Treatment and Outcome

A certain amount of rest and alteration of activities is necessary to allow healing of tendinitis to take place. With mild tendinitis NSAIDs may improve the pain and settle the inflammation. in more severe tendinitis a corticosteroid injection into the subacromial bursa is very effective in settling the inflammation. if there is an ongoing cause this must be addressed or the condition will simply recur. This may be faulty swimming technique in the young athlete or loss of normal scapular movement due to a functional scoliosis (curvature in the spine) in the older patient. Even when the initiating event was traumatic, rehabilitation is often required to restore normal movement of the shoulder complex as a whole. Younger patients with instability need an intensive stabilization program. Sometimes severe instability will require surgical intervention. occasionally patients do not respond to these measures, particularly if they are unable to participate fully in a rehabilitation program. in this situation the tip of the acromion can be surgically removed and any inflammatory tissue cleaned away from the tendon. Bony spurs can also be removed from the underside of the acromioclavic-ular joint. This surgery is usually done by arthroscopy these days.

Partial tears of the rotator cuff tendons are initially managed as for tendinitis, except that corti-costeroid injections are best avoided for the first four to six weeks to allow healing to take place. Complete tears in active young patients are usually repaired surgically. In older patients rehabilitation is often tried first and surgery used only if the outcome is not good. If the biceps tendon and the supraspinatus tendon are ruptured, then surgical repair should be undertaken since these patients often develop a severe destructive form of arthritis at the shoulder if repair is not undertaken.

rubella (German measles) A viral illness common in childhood. In developed countries such as the United States rubella is now rare. Routine vaccination of children against rubella has decreased the incidence of disease. Rubella, and the vaccine used to prevent it, can cause arthritis and arthralgia.

Cause

The illness is caused by the rubella virus that is transmitted from person to person by contact or by droplets when an infected person coughs, sneezes, or talks.

Symptoms

After someone has come into contact with an infected person and becomes infected, the virus incubates for two to three weeks. The first symptom is usually a red, blotchy rash on the face, trunk, and arms. The lymph nodes behind the ear and at the back of the head are often enlarged, and many patients have headache and a runny nose. The symptoms of rubella may be so mild that many patients do not notice them. Some patients, particularly adults, develop arthritis. The rash and arthritis often occur together at the time the patient is making antibodies against the virus, suggesting that the arthritis is due to antigen-antibody complexes. Rubella arthritis can affect large or small joints, and because it is often symmetric it can be mistaken for RA. However, rubella arthritis settles within a few weeks without any specific treatment. There are a few reports of more persistent arthritis after rubella infection. Arthralgia and myalgia are common after rubella vaccination, but arthritis is not. If it does occur, the pattern of arthritis is the same as that occurring after natural rubella infection.

Diagnosis

Blood tests for antibodies against rubella are elevated in infected patients. If someone has recently been infected the IgM antibody is elevated, but if only the IgG antibody is elevated it means that the person was immunized against rubella or was infected in the past. The rubella virus has been isolated from inflamed joints in patients with arthritis, but this test is seldom performed.

Treatment and Outcome

There is no specific treatment for rubella or rubella arthritis. NSAIDs will relieve arthritis symptoms, which usually last only a few weeks and resolve spontaneously. The most serious complications of rubella are birth abnormalities in unborn babies. If a pregnant woman who is not immune to the disease becomes infected with rubella, the chance that she will have a baby with abnormalities of the heart, brain, or other organs is high. This was the impetus for recommending routine vaccination for all children. As a result of widespread vaccination, rubella is now very uncommon in the united States.

SAPHO syndrome (sternoclavicular hyperostosis, acne arthritis) Synovitis, acne, pustules, hyperos-tosis, and osteitis comprise the SAPHO syndrome. This is a rare illness that affects young adults who have arthritis associated with acne or skin conditions that cause pustules.

Cause

The cause of SAPHO syndrome is not known. Some rheumatologists believe that it is a type of reactive arthritis triggered by acne or acne-like skin problems; others believe that it is an infective arthritis caused by an unidentified organism. Most attempts to culture an organism have failed. In a few cases, though, Propiombacterium acnes, the organism that causes acne, has been isolated. In some studies there was a small increase in the frequency of the HLA-B27 tissue type, suggesting a genetic component. SAPHO syndrome can occur in association with pustular psoriasis and inflammatory BOWEL DISEASE.

Symptoms

Arthritis is usually asymmetrical and affects large joints, a pattern characteristic of a reactive arthritis. Acne or some other skin condition that forms pustules is usually present, but the bone lesions can antedate the skin problems. If acne is the underlying skin condition, there are many large and deep pustules that cause painful lumps. Hyperostosis, thickening of a bone, often affects the collarbone (clavicle) and can resemble an infection (osteitis). Patients often develop pustules on their palms and soles.

Diagnosis

The diagnosis is clinical. X rays may show hyperos-tosis or osteitis of the clavicle or another affected bone. The X ray appearance of the bones often sug gests the diagnosis of osteomyelitis, may have to be done to exclude this. affect the clavicle, pelvis, ribs, jaw, and

Treatment and Outcome

Part of the treatment is to control the pustular skin condition, often with antibiotic ointments or tablets, but this seldom controls musculoskeletal symptoms. nonsteriodal anti-inflammatory drugs (NSAIDs), CORTICOSTEROIDS, SULFASALAZINE, COLCHICINE, methotrexate, and infliximab have been used to control the arthritis.

sarcoidosis An illness that causes inflammation in many organ systems, primarily the lungs. Arthralgia or arthritis occurs in approximately 25 percent of patients. Sarcoidosis is more common in African Americans than in Caucasians and usually affects young adults, most often women.

Cause

The cause of sarcoidosis is not known. The similarity of the illness to tuberculosis and the observation that sarcoidosis has been transmitted by organ transplantation suggest an infection, but many researchers have tried unsuccessfully to identify an infectious cause. Characteristically sarcoidosis causes granulomas in tissue. Granulomas, visible under a microscope, are clusters of inflammatory cells arranged in a pattern. Tuberculosis also causes granulomas, but these have areas of dead tissue (caseation), whereas those in sarcoidosis are do not caseate.

Symptoms

The symptoms of sarcoidosis depend on the organs involved. The lungs are affected in 90 percent of patients. The first symptom is often erythema nodosum and enlargement of lymph nodes at the

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