TULSA BONE JOINT ANTOINE TONY JABBOUR MD ORTHOPAEDIC

TULSA BONE & JOINT �ANTOINE (TONY) JABBOUR, MD �ORTHOPAEDIC SPORTS MEDICINE SURGEON �KNEE AND SHOULDER SUBSPECIALTY �CHAPTER 20 PAIN SYNDROMES �CHAPTER 21 NERVE INJURIES �CHAPTER 22 LIGAMENT INJURIES �CHAPTER 23 ATHLETIC INJURIES �CHAPTER 24 PEDIATRIC MUSCULOSKELETAL ABNORMALITIES TONY JABBOUR, MD SPORTS MEDICINE

CHAPTER 20 CHRONIC PAIN SYNDROMES �Pain lasting greater than 6 weeks. �Associated psychiatric diagnosis (cause vs effect). �If no structural disease present, consider MALINGERING. TONY JABBOUR, MD SPORTS MEDICINE

FIBROMYALGIA �Controversial 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

FIBROSITIS �ACR criteria from 1990. Chronic widespread pain both sides of body, above and below waist. 11 -18 tender point spots. TONY JABBOUR, MD SPORTS MEDICINE

EPIDEMIOLOGY �Females 10 x more often than males. �No known objective markers of the disease. �No genetic predisposition. TONY JABBOUR, MD SPORTS MEDICINE

CLINICAL PRESENTATION � 20 -55 YEAR OLD FEMALE. �Pain over entire body especially neck, shoulders and low back pain. �Poor sleep 75%. �Headaches. �Numbness. �Tender points of palpation. TONY JABBOUR, MD SPORTS MEDICINE

OTHER CONDITIONS CONFUSED WITH FIBROMYALGIA �Depression. �Irritable bowel syndrome. �Chronic fatigue syndrome. TONY JABBOUR, MD SPORTS MEDICINE

ETIOLOGY � Unknown. TONY JABBOUR, MD SPORTS MEDICINE

TREATMENT �Difficult. �Psychologically prepare patient for chronicity of symptoms. �No drugs currently indicated (Analgesics and Antidepressants). �Physical Therapy. �Lidocaine trigger point injections. TONY JABBOUR, MD SPORTS MEDICINE

COMPLEX REGIONAL PAIN SYNDROME �Synonyms : 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

LABS �Within normal limits. TONY JABBOUR, MD SPORTS MEDICINE

CLINICAL PRESENTATION � 20 -25 years of age female after wrist fracture, no peripheral nerve injury. TONY JABBOUR, MD SPORTS MEDICINE

THREE STAGES ACUTE �Several weeks to several months, there is increasing pain, decreased range of motion and edema. Warmth initially, then coolness. �Sensitivity to light touch. TONY JABBOUR, MD SPORTS MEDICINE

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. TONY JABBOUR, MD SPORTS MEDICINE

THIRD STAGE (LATE ATROPHIC PHASE) �Most severe. �Hair falling out, nails brittle. �Decreased range of motion with contractures. �X-rays – demineralization and osteoporosis. TONY JABBOUR, MD SPORTS MEDICINE

PATHOPHYSIOLOGY �Not well understood. TONY JABBOUR, MD SPORTS MEDICINE

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