Management of Common Soft Tissue Rheumatism

Review Article Hong Kong Bull Rheum Dis 2009;9:50-56 Management of Common Soft Tissue Rheumatism Ho So and Ronald Man-Lung Yip Abstract: Soft tiss...
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Review Article

Hong Kong Bull Rheum Dis 2009;9:50-56

Management of Common Soft Tissue Rheumatism Ho So and Ronald Man-Lung Yip

Abstract:

Soft tissue rheumatism is one of the most common but often overlooked groups of disorders. Among the more common ones are rotator cuff tendonitis, epicondylitis, De Quervain's tenosynovitis, carpal tunnel syndrome, stenosing digital tenosynovitis, Achilles' tendonitis and plantar fasciitis. The diagnosis of most of these disorders relies on history and physical examination. There are many treatment options once the diagnosis is made. Local glucocorticoid injection, which is easily applicable and inexpensive, is an effective form of treatment. In this article, the current scientific evidence on the management of common soft tissue rheumatism, with particular focus on soft tissue glucocorticoid injection, is discussed.

Keywords: Glucocorticoid injection, Soft tissue rheumatism, Steroid injection

Introduction Soft tissue rheumatism is probably the most commonly encountered group of rheumatic disorders. It includes lesions of the tendons, tendon sheaths, fasciae, bursae, and joint capsules. Common ones are rotator cuff tendonitis, epicondylitis, De Quervain's tenosynovitis, carpal tunnel syndrome, stenosing digital tenosynovitis, Achille's tendonitis and plantar fasciitis. The exact pathogenesis of soft tissue rheumatism is not clear. In most cases, they are thought to be the result of excessive or unaccustomed use causing repeated micro-trauma. The repetitive injury leads to inflammation and thus degeneration and fibrosis. Soft tissue rheumatism can also be associated with systemic diseases such as rheumatoid arthritis and diabetes mellitus. The diagnosis of soft tissue rheumatism disorders is largely clinical. It relies on good knowledge about the anatomy and function of the different body parts. There are many treatment options including rest, topical or systemic analgesics, antiinflammatory drugs, physiotherapy, local glucocorticoid injection and surgery. Local glucocorticoid injection is simple,

DEPARTMENT OF MEDICINE AND GERIATRICS, KWONG WAH HOSPITAL, 25 WATERLOO ROAD, KOWLOON, HONG KONG SAR Ho So MBBS, MRCP Ronald Man-Lung Yip MBchB, FHKAM(Medicine), FHKCP Correspondence to: Ho So

safe and effective. Recent evidence regarding the management of common soft tissue rheumatism with emphasis on local glucocorticoid injection will be discussed below.

Soft Tissue Glucocorticoid Injection For decades, local glucocorticoid injection has been widely used for the treatment of soft tissue rheumatism disorders. Its anti-inflammatory effect can reduce symptoms, provide a painfree period for rehabilitation therapy or definitely treat a condition. It is usually used when conservative measures fail. There are very few contraindications for local steroid injection (Table 1) . Despite its popularity, good methodological quality evidence regarding soft tissue injection in the literature is scarce. According to one large survey of a quarter of the members of American College of Rheumatology in 1993,1 the practice varies remarkably between centers and practitioners with respect to almost all aspects of the procedures: environment, antiseptic use, dose and volume of anaesthetics, type and dose of steroid. However, the assuring message from the study is that most techniques and agents work reasonably well. It is generally believed that shorter-acting glucocorticoid preparations such as Methylprednisolone (Depo-Medrol) cause less local post-injection flare and soft tissue atrophy. Larger drug volume and higher dosage is used for larger joints and vice versa. For example, Depo-Medrol 40 mg or equivalent is used for large areas (shoulders); 20 mg for

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medium sized areas (elbows); 10 mg for small areas (tendon sheaths). It is also a common practice to mix glucocorticoid with local anaesthetics. Local anaesthetics offer immediate pain relief before the anti-inflammatory effect of steroid takes action and the immediate relief of symptoms can be used as an evidence of good placement of the injection. The complications of local steroid injection are usually minor (Table 2). Post-injection inflammatory flare reaction is quite common (2-10%).2,3 It is characterized by an increase in pain, swelling and redness occurring and resolving within 48 hours after injection and is believed to be associated with a reaction to the steroid crystals. It is important to distinguish it from infection which is much more rare (