatism”. This large group of pathological processes of various origins and clinics includes diseases of both tissues located in close proximity to the joints, i.e., periarticular tissues (muscle tendons, their vagina, mucous bags, ligaments, fasciae and aponeurosis), and tissues located at some distance from the joints (muscles, neurovascular formations, subcutaneous fatty tissue).
The most studied are the diseases of the periarticular tissues with clearly defined localization and clinical manifestations, while the RB of soft tissues that are not related to the periarticular, is distinguished by less clear clinical symptoms and often uncertain localization. As a consequence, in this section, we will touch only diseases of the soft periarticular tissues.
These processes primarily include tendinitis, tendovaginitis, bursitis, tendobursity, ligamentitis, and fibrositis.
Diseases of the soft periarticular tissues are very common. In a survey of 6,000 people, they were found in 8% of individuals. The defeat of the periarticular apparatus occurs more often in women aged 34-54 years, especially in individuals.
Causes of Extraarticular Rheumatism
The etiology of independent diseases of the periarticular tissues is very similar to the etiology of arthrosis. The main cause of these painful syndromes is microtrauma professional, household or sports, which is explained by the superficial location of the soft periarticular tissues and their large functional load. It has been established that long-lasting stereotypical movements lead to the development of a degenerative process in the tendons, collagen fibers and ligaments, followed by a slight reactive inflammation in the nearby well vascularized structures – vaginas and serous bags. This is evidenced by the frequent development of periarthritis, tendovaginitis, bursitis in athletes, dancers, painters, violinists, typists. Severe physical strain and direct injury can also cause periarthritis and other soft tissue damage.
Of great importance are neuroreflex and neurotrophic influences that impair trophism and nutrition of the soft periarticular tissues, and contribute to the development of a degenerative process in them. Neuroreflex genesis of such diseases as humeroscapular periarthritis in myocardial infarction, neurotrophic “shoulder – hand” syndrome, shoulder tendinitis in cervical spondylosis is an established fact.
However, the possibility of the development of painful syndromes in the soft periarticular tissues of individuals with a normal load on these tissues (not exceeding physiological), which lack the influence of neuroreflex factors, suggests that there are a number of reasons that reduce the resistance of tissues to the usual physiological load. These primarily include endocrine and metabolic disorders, as indicated by the frequent development of diseases in women in menopause, especially those suffering from obesity, diseases of the liver and biliary tract. This is evidenced by the frequent combination of periarthritis and arthrosis, having a similar genesis. As with arthritis, this process cannot exclude the importance of the genetic factor, congenital weakness of the tendon-ligation apparatus or its increased reactivity to the action of various factors that impair nutrition and trophic periarticular tissues. The specific mechanisms of the influence of these causes on the development of the degenerative process in the periarticular tissues have not yet been studied, but their significance is confirmed by practice.
There are a number of provoking factors contributing to the development of this pathology. The effects of cooling and dampness are well known, which is associated with the over-irritation of skin receptors and spasm of capillaries, which interferes with microcirculation in the periarticular tissues, local metabolism and trophism. Clinical experience shows that in some cases a focal infection is a provoking factor in the development of the disease of the periarticular tissues. In most cases, the occurrence of painful syndromes in the periarticular tissues is the result of the combined effects of several pathogenetic factors.
Pathogenesis during Extra-articular Rheumatism
Pathogenesis and pathological anatomy. Diseases of the soft periarticular tissues may be inflammatory or degenerative.
Inflammatory diseases of these tissues are most often secondary and arise as a result of the spread of the inflammatory process from the joint with arthritis of various origins. Independent, primary diseases of the periarticular tissues have a G in their basis a predominantly degenerative process, very similar to that observed in arthrosis. Since the causes of the degenerative process in the articular and periarticular tissues are identical, there is often a simultaneous development of degenerative changes in these tissues, that is, arthrosis is often accompanied by periarthritis, tendovaginitis and other lesions of the periarticular apparatus. However, a degenerative process can also occur as often (with subsequent slight reactive inflammation) in the soft periarticular tissues with completely intact joints.
The similarity of the pathogenesis of degenerative diseases of the joints and periarticular tissues allows some authors to consider arthrosis and the primary disease of the periarticular tissues as clinical variants of a single pathological process.
The primary degenerative process of the periarticular apparatus is most often localized in the tendons (constantly carrying a large load). Due to the constant tension and microtrauma in poorly vascularized tendon tissue, tears of individual fibrils are observed with the formation of foci of necrosis with hyalinization and calcification of collagen fibers. In the future, sclerosis and calcification of these foci occur, and in nearby well-irrigated synovial formations (vagina, tendons, serous bags), as well as in the tendons themselves, signs of reactive inflammation appear, similar to those that occur during arthrosis.
The processes described above most often develop in the place of attachment of the tendons to the bone, in the so-called insertions of the tendons. At the same time, an isolated defeat of the tendon (tendonitis) rather quickly turns into tendobursit due to the inclusion of a nearby serous bag in the process. At the same time, tendoporiostitis develops in connection with the reaction of the periosteum at the site of contact with the affected tendon.
Histologically, in the focus of tendon necrosis, glycosaminoglycans (mucopolysaccharides) are depolymerized with the formation of a fibrinoid substance, a leukocyte and histiocytic reaction around and subsequent sclerosis and calcification. Most often, insertions of short and wide tendons that carry a large load, such as tendons of short shoulder rotators, suffer.
When reactive brown in serous bag observe hyperemia, edema with a rapid accumulation of serous or purulent exudate in the cavity of the bag. The outcome of this process is mostly favorable: necrosis foci, exudates and calcifications dissolve. However, in some cases there are residual phenomena in the form of fibrous adhesion of the walls of the bags and the tendon sheath, which complicates the slipping of the tendon during its contraction and relaxation and leads to functional impairment.
Although the defeat of the synovial formations (synovial sheaths, serous bags) is most often combined with the defeat of the tendons, it can also occur in isolation, sometimes spreading to nearby tendons and causing secondary tendonitis. The degenerative process in the tendons is very often combined with a similar damage to the ligaments, especially in cases where the long and thin tendons pass through narrow ligaments (on the hands and feet). The anatomical relationships here are so close that it is sometimes difficult to resolve the issue of the primacy of the lesion of a particular tissue, i.e., primary tendovaginitis or ligamentitis develops. In these cases, both terms (tendovaginitis and ligamentitis) are often used as synonyms.
The defeat of aponeuroses and wide fascias (fibrositis) is characterized by the predominance of fibrosclerotic processes. They can be common (for example, the defeat of the entire palm aponeurosis) or focal (formation of fibrous nodules). In the initial phase, a serosinfibrous effusion is observed, which is replaced by a pronounced fibroblastic proliferation with the formation of nodules and subsequent fibrous-cicatricial changes, sometimes leading to the formation of persistent contractures.
The variety of pathological changes leads to a large polymorphism of clinical manifestations of diseases of periarticular tissues. Thus, the following main processes of the periarticular tissues are distinguished.
- Tendonitis is an isolated degenerative lesion of the tendon (with slight secondary inflammation). Usually this is the first short phase of the degenerative process in the periarticular tissues.
- Tendovaginitis (tenosynovitis) is often the second phase of the pathological process that develops as a result of the contact of the affected tendon with well-irrigated synovial tissues.
- Ligamentitis – an inflammatory lesion of extra-articular ligaments; most often the ligamentous canal through which the tendon passes in the wrist and ankle joints.
- Calcification is the deposition of calcium salts in the foci of necrosis and in serous bags.
- Bursitis is a local inflammation of the serous bag that develops most often as a result of contact with the affected tendon (tendobursitis).
- Tendon lesions, in addition, are usually classified according to the preferential localization of the pathological process. The combination of the lesion of the insertion of the tendon and the surrounding formations – the periosteum and the serous bag – is called periarthritis. This process most often develops in short and wide tendons carrying a large functional load. The lesion of the middle part of the tendon and its vagina (most often it is thin and long tendons) is designated as tendovaginitis or tenosipsvit. The lesion located in the tendon ligament is called myotendinitis.
- Fasciitis and aponeurosis-diseases of the fascia and aponeuroses are commonly referred to as the general term fibrositis.
Symptoms of Extraarticular Rheumatism
In case of lesions of the tendon apparatus, clinical manifestations — pain and limitation of movements — are observed only after the synovial formations, the tendon sheath and the serous bags, are included in the pathological process. The primary isolated lesion of the tendon itself usually does not show any clinical symptoms. Clinical manifestations of soft periarticular tissues have some features that allow differential diagnosis with diseases of the joints, which sometimes presents difficulties due to close topography, and sometimes close contact of articular and extra-articular tissues (for example, insertions of muscle tendons and periosteum of the epiphyses). Pain arising from the defeat of the tendons, first, arise or intensify only with movements associated with the affected tendon, while all other movements, due to the intactness of the joint itself and other tendons, remain free and painless. Secondly, they appear only with active movements, when there is tension in the affected tendon. Passive movements are painless due to the lack of shortening of the tendon.
Palpation of the affected area is not determined by diffuse pain or tenderness along the joint space; as it is observed in case of joint disease, and local pain points corresponding to the insertion of the tendon insertion to the bone or the anatomical location of the tendon itself. A small and rather well defined swelling in the area of the affected tendon or serous bag (as opposed to diffuse with arthritis) is revealed.
The localization of the lesions of the periarticular tissues is determined by the intensity of their functional load. The tendons of the hands are mainly affected, which is associated with the many and varied functions of the upper limbs, resulting in almost constant tension of these tendons. Degenerative diseases of the joints are localized, on the contrary, most often in the joints of the legs, which are supporting, therefore, carrying a greater functional load.
The most frequent localization of periarthritis in the upper limb is the shoulder region, where the short rotators of the shoulder and the biceps tendon are constantly subjected to a large functional load, and in difficult conditions (the passage of the tendons in a narrow space). This is the reason for the frequent occurrence of tsndoperiosteitis of the supraspinatus and supraspinatus muscles, subacromial tendobursitis and tenosynovitis of the long head of the biceps.
In the area of the elbow joint periarthritis occur less frequently. Usually develops tendoniticitis in the area of attachment of the extensor tendons and the instep support of the forearm to the external condyle of the shoulder (external epicondylitis). Tendobursitis of tendons that are attached to the inner condyle of the shoulder (internal epicondylitis) is less common, and tendonostomy of the biceps muscle attached to the acromion (acromialgia) tends to occur.
Frequent localization of the degenerative process on the upper extremities are the long and thin tendons of the wrist and hand, which pass through narrow fibrocyteal channels. A variety of painful syndromes develop: tendovaginitis of the tendons of the muscles that take and extend the thumb (de Querven’s disease), tendovaginitis of the ulnar extensor of the hand (ulnar styloiditis), tendovaginitis of the flexor of the fingers (carpal canal syndrome), etc. fingers.
In the lower limbs, a lesion of the tendon apparatus and ligaments is much less common. In the area of the hip joint, tendiners of the gluteal muscles can develop at the place of their attachment to the large tubercle (trochanteritis) and the iliopsoas muscle in the place of its attachment to the small tubercle.
In the area of the knee tendon bursitis develops tendons attached to the inner surface of the knee and tibial tuberosity.
The foot and ankle area are the site of the most frequent localization of the degenerative process in the tendons, which, like the wrist, pass through narrow ligaments, as well as at the site of attachment of the Achilles tendon to the calcaneal tubercle (achillodynia) and at the site of attachment to the heel bone of the plantar muscles and plantar aponeurosis (with the development of the calcaneal bursitis).
The listed lesions of tendons, ligaments and aponeuroses, complicated by the reaction of serous bags and tendon sheaths, can be observed both in isolation and in various combinations.
In 30–40% of patients, on a radiograph, calcifications are found along the affected tendon, as well as a periosteal reaction – induration and small osteophytes at the site of attachment of the tendon to the bone (tendoproiditis).
Treatment of Extraarticular Rheumatism
No other disease has such a wide choice of medical remedies – from rubbing with antirheumatic drugs, ointments based on medicinal plants, ointments with various components irritating the skin, using heat and cold in the most different forms, massage, electrotherapy up to acupuncture and other medical techniques .
Acceptance of antirheumatic drugs is of secondary importance – non-steroidal antirheumatic drugs that suppress pain and the inflammatory process are widely used here. This does not apply to rheumatic polymyalgia, in which, as we noted above, the use of anti-inflammatory hormones of the adrenal cortex, corticosteroids (prednisone), is quite characteristic. Similarly, pains are treated for tendon diseases – by injecting these hormones directly into places where pain is felt.
The most popular drugs for extra-articular rheumatism include medical ointments and solutions (even Schweik in the first chapter of Hasek’s book smeared his knees with opdoledmok – a solution containing camphor and mint), that is, substances that cause skin irritation and reflex enhancement of blood supply to tissues, which gives a good therapeutic effect. Ointments (thicker than solutions) contain various nonsteroidal antirheumatic drugs and rubbed into the skin until they are absorbed.
Local or general heat use is an excellent treatment. Sources of heat can be a Solux lamp, a hot bath with medicinal additives (solfatan, peat), an electric heater, a warm compress or wax applied to the skin, therapeutic mud, including those from Piešянan, applied as a fabric compress, which should be “heated” at home. “As written in the instructions. Sometimes the patient prefers cold compresses.
Doctors often prescribe electrotherapeutic procedures, such as iontophoresis (the introduction of drugs into the skin through the effects of electric current), diathermy (works with the help of electric waves, most often short, which are similar to radio waves), ultrasound (ultrasonic device produces a certain sound so high) the human ear does not distinguish it, but the tissues of the body feel its vibrations, and thus their blood supply increases).
Somewhat more complex are the healing techniques for a sore shoulder. First of all, it is necessary for the doctor to determine the cause of the disease. It requires patience, and you need to realize that in the final stage, the result of treatment will always be improvement, although sometimes it takes several months to wait. When treating, you should first give preference to rest, not to engage in too active development of the shoulder. The shoulder should be spared, and sometimes using a sling for the hand. After the first attack of the disease has passed, the shoulder can be developed with swinging movements or with the help of a healthy hand. These exercises are suitable for other types of rheumatic diseases. It is advisable to first take the introductory classes under the guidance of a rehabilitation specialist.