Periarthritis is a collective name for a wide and diverse group of diseases of the periarticular tissues of a degenerative, less often inflammatory nature. Affects tendons, ligaments, bursae, fascia, muscles, and other structures. It is manifested by pain, restriction of active movements while maintaining the volume of passive ones, sometimes by edema, local hyperemia. The course is usually chronic. Pathology is diagnosed according to the survey, external examination, X-ray results, ultrasound, MRI. Treatment includes NSAIDs, muscle relaxants, analgesics, therapeutic blockades, exercise therapy, physiotherapy. Sometimes operations are shown.
ICD 10
M75.0 M77.9
Meaning
Periarthritis is a widespread group of pathologies. It accounts for more than a quarter of the total number of diseases of periarticular tissues. It is possible both the defeat of individual structures and the involvement of several neighboring anatomical formations, which is the reason for the large clinical diversity, can complicate diagnosis. Patients of middle and elderly age suffer mainly, in the presence of injuries, overloads, provoking diseases, young people and even teenagers are affected. Periarthritis is more often diagnosed in women, but some forms may prevail in men.
Causes
The disease develops independently or accompanies other rheumatic pathologies: osteoarthritis, spondyloarthritis, rheumatoid arthritis. There is a definite relationship between the type of rheumatic disease and concomitant periarthritis. For example, with arthrosis of the knee joint, bursitis of the “goose bag” is often detected, coxarthrosis is often combined with trochanter tendinitis.
At the same time, the structure of periarthritis is dominated by independent lesions that are not associated with other processes. In such cases , the occurrence of pathology is provoked by the following factors:
- increased joint mobility (hypermobility syndrome);
- small developmental anomalies and structural features, which create a high load on certain areas, form an anatomical obstacle to the free sliding of the tendon.
- stereotypical movements that, with frequent repetition, cause constant overload, the appearance of microtrauma.
The latter feature is typical for athletes and people of certain specialties. For example, periarthritis of the shoulder joint is often found in basketball players, volleyball players, shot throwers, the elbow often suffers from tennis players. The professions associated with an increased risk of shoulder injury include plasterers and painters, de Quervain’s disease is detected in pianists, seamstresses, carpenters.
Hypothermia plays a certain role. Sometimes secondary periarthritis develops against the background of endocrine, parasitic, infectious diseases. In some patients, the cause of pathology is prolonged immobilization or violations of the regime during rehabilitation after injuries and operations on bones, joints, periarticular tissues.
Pathogenesis
The wide prevalence of pathologies of tendons, ligaments and other connective tissue periarticular formations is due to the peculiarities of the structure and metabolic processes of these structures. The characteristic differences are the low level of vascularization, slow collagen metabolism, which result in insufficient intensity of reparative processes.
With constant overloads or frequent microtraumatization, tissues do not have time to recover. Individual fibers are torn, necrosis sites are formed, followed by hyalinization, deposition of calcium salts. In the future, the foci are sclerosed and calcified. In the ligaments and tendons themselves, as well as in neighboring structures with a higher level of metabolism (bursae, tendon sheaths), reactive inflammation occurs.
Morphological examination of the affected formations in the early stages reveals inflammatory cellular infiltration, defects of individual tendon and muscle fibers, necrosis zones, effusion into the cavity of the periarticular bags and synovial sheaths. With the progression of the disease, hyalinosis, fibrosis and calcification prevail.
Classification
Taking into account the involvement of certain periarticular structures, the following variants of periarthritis are distinguished:
- tendinitis – tendons are affected;
- tenosynovitis – tendon vaginas suffer;
- enthesopathy – inflamed attachment points of ligaments and tendons to the bones and capsules of joints;
- bursitis – changes in synovial bags are observed;
- capsulitis – the lesion of articular capsules is determined;
- aponeurosis, fasciitis – fascia and aponeurosis suffer;
- myofascial pain syndrome – painful seals (trigger points) appear in the muscles.
Periarticular structures are closely related to each other, therefore several neighboring anatomical formations are often involved in the pathological process. Simultaneous damage to the tendon and its vagina (tendovaginitis), the transition of enthesopathy to tendinitis, and other options are possible.
Symptoms
Clinical manifestations are determined by the localization and type of pathology. At the same time, all periarthritis combines several characteristic common features. Pain syndrome occurs or increases only with certain movements. There is no spilled edema, local swelling in the area of damage is possible. Sometimes external changes are not detected. With the restriction of active movements (sometimes significant, complicating self–care), passive ones are preserved in full or almost in full. Stiffness is formed only at the final stage of the disease.
Periarthritis of the shoulder joint
They account for up to 80% of the total number of periarthritis, include tendinitis and impeachment syndrome. With tendinitis, there is an isolated lesion of the biceps tendon or supraspinatus muscle, the capsule of the joint or all of the listed structures. Pathology is diagnosed after 40 years, athletes and people with joint injuries are sometimes found at a young age.
The main symptom is pain during certain movements: trying to stretch or raise your hand, dressing, undressing. There may be night pains due to changes in the position of the hand. A distinctive feature is the sharp soreness when the limb is thrown forward. Subsequently, the pain syndrome remains at rest, prevents even minor movements. Edema is absent or weakly expressed. Palpation reveals pain along the anterior edge of the acromion and in the inter-tubercular furrow.
Impigment syndrome develops against the background of infringement of tendons during movements. Mature men who are engaged in heavy physical labor are more likely to suffer. At first, discomfort appears with intense loads. Then there is pain when the shoulder is withdrawn and rotated. The pain becomes constant, limits the ability to work, worries at night. Clicks and crunches appear during the movements. There is a decrease in muscle strength, stiffness. Concomitant tendovaginitis, bursitis, and sometimes arthrosis of the shoulder joint are formed.
Periarthritis of the elbow joint
External (lateral) epicondylitis or the elbow of a tennis player is provoked by repeated rotation and extension of the forearm. Pains occur during these movements, are clearly localized on the outer surface of the elbow. Internal (medial) epicondylitis is characterized by pain on the inner surface of the joint, which increases when the forearm rotates outward, bending with resistance. Both types of periarthritis are often associated with sports or professional activities.
Bursitis of the elbow joint becomes a consequence of high physical exertion or the need to constantly rest your elbows on the table. It is more often diagnosed in young and middle-aged people. The acute form is manifested by swelling, indistinct pain, local edema, hyperemia, hyperthermia. Palpation is determined by fluctuation. With the chronization of the process or the primary chronic course, there are no signs of inflammation, soreness decreases. A soft or elastic “bag” with liquid is preserved, sometimes with solid inclusions (rice corpuscles).
Periarthritis of the wrist joint and hand
Carpal tunnel syndrome is often found in women over 40 years of age. Caused by compression of the median nerve. It is manifested by paresthesia, numbness and neuropathic pain in 1-3, partially – 4 fingers. The hand becomes “awkward”, does not participate well enough in the movements. For de Quervain’s disease, gradual development and chronic course are typical. At first, pain is bothered with a significant retraction and extension of 1 finger, then any movements become painful. In some patients, the symptom persists at rest.
Tenosynovitis of the common extensor of the fingers (snapping finger) is more often observed in older women. The defeat of 3-4 fingers is characteristic. Flexion and extension are difficult, accompanied by a click. To unbend the “jammed” fingers, the patient uses the other hand. At the base of the finger on the palm, a dense nodule can be determined, shifting during tendon movements.
Periarthritis of the hip joint
The most common lesion is trochanteritis, primarily enteritis of the large trochanter. Complicates osteoarthritis in elderly women or occurs independently. There are pains radiating along the outer surface of the thigh, increasing in the lying position on the sick side. Palpation of the large trochanter is painful. An increase in the symptom during movements indicates the involvement of tendons and the development of enthesopathy.
Bursitis are less common than trochanterites. Trochanter bursitis is manifested by constant pain in the area of the large trochanter. At night, when turning to the affected side, patients wake up due to pain. Pressing on the spit is sharply painful. Due to the proximity of the bag to the joint, iliac-scallop bursitis proceeds with symptoms of coxarthritis. When fluid accumulates in the projection of the bursa, a tumor-like formation is palpated, compression of the femoral nerve with paresthesia and weakness of the thigh muscles is possible.
Periarthritis of the knee joint
Baker’s cyst develops more often after injuries or against the background of synovitis of various genesis. A painless oblong dense elastic formation appears on the posterior surface of the joint. Cysts of considerable size are accompanied by discomfort, heaviness during physical exertion. There may be pain in the calf muscle, hypesthesia on the posterior surface of the lower leg.
Prepatellar bursitis is provoked by prolonged kneeling or repeated injuries. There is swelling, fluctuation, local hyperemia and hyperthermia, minor soreness. Crow’s foot bursitis occurs with arthrosis, prolonged stay on the feet. The soreness when walking on the inner surface of the lower leg is 3-4 cm below the joint, which increases with flexion and extension.
Periarthritis of the ankle and foot
Achillodynia often accompanies spondyloarthritis. It can be observed with pronounced flat feet, hypermobility syndrome. There is swelling and painful sensations in the area of attachment of the tendon or its distal part. The symptom increases with prolonged standing and walking. With tendinitis of the tibial muscles, the zone of greatest pain is localized along the inner surface of the ankle. Fibular tendinitis is manifested by thickening and pain under the outer ankle.
Diagnostics
Rheumatologists and orthopedic traumatologists are engaged in determining the nature of pathology. When making a preliminary diagnosis, attention is paid to the presence of characteristic signs of periarthritis (absence of diffuse edema, discrepancy between passive and active movements, etc.). To confirm the diagnosis, clarify the type of pathology, the following methods are used:
- Radiography of the joint. At an early stage, the X-ray picture is unchanged. In the future, signs of calcification and bone remodeling, discontinuity of the cortical layer in the areas of attachment of ligaments and tendons are visualized.
- Ultrasonography. Ultrasound of joints and soft tissues, depending on the localization of periarthritis, determines a decrease in echogenicity, inhomogeneity, areas of thickening, increased vascularization, bone erosion, areas of ossification in connective tissue.
- Magnetic resonance imaging. There may be thickening and swelling of the ligament or tendon, bone edema in enthesopathies. The technique has a high informational value in the study of deep joint bags, which are difficult to examine during a routine examination. Confirms the presence of fluid, inflammatory changes.
Laboratory methods for primary periarthritis are not informative enough. They are prescribed for suspected symptomatic pathology in endocrine diseases, parasitosis, acute and chronic infections, rheumatoid lesions. Different types of periarthritis differentiate among themselves, taking into account the possibility of a combination of several pathologies. Sometimes a distinction with traumatic injuries is required.
Treatment
In most cases, therapy is carried out on an outpatient basis. An obligatory part of treatment is the exclusion or minimization of the influence of provoking factors, primarily chronic overload. In the acute period, complete rest is recommended, splints are applied or orthoses are used to unload the affected area.
Drug therapy
The leading role is played by NSAIDs used in the form of local (ointments, creams, gels) and systemic (oral and parenteral) forms. Permanent or long-term administration of NSAIDs is associated with the risk of gastrointestinal damage, so medications are used in the acute stage, if possible, administered intramuscularly or in the form of rectal candles. Local remedies are quite effective for superficial lesions, but do not provide the desired result when deep structures are involved.
Taking narcotic and non-narcotic analgesics for periarthritis is undesirable, it is recommended for a short course only at the height of the pain syndrome. These drugs, firstly, do not act on the pathogenetic mechanisms of the development of the disease, and secondly, provoke the phenomenon of “analgesic personality” – a condition in which the patient, without feeling pain, chooses too active motor mode, aggravating tissue damage.
In addition, drug therapy may include sedatives and muscle relaxants. If the pain syndrome persists for a long time, anticonvulsants and antidepressants are recommended to prevent chronization. Local blockades with anesthetics or a combination of anesthetics and glucocorticoids are of great importance. With the correct selection of the dose, frequency and place of administration, the method ensures the elimination of even intense pain syndrome resistant to other methods of therapy.
Physical methods
After the acute phenomena subside, treatment using physical factors comes to the fore. Patients are trained in special complexes of physical therapy, referred to massage and manual therapy. The number of physiotherapeutic techniques that have shown good effectiveness in periarthritis includes mud applications, medicinal electrophoresis and phonophoresis.
Laser therapy, magnetotherapy and cryotherapy are effective. Shock wave therapy is indicated for some patients. When choosing methods of physical impact, it is taken into account that all measures should be gentle. Active techniques are used in the pain-free zone. With excessive movements, massage loads, it is possible to develop vascular and muscle spasm with subsequent ischemia, increased pain syndrome and deterioration of the condition.
Surgical treatment
Surgical interventions are indicated to eliminate obstacles to the movement of tendons, with the chronic course of some bursitis, ineffectiveness of conservative measures, signs of degeneration of connective tissue structures according to imaging studies. The choice of method is determined by the nature of periarthritis:
- Tendinitis, enthesopathy: tenotomy, tendoperiosteotomy, in some cases – in combination with fasciotomy and other operations.
- Bursitis of the elbow joint: excision of the bag in the chronic form of the disease, opening and drainage of the bursa during suppuration.
- Baker’s cyst: open or endoscopic removal of the formation.
- Achillobursitis: correction of Haglund deformity, excision of the anterior bursa, opening and drainage during suppuration, suture of the Achilles tendon with spontaneous rupture.
- Impression syndrome: subacromial decompression, anterior acromioplasty, tendon repair, excision of the periarticular sac with concomitant bursitis.
In the postoperative period, painkillers and antibacterial agents are prescribed, bandages are performed. After the wound is healed, rehabilitation is carried out using physical therapy, physiotherapy and massage techniques.
Forecast
With the exclusion of provoking factors, the timely start of treatment, the prognosis is quite favorable. Clinical manifestations disappear or significantly decrease, performance is restored. Due to the tendency to chronic course and structural changes of the periarticular formations during overloads and during periods of exacerbation of diseases of nearby joints, relapses are possible.
Prevention
Preventive measures involve minimizing monotonous and excessive loads, observing optimal motor patterns when performing professional duties and playing sports. It is necessary to treat diseases of joints, other organs and systems that can provoke the development of periarthritis in a timely manner.
