TULSA BONE & JOINTANTOINE (TONY) JABBOUR, MDORTHOPAEDIC SPORTS MEDICINE SURGEONKNEE AND SHOULDER SUBSPECIALTYCHAPTER 20 PAIN SYNDROMESCHAPTER 21 NERVE INJURIESCHAPTER 22 LIGAMENT INJURIESCHAPTER 23 ATHLETIC INJURIESCHAPTER 24 PEDIATRIC

MUSCULOSKELETAL ABNORMALITIES

TONY JABBOUR, MD SPORTS MEDICINE

CHAPTER 20CHRONIC PAIN SYNDROMES

Pain lasting greater than 6 weeks.Associated psychiatric diagnosis (cause vs

effect).If no structural disease present, consider MALINGERING.

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FIBROMYALGIAControversial diagnosis.Syndrome of:

1. Diffuse musculoskeletal pain.2. Sleep disturbance.3. Exhaustion.

Most common cause of generalized musculoskeletal pain in female 20-25 years old.

Physical examination normal except for disproportionate tenderness to palpation.

X-rays and labs are within normal limits.TONY JABBOUR, MD SPORTS MEDICINE

FIBROSITISACR criteria from 1990. Chronic widespread pain both sides of body, above and below waist. 11-18 tender point spots.

TONY JABBOUR, MD SPORTS MEDICINE

EPIDEMIOLOGYFemales 10 x more often than males.No known objective markers of the disease.No genetic predisposition.

TONY JABBOUR, MD SPORTS MEDICINE

CLINICAL PRESENTATION20-55 YEAR OLD FEMALE.Pain over entire body especially neck,

shoulders and low back pain.Poor sleep 75%.Headaches.Numbness.Tender points of palpation.

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OTHER CONDITIONS CONFUSED WITH FIBROMYALGIADepression.Irritable bowel syndrome.Chronic fatigue syndrome.

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ETIOLOGYUnknown.

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TREATMENTDifficult.Psychologically prepare patient for chronicity

of symptoms.No drugs currently indicated (Analgesics and

Anti-depressants).Physical Therapy.Lidocaine trigger point injections.

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COMPLEX REGIONAL PAIN SYNDROMESynonyms : RSD/Algodystrophy/Causalgia/Shoulder-Hand

Syndrome/Sudek’s dystrophy.Disorder of extremities characterized by severe and

continuous pain, decreased range of motion and demineralization of adjacent bony structures.

Vasomotor instability (changes in skin color and temperature.

1994 WHO coined term “Complex Regional Pain Syndrome”.

Two Types: Type 2 – symptoms are attributable to nerve lesions.

Type 1 – no nerve lesions.TONY JABBOUR, MD SPORTS MEDICINE

LABSWithin normal limits.

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CLINICAL PRESENTATION20-25 years of age female after wrist

fracture, no peripheral nerve injury.

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THREE STAGESACUTE

Several weeks to several months, there is increasing pain, decreased range of motion and edema. Warmth initially, then coolness.

Sensitivity to light touch.

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MIDDLE (DYSTROPHIC PHASE)Three to six months after injury.Increased soft tissue edema secondary to

increased regional sympathetic activity.Skin changes (thickening, brawny changes).Early atrophy.

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THIRD STAGE (LATE ATROPHIC PHASE)Most severe.Hair falling out, nails brittle.Decreased range of motion with

contractures.X-rays – demineralization and osteoporosis.

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PATHOPHYSIOLOGYNot well understood.

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TREATMENT

Early mobilization, aggressive physical therapy.Non-steroidal anti-inflammatories,

corticosteroids.Regional nerve blocks (decreased overactivity

of sympathetic nervous system; 2/3 respond favorably).

Surgical sympathectomies.Spinal cord stimulation.Intrathecal Baclofen.

TONY JABBOUR, MD SPORTS MEDICINE