Periarticular Soft Tissue Rheumatism Syndromes

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Soft-tissue rheumatism syndromes are common inflammatory conditions clinically characterized by pain. For a bone scintigraphic discussion, the syndromes are arbitrarily categorized into (a) the periarticular soft-tissue rheumatism syndromes, and (b) the muscular and musculotendinous rheumatism syndromes. The former group includes bursitis, tenosynovitis, and enthesitis and the latter includes myositis ossificans, rhabdomyolysis, musculotendinous unit injuries (Baker 1984), and distal femoral cortical desmoids (Kimmel-stiel and Rapp 1951). The diseases that belong to the latter group are described in the next section.

The symptoms of periarticular soft-tissue rheumatism syndromes are pain, tenderness, and swelling in the bursa, tendon sheath, and enthesis. The most common positive laboratory test is an elevated erythrocyte sedimentation rate. Individual lesions manifest as bursitis, tenosynovitis, capsulitis, fibrositis, or calcium deposition disease. Etiologically, trauma and repeated physical stress are likely causes in

Calcification Breast Tissue

Fig. 12.24A, B Aggravation of osteoarthropathy in failed chemotherapy. A Posterior whole-body bone scintigraph in a 65-year-old woman with breast carcinoma shows intense tracer uptake in multiple lesions of osteoarthropathy (arrows) and metastases (arrowheads). B Follow-up whole-body scan 6 months after chemotherapy reveals worsening of both osteoarthropathy and metastases most patients, but in occasional patients actual tear and rupture of fibrous aponeurosis and en-thesis are responsible (see "Musculotendinous Unit Injuries" below). Cases without etiology are not rare. These disorders often mimic rheumatic arthropathy and even gouty arthritis, but no essential relationship has been found with any rheumatic articular diseases (Bluestone 1988). From among the many soft-tissue rheumatism syndromes, calcific bursitis, tenosyno-vitis, adhesive capsulitis of the shoulder, and plantar fasciitis clinically deserve detailed description from the combined radiographic and scintigraphic point of view.

Plain radiography, aided by the soft-tissue technique, plays a useful role in the diagnosis of most cases of tenosynovitis, bursitis, and plantar fasciitis. The presence of amorphous calcification in a bursa is a pathognomonic

Fig. 12.24A, B Aggravation of osteoarthropathy in failed chemotherapy. A Posterior whole-body bone scintigraph in a 65-year-old woman with breast carcinoma shows intense tracer uptake in multiple lesions of osteoarthropathy (arrows) and metastases (arrowheads). B Follow-up whole-body scan 6 months after chemotherapy reveals worsening of both osteoarthropathy and metastases sign of calcific bursitis (Figs. 12.25A and 12.26A), and tendinitis is indicated by thickened tendon with occasional mineralization (Fig. 12.27A). In addition, erosion with osteosclerosis (Fig. 12.28 A) or erosion alone (Figs. 12.29A) may occur in the bones in contact with or in close approximation to an inflamed bursa or tendon. The plain radiographic diagnosis of tenosynovitis in the wrist (Fig. 12.30A), adhesive capsulitis in the shoulder (Fig. 12.31 A), and plantar fasciitis in the

Plantar Capsulitis

Fig. 12.25A, B Calcareous trochanteric bursitis (periarticular crystal deposition). A Anteroposterior soft-tissue radiograph of an aching left hip in a 46-year-old woman reveals a bean-sized, calcareous deposit in the supratro-chanteric region (open arrow). B Anterior pinhole scan shows very subtle tracer uptake in the calcareous deposit (open arrow). This was not detected on ordinary scinti-graph

Fig. 12.25A, B Calcareous trochanteric bursitis (periarticular crystal deposition). A Anteroposterior soft-tissue radiograph of an aching left hip in a 46-year-old woman reveals a bean-sized, calcareous deposit in the supratro-chanteric region (open arrow). B Anterior pinhole scan shows very subtle tracer uptake in the calcareous deposit (open arrow). This was not detected on ordinary scinti-graph

Subdeltoid Bursa

Fig. 12.26A, B Calcific subdeltoid and coracoid bursitis. A Anteroposterior radiograph of a painful right shoulder in a 59-year-old man shows calcium deposits in the subdeltoid bursa (white arrow) and coracoid bursa (open arrows). There is sclerosis localized in the upper aspect of humeral neck (black arrows). B Anterior pinhole scan shows tracer uptake in a calcific subdeltoid bursa (arrowhead) and associated sclerosis (double arrows) as well as in a calcific coracoid bursa (single arrow)

Achilles Calcified Tendinitis

Fig. 12.27A, B Calcific Achilles tendinitis. A Lateral radiograph of a painful right hindfoot in a 63-year-old woman shows calcifications in the Achilles tendon which is thickened (between arrows). B Lateral pinhole scan reveals two small nodular hot spots in the posterior aspect of the calcaneus, indicating calcified tendinitis (thick arrows). Upper retrocalcaneal tracer uptake denotes osteitis associated with tendinitis (thin arrows)

Images Bone Scan Hot Spots

Fig. 12.28A, B Supra-acromial bursitis with regional bone erosions. A Anteroposterior radiograph of a painful left shoulder in a 43-year-old woman reveals irregular erosions in the upper aspect of the acromion (arrowhead). B Anterior pinhole scan shows intense tracer uptake in the corresponding area of the acromion (arrowhead)

Bone Scan Hot Spots

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