Tendonitis, a sequel

In posting "On fire and frozen...", saying no thank you is many times, not an option. And you are right, after 3 trips in 2 months, lugging baggages around, my left bicipital tendons gave. It is different reading it in books, and having it for real. But this just shows that rheumatism respects no one, and certainly, makes sure that all would experience one form or another of this painful malady in his/her  lifetime.

The good thing about having bicipital tendonitis is that I now actually feel what the patient tells me he feels. That is a good thing, and gives a human side to an otherwise automatic reaction by a doctor to a patient's cry. Suddenly, the pain is lancinating, gnawing, with the patient in real distress - according to MY shoulder!

Being a rheumatologist gives you a plethora of interventions to choose from. What did I choose? A self-made bicipital splint made of an adhesive plaster and tying it around the arm nearest the shoulder,  where it hurts. In addition, an NSAID liniment.

Principle? Fix or splint from too much distending motion, the insertion of the bicipital tendon.
Is it working now? I would like to think so. I'm in the airport yet again lugging my carry on baggage, using a lighter shoulder bag, and carrying both with my right hand and shoulder, and hoping that the right shoulder does not give.

Principle? Rest as much as can be afforded the poor tendons.

Updates forthcoming. In the meantime, smile and get on with life which does not tarry with pain.

On fire and frozen - tendonitis, anyone?

The shoulder is the most movable joint of the body. Anatomically, this joint is where a shallow socket which is the glenoid fossa of the scapula (wings), meets the ball, which is the head of the humerus or arm bone. Despite this unique arrangement, shoulder joints are kept aligned and intact because of a very competent and strong supporting capsule, criss crossed by tendons to make a surrounding, circumferential cuff called the rotator cuff.

There are 4 of these tendons, and one other tendon just outside the capsule that can cause trouble - tendon of the biceps muscles, with its 2 heads, the short and the long head. These tendons are lodged in a groove along the front of the arm bone, but as how biceps go, we can twist and over exert during lifting, and so we can "over-pull" the tendon. The resulting pain can be exquisite, and each motion of reaching out to the lower back to scratch an itch becomes impossible.

Bicipital tendonitis is quite a common occurrence, and with rest, the biceps tendon quiets down. But some "pulled" tendons don't. The pain smolders and like embers, can be fanned into a full blown conflagration, and rightly so -  continued work or gym-related lifting, pulling and other daily activities, just cannot be avoided. Increasing pain keeps you to move the shoulder less and less.  A week or 2 of decreased shoulder motion gets the rest of the rotator cuff tendons stiff. They later "freeze" to cause the "frozen shoulder".

Biceps tendon  on fire and shoulder cuff frozen - bad combination. It spells sleepless nights, gnawing shoulder pain, painful limitation of activities that in the past you could do without thinking. And for a working and active individual, this is catastrophe, indeed!

What else do we need to know about tendons?

Tendons are  found where there are muscles. They insert muscles to bone, thereby moving the skeleton as muscles move. But there is a catch - they are not well supplied with blood, and this makes healing slow.

Rest is best, with guided physical treatment, using deep and superficial heat or sometimes cold. Please avoid massage during the painful phase, it will only prolong the healing process. Exercises are introduced slowly and designed to allow slow but sure recovery of motion. Some cases count years, with residual limitation on stretching out of arms, but full recovery is possible.

Pain medicines? Not fully helpful. Treatment is applied over the area that hurts, and this can include anti-inflammatory liniments and steroid injection. The latter can effectively remove pain fast, but the recovery of motion takes the slow and long way.

And so, tendonitis anyone? I'd say, no thanks.

Photos from Google images of rotator cuff tendonitis.

Arthritis and mood disorders

Practicing rheumatology is hearing the word pain  - patient in and patient out, on every clinic day, making the practice a class all its own. The rheumatologist sees that pain is handled in as many ways as there are individuals with arthritis. On some occasions, patients react to pain violently enough to create a "transference" of sorts that causes many a rheumatologist to find the last patient's pain already in his own joint.

While pain is the most important protective mechanism of all of animal kingdom, pain lasting longer than 6 weeks or so becomes a "disease". Arbitrarily, 6 is not a magic number, but denotes chronicity and a duration where many processes in the nervous system have been activated to transform the pain complaint into the "pain disease".

I invite you to recall the last time you had a headache. Normally, headaches make a person moody, withdrawn and quiet. Some would try to sleep it off, but not before taking the favorite pain pill for relief. Even then, knowing that this pain would go away does not keep bad mood at bay. Invariably, all sorts of pain, the quick ones like stubbing the toe, or the headaches you can sleep off, can spoil a well meaning day.

Pain of arthritis is a different story. It can be of varying intensity, with gout pain possibly occupying top spot, followed by the pain of ankylosing spondylitis and reactive arthritis. Add to that duration- arthritis pain can be "forever". But wait till a rheumatoid arthritis patient comes in in tears, wanting never to wake up, and you know that this is a different kind of pain. It is as if dying is relief and the only hope. But a patient with arthritis who wants to die is pathetic. Many arthritides mame but do not kill.

We recently held a symposium on mood disorders in the arthritides. This was prompted by our paper which uncovered that about 40% of our lupus patients have anxiety/ depression. This is a high rate and is disturbing, since mood disorders can affect the way patients view the illness, but more important, accept treatment. Likewise, treatment for different forms of mood disorders is available and can spell the difference between a difficult-to-treat patient and the rest of them. Putting principles learned from this symposium, let me cite a case.

Mr D. was admitted yet again for a bout of gout affecting this time, as many as 6 joints. He is bad case of chronic tophaceous gout, with crops of urate deposits, 5X6 cm masses over the hands, elbows, knees and ankles. Dehydrated and irritable, he would only take the medications he was familiar with but had poorly complied. Suggestions to bring in a physical therapist and to call another doctor for his other problems were met with a flat no. Arthritis improved over the next 7 days, but by the 10th day, he still refused to budge from bed due to pain. Finally, I decided to  give an antidepressant. He was smiling the following day (!) and was moving his lower extremities, finally sitting up and dangling legs on the 12th day. He consented to calling the second doctor to check his other problems. It could not have been just the arthritis treatment - the overall recovery was amazingly fast. While anecdotal, it validated what I long wanted to do- treat the patient and not just the arthritis.

One sees the importance of recognizing mood disorders that accompany medical problems that cause prolonged pain. Additional treatment for such disorders may actually make sending a happier patient home easier.

Of Gout and men

     Gout is known as the "disease of kings", as it is wont to affect high profile statesmen, intellectuals, athletes, artists and actors, and practically anybody's who's who. It is also said to be the "king of diseases", in the intensity of pain and disability which are its hallmarks.

      Looking at the following persons plagued by the gout, one might hypothetically ask how the world would have been, had these men not have the gout.
(from: 8 famous people with gout, http://www.health.com/health/gallery/0,,20451892_9,00.html?)

       King Henry VIII, Benjamin Franklin, Samuel Johnson are among the best documented pre-20th century cases of the gout.  





It is said that King Henry VIII was infamous for both his head-chopping spree, and his gout malady. Without the gout, would his queens have kept their heads?

Benjamin Franklin, inventor and statesman, who was famous for  drafting the Declaration of Independence of the United States of America, was infamous for the absences he made during the drafting due to the gout. The Declaration of Independence is one of the world's greatest document, complete in content and intent, but as an inventor, could he have made other great inventions?

British author and poet, a top man of letters, seemed to have a mild form of gout, 'which never climbed above the ankles". He probably also had Tourette's syndrome. Would he have written greater works and expanded his Irene or Vanity of Human Wishes ?








Gout affects such illustrious names, so that if you have the gout, surely, you are in good company.