Periarthritis shoulder

A bursa is a fluid-filled sac that cushions and reduces friction between moving
parts of the body.

The subacromial bursa is a fluid-filled sac in the shoulder that cushions the
space between the rotator cuff tendons and the acromion.

Bone spurs are projections that can cause the subacromial space to narrow and
become smaller. As a result, there is less room for tendons and other soft
tissues, making impingement more likely.
 Carpal tunnel structure:
The carpal tunnel is formed by the carpal bones on the bottom of the wrist and
the transverse carpal ligament across the top.
 Median nerve function:
This nerve provides sensation to the palm side of the thumb, index, middle,
and part of the ring finger, as well as controlling some muscles at the base of
the thumb.
 Ankylosing Spondylitis

Autoimmune diseases occur when the body's immune system attacks its own
healthy tissues. This happens when the immune system can't distinguish
between the body's own cells and foreign cells.
Possible causes:
 Genetics: Some autoimmune diseases run in families.
 Environmental factors: Exposure to chemicals, sunlight, cigarette smoke, and
certain infections can increase the risk of developing an autoimmune disease.
 Hormones: Certain female hormones may play a role in when autoimmune
diseases flare up.
 Infections: Viral infections can trigger autoimmune diseases.
 Stress: Stress can contribute to autoimmune diseases.
 Certain viral infections, like those caused by Epstein-Barr virus (EBV),
Cytomegalovirus (CMV), and parvovirus B19, can potentially trigger or
exacerbate autoimmune diseases, including multiple sclerosis, rheumatoid
arthritis, and celiac disease.
 The Epstein-Barr virus (EBV) causes infectious mononucleosis, also known as
"mono"
 CMV is related to the viruses that cause chickenpox, herpes simplex and
mononucleosis.
 Parvovirus B19 causes fifth disease, also known as erythema infectiosum or
slapped cheek syndrome. It's a viral infection that's most common in children.
Symptoms
 Fever
 Runny nose
 Headache
 Itchy rash on the face, chest, back, buttocks, arms, or legs
 Swollen and painful joints in adults
Transmission :
 Spreads by coughs and sneezes or by touching contaminated objects
 some viral infections are potentially associated with an increased risk of
developing or triggering the ankylosing spondylitis condition,
including Mycoplasma pneumoniae (MP) and Human Papillomavirus (HPV),
HIV.
 HIV, which stands for Human Immunodeficiency Virus, is a virus that attacks
the body's immune system, specifically the CD4+ T cells, eventually leading to
Acquired Immunodeficiency Syndrome (AIDS) if left untreated.
 CD4 cells or T helper cells are crucial type of T cells that plays a central role on
coordinating the immune system’s response to infections and other threats.

Ankylosing spondylitis (AS) is a type of arthritis that causes inflammation in

the spine and other joints. It can cause pain, stiffness, and difficulty moving.

Ankylosing spondylitis (AS) is also known as axial spondyloarthritis,

Bechterew's disease, and Marie-Strumpell disease.

Ankylosing Spondylitis is an Autoimmune disease.

Autoimmune disease is a condition where the body's immune system attacks its
own healthy tissues.

Types of autoimmune diseases:

Rheumatoid arthritis, Psoriasis, Psoriatic arthritis, Systemic lupus
erythematosus (SLE).
Causes:
The Exact cause of Ankylosing spondylitis is unknown, but genetics and
environment are thought to play a role.
 Idiopathic relating to or denoting any disease or condition
which arises spontaneously or for which the cause is unknown.
Spontaneous means the condition happens without warning.
 HLA-B27 is a variant of the human leukocyte antigen (HLA) gene.
 It's present in about 8 in every 100 people in the general population.
 Having the HLA-B27 gene variant doesn't necessarily mean you'll develop AS.
 People with the HLA-B27 gene variant have a greatly increased risk of
developing AS.
 The exact way HLA-B27 increases the risk of developing AS is not fully
known.
 Pathology :
 The disease usually starts in the sacroiliac joints and then involves spine.
Synovitis of the sacroiliac joint and vertebral facet joint occurs.
 Other joints involved are hip and knee. In late stages, fibrous ankylosis followed
by bony ankylosis occurs.
 Ankylosis – Abnormal stiffening and immobility of a joint due to fusion of the
bones.
 Bony bridging occurs across the adjacent spines and stiff, rigid spine results.
 Inflammation of ligaments and tendons occurs, in particular on the site of their
insertion (enthesopathy).
 Enthesopathy refers to any disorder or disease affecting the entheses, which are
the sites where tendons and ligaments attach to bone.
 A common autoimmune enthesitis is at the heel where the Achilles tendon
attaches to the calcaneus.
 At the hip joint, the iliofemoral ligament (Y ligament of Bigelow) attaches to
the anterior inferior iliac spine of the pelvis and the intertrochanteric line of the
femur, while the ischiofemoral ligament attaches to the ischium and the base of
the greater trochanter.
 "bony bridging" refers to the formation of new bone tissue that connects or
spans a gap or defect between bone fragments, often after a fracture or injury, or
in conditions like ankylosing spondylitis.
 Bony Bridging as a Sign of Healing:
The presence of bony bridging is often a positive sign, indicating that the
fracture is healing and that the bone fragments are uniting.
 Bony Bridging in Ankylosing Spondylitis:
In ankylosing spondylitis, a chronic inflammatory disease affecting the spine,
bony bridging can occur between vertebrae, leading to fusion and stiffness .

 Signs and Symptoms :

 A specific type of Axial spondyloarthropathy characterized by chronic inflammation
in the spine and sacroiliac joints.
 The disease occurs in the third and fourth decades of life and is more common
in males.
 The Back Pain and Stiffness:
The most common symptom is diffuse back pain and stiffness, often worse in
the morning or after periods of inactivity.
 Improved with Activity, Worsens with Rest:
Pain and stiffness tend to improve with movement and exercise, but worsen
with prolonged inactivity.
 Fatigue:
Severe tiredness that doesn't improve with sleep or rest is common.
 Pain and Swelling in other Joints:
Inflammation can affect other joints like hips, knees, shoulders, and ribs.
Tenderness over one or both sacroiliac joints occur.
Cervical spine involvement is most commonly seen.
 Enthesitis:
Painful inflammation where tendons and ligaments attach to bones, often in
the heels or around the ribs.
 Eye Inflammation (Uveitis):
Some people experience eye pain, redness, and vision changes due to
inflammation in the eye.
 Difficulty Taking Deep Breaths:
 In advanced cases, inflammation of the joints connecting the ribs can make
deep breathing difficult.

Thoracic spine is involved, chest expansion is diminished to less than 5cm due
to involvement of costovertebral joints.
Costo is a latin word which means rib or side.

Other Possible Symptoms:

 Loss of Appetite and Weight Loss
 Digestive Problems: Some people may experience abdominal pain, diarrhea, or
inflammatory bowel disease (IBD).
 Skin Rashes: Skin rashes, such as psoriasis, can occur.
 Depression and Anxiety: The chronic nature of AS can sometimes lead to
emotional challenges.
 Anemia: Reduced red blood cells carrying oxygen, caused by the inflammation,
can lead to fatigue.
 Organ Damage: In some cases, AS can lead to heart, lung, or eye damage.
 Pain and stiffness in the neck and buttocks
 Kyphosis.

 Occiput-to-Wall Distance (OWD):

Measures the distance between the back of the head (occiput) and a wall,
assessing thoracic kyphosis and cervical mobility.
  AS is a chronic inflammatory disease primarily affecting the spine, leading to
decreased spinal mobility and fusion of vertebrae.
 Assessing spinal mobility is crucial in monitoring disease progression and
treatment effectiveness.

Modified New York criteria for

ankylosing spondylitis
A. Diagnosis*

1. Clinical criteria

a) Low back pain and stiffness for more than three months, which improves by exercise, but is not relieved

b) Limitation of motion of the lumbar spine in both the sagittal and frontal planes

c) Limitation of chest expansion relative to normal values correlated for age and sex

2. Radiological criterion:

Sacroiliitis grade ≥2 bilaterally or grade 3–4 unilaterally

B. Grading

1. Definite ankylosing spondylitis is considered if the radiologic criteria is associated with at least one clinical c

2. Probable ankylosing spondylitis if:

a) Three clinical criteria are present

b) The radiologic criterion is present without any signs or symptoms satisfying the clinical criteria (other ca

Radiographic criteria

Grade 0 = normal

Grade 1 = suspicious changes

Grade 2 = minimal abnormality – small localized areas with erosions or sclerosis, without alteration in the joint w
Grade 3 = Unequivocal Abnormality – Moderate or Advanced sacroilitis with one or more of erosions, evidence o
Widening, narrowing for partial ankylosis

Grade 4 = severe abnormality –total ankylosis.

 The modified New York criteria for ankylosing spondylitis are mostly
used for classification.
 All three clinical and the radiographic criteria refer exclusively to axial
involvement, including the spinal, costovertebral, costosternal, and
sacroiliac joints.
  The proportion of children and adolescents that fulfill those criteria
before they reach the age 17 years is probably <15%. In such a case they
usually have a combination of peripheral and axial symptoms.
 It is assumed that stated otherwise, publications on ankylosing spondylitis
never refer to definite or probable disease, but to definite ankylosing
spondylitis.
 Unequivocal means clear or certain.
 Sclerosis means abnormal hardening of body tissue.
 Sacroilitis means inflammation of sacroiliac joint which connects the spine to
the pelvis.
 Conservative Management :
 Medication:
 Nonsteroidal anti-inflammatory drugs (NSAIDs): Help reduce pain and
inflammation.
 Ibuprofen (Advil, Motrin)
 Naproxen (Aleve)
 Diclofenac
 Celecoxib (Celebrex)
 Etoricoxib (Arcoxia)
 Tumor Necrosis Factor (TNF) is a protein, specifically a cytokine, that plays a
crucial role in the body's inflammatory response, immune system function, and is
implicated in various diseases, including autoimmune conditions and cancer.
 TNF is a crucial protein involved in the body’s inflammatory response, helping to
fight infections and heal damaged tissues.
 In autoimmune diseases, excess levels of the inflammatory protein TNF (tumor
necrosis factor) are associated with chronic inflammation and can lead to the
development of pathological complications, including autoimmune diseases
 Tumor necrosis factor (TNF) inhibitors: May be used if NSAIDs are not
effective.
 FDA ( Food and Drug Administration) approved Tumor necrosis factor inhibitor
drugs include Infliximab, Adalimumab, etanercept, Golimumab, Certolizumab
pegol.


 Other medications: In some cases, other medications like sulfasalazine may be

considered, but their use is generally limited.
 Lifestyle Modifications:
 Smoking cessation: Smoking can worsen AS symptoms.
 Good posture: Practicing good posture can help prevent further spinal curvature.
 Stress management: Stress can exacerbate pain and symptoms.
 Healthy diet: A balanced diet can support overall health and well-being.
 INVESTIGATIONS :
 Increased C reactive protein levels.
 C Reactive protein plays a key role in the innate immune system, acting as an
early defense mechanism against infections and inflammation. Innate means
Inborn.
 C-reactive protein (CRP) is a protein produced by the liver that increases in
response to inflammation or infection in the body, serving as a marker for
inflammation and potentially indicating various health conditions.
 CRP is a protein synthesized by the liver and released into the
bloodstream.
 Function:
It's an acute-phase reactant, meaning its levels rise rapidly in response to
inflammation or infection.
Elevated CRP levels can be a sign of various conditions, including infections,
autoimmune diseases (like rheumatoid arthritis and lupus), and even an
increased risk of heart disease.
Measurement of C reactive Protein :
A simple blood test can measure CRP levels.
 What the test can show:
The CRP test can help doctors assess the presence and severity of
inflammation, but it doesn't pinpoint the exact cause or location of the
inflammation.
 High-sensitivity CRP (hs-CRP):
A more sensitive version of the CRP test that can detect very low levels of
inflammation, often used to assess heart disease risk.
 Normal CRP levels:
Generally, CRP levels are low or undetectable in healthy individuals.
 Interpreting CRP levels:
 Low levels: Suggest minimal or no inflammation.
 Elevated levels: Can indicate inflammation, infection, or other underlying
conditions.
A normal C-reactive protein (CRP) level is generally considered to be less than
0.3mg/dl (or 3mg/l).
Less than 0.3 mg/dL: Normal (level seen in most healthy adults).
0.3 to 1.0 mg/dL: Normal or minor elevation (can be seen in obesity, pregnancy,
depression, diabetes, common cold, gingivitis, periodontitis, sedentary lifestyle,
cigarette smoking, and genetic polymorphisms).
1.0 to 10.0 mg/dL: Moderate elevation (Systemic inflammation such as RA,
SLE, or other autoimmune diseases, malignancies, myocardial infarction,
pancreatitis, bronchitis).
More than 10.0 mg/dL: Marked elevation (Acute bacterial infections, viral
infections, systemic vasculitis, major trauma).
X ray of Cervical spine In ankylosing spondylitis (AS), cervical spine X-rays
can reveal characteristic changes like "squaring" of vertebral bodies, "shiny
corners" (Romanus lesions).
Vertebral squaring, a radiographic finding, refers to the loss of the normal
concavity of the anterior border of vertebral bodies, often seen in conditions like
ankylosing spondylitis.

In the context of inflammatory spondyloarthropathies like ankylosing

spondylitis, a "shiny corner sign" refers to reactive sclerosis (increased bone
density) appearing at the vertebral endplate corners, a result of inflammatory
erosions known as Romanus lesions.
Spondyloarthropathy (or spondyloarthritis) refers to a group of inflammatory
arthritis conditions, primarily affecting the spine and potentially other joints,
including ankylosing spondylitis, psoriatic arthritis, and reactive arthritis.
Calcification of Anterior Longitudinal ligament, Interspinous ligament and
Lateral ligament occurs.
While both calcification and sclerosis involve hardening of tissues, calcification
is the accumulation of calcium deposits, while sclerosis is a general term for
hardening or thickening of tissue, often due to fibrosis or inflammation.
Fibrosis means the thickening and scarring of connective tissue, usually as a result of injury.
5 signs of Inflammation :
Dolor (Pain)
Calor (heat)
Rubor ( Redness)
Tumour ( Swelling)
Loss of function (Functio lesa)

Physiotherapy Management of Ankylosing spondylitis:

Deep Breathing Exercises.

Deep breathing exercises, especially diaphragmatic breathing, Pursed Lip

breathing and Apical Breathing can help individuals with ankylosing spondylitis
(AS) improve lung capacity, strengthen the diaphragm, and promote relaxation,
which can be beneficial as Ankylosing spondylitis can lead to chest wall
restriction and difficulty breathing.

Apical breathing involves the neck and upper chest muscles(like the
sternocleidomastoid and scalenes) taking over the primary role in respiration,
instead of the diaphragm, which is the main muscle responsible for breathing.

Hydrotherapy.

It utilizes both warm and cold water, with warm water being the most common
and well known form, but also including treatments that alternate between hot
and cold water.
 Warm Water Hydrotherapy:
 This involves exercises or treatments in a warm-water pool, typically heated
between 32-35 degrees Celsius (90-95°F).
 The warmth helps muscles relax, reduces pain, improves joint range of motion,
strengthens muscles, and improves exercise tolerance.
 Examples include aquatic physical therapy, warm-water baths, and whirlpool
spas.
 It can also be used in labor to increase comfort and decrease pain and anxiety
 Cold Water Hydrotherapy:
 Cold water immersion can help reduce muscle soreness, cool down after a
workout, and potentially boost mood and the immune system.
 Some forms of hydrotherapy, like contrast baths, alternate between hot and cold
water, which can improve circulation and potentially reduce inflammation.
 Examples include cold showers, ice baths, and contrast baths.
 Effects of Hydrotherapy on Ankylosing spondylitis :
 Reduced Pain and Inflammation:

The warmth of the water can help relax muscles and reduce pain, while the
buoyancy of the water takes pressure off joints, making it easier to move and
exercise.
Buoyancy or upthrust, is the upward force exerted by a fluid that opposes the
weight of an object partially or fully immersed in it.
This force is what allows objects to float or rise in a fluid.
 Improved Flexibility and Range of Motion:
Hydrotherapy allows for gentle, controlled movements, which can help
improve flexibility and range of motion in the spine and other joints, which are
often affected by AS.
Mobility refers to the ability to move joints through their full range of motion,
while flexibility is the ability of muscles and soft tissues to stretch and
lengthen.
 Strengthened Muscles:
The resistance of the water can help strengthen muscles, which can be
beneficial for maintaining posture and stability.
 The warmth and buoyancy of water may block nociception by acting on thermal
receptors and mechanoreceptors, thus influencing spinal segmental mechanisms.
 Mechanoreceptors are somato sensory receptors that responds to mechanical stimuli
such as touch or sound.
 Spinal segmental mechanisms refer to the processes with in the spinal cord that
modulate pain signals, specifically involving the dorsal horn and its interactions
with incoming sensory information and descending pathways.
 The dorsal horn of the spinal cord, also known as the posterior horn or sensory
horn, is a region of the spinal cord’s gray matter that receives and processes sensory
information from body and transmitting it to the brain.

 There are many forms of water therapy, mainly including hydrotherapy (HT) and
balneotherapy (BT).
 In fact, both HT and BT involve the use of water in any form or at any temperature
for therapeutic purposes. However, the definition of HT and BT is frequently
confused, and the terms are used interchangeably.
 HT consists of the use of plain water (tap or very low mineralized water). On the
other hand, BT employs generally natural thermal mineral water, as well as mud or
gas, which is usually practiced in spas.
 Compared to HT, whose therapeutic effects may be mostly attributed to the
physical properties of water, BT also provides thermal stimulus and chemical
substances that are believed to be able to exert therapeutic effects.


 The beneficial effects of water therapy may result from the combined effect of
water (e.g., resistance, buoyancy, and heat).
 Aquatic exercises, including ROM, strengthening and respiratory exercise. 45min a
day, 5 days a week, and for 3 months.
 Aquatic exercises including aerobic exercise which include walking, front arm
raises, lateral arm raises, active ROM, stretching, strengthening, postural,
respiratory exercise and relaxation. For 60min once a day, 5 days a week and for 4
weeks.
 Land-based exercise including respiration-postural exercises which include core
strengthening exercises, chin tucks, wall slits and dorsal/lumbar extension
exercises, 30min once a day and for 6 months.
 Stretching which includes Active and positive stretching.
 Stretching of Anterior Muscle chain which includes biceps brachii, pectoralis
major, pectoralis minor, abdominals, serratus anterior and quadriceps muscles.
 Stretching of posterior muscle chain which include Erector spinae, Hamstrings,
Gluteal muscles, calf muscles, posterior deltoid and lattismus dorsi muscles.


Ultrasound therapy and Transcutaneous Electrical Nerve Stimulation for pain
relief.

Cervical and Lumbar spinal strengthening exercises to relieve stiffness in the

spine and to strengthen the muscles of Cervical and lumbar spine.

Hip strengthening Exercises.

Foot and Ankle strengthening Exercises.

The BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is a self-

administered questionnaire used to assess disease activity in patients with
ankylosing spondylitis, a chronic inflammatory disease affecting the spine and
joints, with a score ranging from 0 to 10, where higher scores indicate greater
disease activity.
 BASDAI Score Interpretation :
 < 1.4 - < 2: Remission
 < 2.8 - < 4: Low disease activity
 > 5.9: High disease activity
 > 4: Traditionally, a BASDAI score greater than 4 is considered to indicate
active disease.
 The Bath Ankylosing Spondylitis Functional Index (BASFI) is a set of 10
questions designed to determine the degree of functional limitation in
patients with Ankylosing spondylitis(AS).
 The BASFI scores ranges between 0 and 10 points. A higher score indicates a
higher degree of functional limitations.

RHEUMATOID ARTHRITIS

Collagen vascular diseases" are a group of autoimmune disorders where the

body's immune system mistakenly attacks its own tissues, particularly
connective tissues, leading to chronic inflammation and various symptoms.

Many of these disorders have joint manifestations. The most important of these
is Rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes

inflammation in the joints.

It can lead to cartilage damage, bone erosions, pain, and subsequent joint
changes.

Genetically predisposed" individuals are those who have an increased likelihood

of developing a particular disease or condition due to specific inherited genetic
variations or traits.

This means they are more susceptible to certain illnesses or behaviours because
of their genes, though it doesn't guarantee they will develop the condition.

Rheumatoid arthritis is more common in women and occurs between 25 and 40

years of age.

Causes:

 HLA-DR4 is a variant of the human leukocyte antigen (HLA) gene.

It's present in the general population with rheumatoid arthritis.
 Abnormal immune response: Rheumatoid arthritis may be a manifestation of
an immune mediated response to infections caused by mycoplasma, Epstein-
barr virus, cytomegalovirus, parvo virus in a genetically predisposed individual.

Rheumatoid factor (RF) is a protein produced by the immune system that can
attack healthy tissue. A rheumatoid factor test (RF test) measures the level of
RF in your blood.
 Rheumatoid arthritis
High levels of RF are associated with rheumatoid arthritis, an autoimmune
disorder that damages joints.
A normal, healthy amount of rheumatoid factor is less than 20 units per
millilitre (<20 U/mL). It can also refer to the test as being negative or positive.
A negative result means you have a normal amount of RF in your blood.
Positive means you have high levels of rheumatoid factor.
In Medicine, Signs are objective, observable indicators of a condition, while
symptoms are subjective experiences reported by the patient.

Five potential signs of rheumatoid arthritis (RA) include joint pain, swelling,
stiffness (especially in the morning), fatigue, low-grade fever, often affecting
the same joints on both sides of the body.
 Joint Pain, Swelling, and Stiffness:
RA is a chronic inflammatory condition that causes pain, swelling, and
stiffness in the joints, often starting in the smaller joints of the hands and feet.
 Morning Stiffness:
Stiffness is a hallmark of Rheumatoid arthritis, often lasting for 30 minutes or
longer, especially in the morning or after periods of inactivity.
 Fatigue:
Many people with Rheumatoid arthritis experience persistent fatigue, feeling
unusually tired or having low energy.
 Low-Grade Fever:
Some individuals with Rheumatoid arthritis may experience a low-grade fever,
which can be a sign of the body's inflammatory response.
 Symmetrical Joint Involvement:
Rheumatoid arthritis typically affects the same joints on both sides of the
body, for example, both hands or both knees.
Presence of pannus formation in the joints.
Clinical manifestations of Rheumatoid arthritis are morning stiffness, pain in
the shoulder, Neck and pelvic girdle, loss of mobility with fever, fatigue,
malaise, loss of body weight and development of rheumatoid nodules.

Rheumatoid nodules are firm, subcutaneous lumps that often appear in people
with rheumatoid arthritis (RA), particularly in areas like the elbows and fingers,
and can also occur in Internal organs.
Pathology:

1.Stage of Synovitis: Initial lesion occurs in the synovium, leading to vascular

stasis, infiltration of the subsynovial layers with inflammatory cells and
formation of fibrinous exudate.

Exudate is a fluid that leaks from blood vessels, while transudate is a fluid that
passes through a membrane.

2.Stage of destruction.

3. Stage of deformity.

Mallet Finger : Mallet finger also some times called baseball finger or hammer
finger is a condition where the end of the finger(distal phalanx) is bent and can
not be straightened.
Swan neck deformity involves hyperextension of the middle joint (PIP) and
flexion of the distal joint (DIP), while boutonniere deformity shows flexion of
the middle joint (PIP) and hyperextension of the distal joint.(DIP)
Differential diagnosis of Rheumatoid arthritis :

Gout
Normal uric acid levels in the blood typically range from 3.5 to 7.0mg/dl for
men and 2.5 to 6.0mg/dl for women

Systemic lupus erythematosus

Ankylosing spondylitis

Medical Management:

NSAIDS which include naproxen, ibuprofen, infliximab,

Disease modifying anti rheumatoid drugs which include Methotrexate,

pencillamine.

Cytotoxic drugs which include Azathioprine, Leflunomide, Cyclosporine,

cyclophosphamide.