PERIARTHRITIS (periarthritis, singular; grech, peri around, near + arthron a joint + - itis) — a dystrophic or inflammatory disease of an insertion of sinews (the place of attachments of sinews to bones) and the serous bags surrounding joints, causing pathological changes in circumarticular fabrics.
According to domestic classification of diseases of joints (1971) of P. carry to extraarticular diseases of soft tissues of a musculoskeletal system. According to M. G. Astapenko and P. S. Eryalps (1975), P. make 26,1% of all extraarticular diseases of soft tissues of a musculoskeletal system.
Allocate P. caused by dystrophic process and actually inflammatory P. which meets seldom and is noted mainly at chronic arthritises. In this article P. caused by dystrophic process is described; actually inflammatory P. is described In article pseudorheumatism (see).
The etiology and a pathogeny
are the Reason of this type of P. hl. obr. the repeated microtraumas of sinews connected with features of a profession or the strengthened sports (P. of a shoulder at the smith, P. of a wrist at the painter, P. of an elbow at the tennis player etc.). Development of dystrophic process is promoted also by disbolism (e.g., obesity), endocrine disturbances (e.g., in a climacteric), neyroref-lektorny, vascular and other disorders. Under the influence of loading and the raised traumatization in badly vaskulyarizirovanny tissue of sinews the centers of a necrosis with the subsequent their sklerozirovaniye, calcification and emergence of a reactive inflammation, including in nearby serous bags develop — bursitis (see). Reaction of a periosteum in the place of contact with it of the affected sinew is at the same time possible — periostitis (see).
the short and wide sinews bearing big loading Most often are surprised. Histologically in a sinew fibrinoid changes, moderate leukocytic and histiocytic infiltration come to light, sites of a sclerosis are found. At development of a reactive bursitis the hyperemia of fabrics of a bag, their hypostasis, accumulation in a cavity of a synovial bag of serous exudate is noted. Gradually there is involution of these changes, but in some cases residual changes are possible: a fibrous union of walls of a bag, adjournment of salts of calcium in them that promotes emergence of functional disturbances.
The clinical picture
the Most frequent localization of P. is area of a shoulder joint (humeroscapular P.) that is caused by anatomic features shoulder joint (see), and also the fact that on its tendinous device the raised loading constantly falls. Less often sinews of the muscles which are attached in an elbow joint, a wrist and a brush are surprised. The item of the lower extremities meets even less often since mechanical loading during the walking is necessary hl. obr. on joints, and sinews test smaller, than on hands, a tension.
Humeroscapular periarthritis. The sinew of a supraspinal muscle is surprised most often, is more rare than a long head of a biceps of a shoulder with development reactive acute or hron, inflammations both in the sinew (tendinitis), and in nearby serous bags — subdeltoid and podakro-mialny.
Humeroscapular P. is characterized by pain at assignment and rotation of a shoulder, restriction of these movements, existence on the anterolateral surface of a shoulder of painful points, and sometimes a small swelling. On the roentgenogram — osteoporosis of a head of a humeral bone, a periostitis in the field of a big hillock, calcificats. In most cases within several weeks the absolute recovery is noted. At hron, a current there can be a spayaniye of walls of a bag, develop hron, the capsulitis and processes of calcification of the struck fabrics leading to considerable restriction of mobility of a shoulder.
A special form of humeroscapular P. — an algodistrofichesky syndrome a shoulder — a brush, Staynbrokkerom described in 1947 (O. Steinbrocker). It is characterized by sharp kauzalgichesky pains and the changes in a brush (diffusion cold hypostasis, cyanosis, an atrophy of muscles, osteoporosis) expressed vasculomotor trofichesshshi from the outcome in a resistant flexion contracture of fingers (see. Contracture ).
The periarthritis of an elbow joint develops most often in areas of an outside epicondyle of a humeral bone (a so-called elbow of the tennis player) where extensor tendons of a brush and an instep support of a forearm are attached. Pains in the field of an outside epicondyle at extension or supination of a forearm with irradiation are characteristic to the outer edge of a hand and restriction of passive movements because of pain up and down during the rendering to patients resistance to these movements. At a palpation morbidity in the field of an outside epicondyle of a humeral bone is defined (see. Epicondylitis ).
In several weeks or months there occurs recovery, but a recurrence is possible.
Periarthritis of a radiocarpal joint. More often the sinew of a humeroradial muscle in the place of its attachment to an awl-shaped shoot of a beam bone is surprised. The main symptom — the pain in the field of an awl-shaped shoot (above a radiocarpal joint) amplifying at supination of a forearm; in the same place at a palpation morbidity and a small swelling are defined. Current long and persistent.
The periarthritis of a hip joint arises at damage of sinews of the average and small gluteuses which are attached to a big spit of a femur. It is characterized by attacks of the pains in the field of a hip joint irradiating in a hip. Development of an attack has character of painful crisis. At an objective research — painful points are localized around a big spit; during the pressing on its posterosuperior corner pains sharply amplify. At height of an attack all movements are limited, during the subsiding — only internal rotation.
Periarthritis of a knee joint. The inflammation of sinews of semitendinous and semimembranous muscles in the place of their attachment is usually observed. Symptoms — pain in the field of an inner surface of a knee joint during the walking, hl. obr. at the time of bending of a leg in a knee, and long standing. At a palpation painful points in the specified area, sometimes a dermahemia and a swelling are defined.
The periarthritis of foot arises owing to a strong tension of sinews with the subsequent dystrophic changes and a reactive inflammation of insertion of an Achilles tendon, sinews of the bottom muscles which are attached to a calcaneus and defeat of nearby synovial bags. As a result of this process on an outer or lower surface of a calcaneus exostoses — spurs are formed (see. Spurs bone ). Reactive, the inflammation in the fabrics surrounding the formed spurs is often shown by pain at a nastupaniye on a heel (talalgia) and during the pressing in the place of an attachment of an Achilles tendon where the thickening or the roundish painful swelling caused by an inflammation of the synovial bag which is here (bursitis) can be observed. During the pressing on a heel the severe pain caused by a podpya-exact bursitis can be noted.
the Diagnosis is made on the basis of the following symptoms: the pain arising only at the certain movements connected with participation of the affected sinew and painlessness during the performance of other movements; a limited superficial swelling in the location of a synovial bag or in-sertion of a sinew; strict local morbidity at a palpation (painful points); restriction only of certain active movements connected with load of the affected sinew; the normal volume of the passive movements (which are carried out by means of the doctor); given to a X-ray analysis: at hron, P.'s current — a small periostitis and osteoporosis in the place of an attachment to a bone of the affected sinew, and also a thickening and calcification of soft circumarticular tissues; an intaktnost of the corresponding joint (there can sometimes be an accompanying osteoarthrosis).
Owing to localization patol, process in close proximity to joint educations of P. it is sometimes difficult to distinguish from true diseases of joints. The main differential diagnostic characters of the periarthritis caused by dystrophic process of arthritis and arthrosis are given in the table.
At a periarthritis owing to their tendency to hron, to a current carry out prolonged and persistent treatment, a cut consists in restriction of load of the affected sinew, use of analgesic and anti-inflammatory drugs, a fiziobalneoterapiya; sometimes an operative measure is required.
The immobilization of the patient of an extremity is reached by means of bandages, and in hard cases — imposings of gypsum. Anesthetics and anti-inflammatory drugs are at the same time applied (aspirin, analginum, indometacin, Butadionum, Rheopyrinum, Brufenum in usual therapeutic doses). At the expressed pains infiltration of the struck area is shown by novocaine and a hydrocortisone. Injections are repeated in 5 — 10 days before reduction of pains.
At the most acute pains conduct a short course of glucocorticosteroids inside (Prednisolonum of 10 — 20 mg a day within 10 — 15 days with the subsequent slow dose decline of 1/4 tablets each 5 days).
Physical methods of treatment shall be applied at the very beginning of a disease. Fonoforez using a hydrocortisone, microwave therapy, an electrophoresis of pharmaceuticals have good soothing effect, improve blood circulation.
At hron, a current hydrosulphuric and radonic bathtubs are shown, during the subsiding of pains — careful to lay down. gymnastics (at first passive movements); massage is contraindicated. At persistent pains the roentgenotherapy is applied. Only at inefficiency of all methods of conservative treatment an operative measure is shown (excision of commissures for the purpose of recovery of mobility of a sinew, removal of spurs and so forth).
Forecast usually favorable. At systematic treatment there is a gradual rassasyvaniye of the centers of a necrosis and calcificats. Pain disappears, mobility of an extremity is completely recovered. However at a prolonged current the residual phenomena owing to fibrous unions of circumarticular fabrics are possible that leads to permanent disturbance of mobility of a joint.
Table. The main differential diagnostic characters of the periarthritis caused by dystrophic process, arthritis and arthrosis
Bibliography: Astapenko M. G. and Eryalis P. S. Extraarticular diseases of soft tissues of a musculoskeletal system, M., 1975; Eryalis P. S. To a question of diagnosis and prevalence of extraarticular defeats of soft tissues of extremities and spins, Vopr, revm., No. 2, page 76, 1972; S yo z e S. et Rycke waert A. Maladies des os et articulations, p. 1065, P., 1970.
M. G. Astapenko.