#369 Hand, Foot, Wrist and Ankle Pain, Myositis and Myopathy: A Rapid Review (TFTC)

November 30, 2022 | By Matthew Watto, MD

Video

Recap and review the top pearls from recent episodes #339 Hand and Wrist Pain, #348 Foot and Ankle Pain,  and #351 Myopathy and Myositis with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.

Note No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for shows #339, #348 and #351!

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Show Segments

• Intro, disclaimer, guest bio
• Hand and Wrist pain: CMC joint arthritis, tenosynovitis, carpal tunnel syndrome, trigger finger
• Foot and Ankle pain: Ankle sprains, Achilles tendon injuries, Posterior tibial tendon dysfunction
• Myopathy and Myositis pearls
• Outro

Credits

• Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Show Notes: Matthew Watto MD, FACP
• TFTC Cover Art design: Edison Jyang
• Technical Production: Pod Paste

Episode #339 Hand and Wrist Pain

Featuring Ted Parks and production and graphics by Paul Williams

De Quervain’s tenosynovitis vs 1st CMC joint arthritis

Both present as thumb pain often on the dorsoradial side. Differentiate the two by a positive Finkelstein’s test (De Quervain’s) or reproduction of pain by grinding the thumb like a mortar and pestle (CMC arthritis). Treatment for both is NSAIDS and rest using a thumb spica splint. Steroid injections are effective. 

Don’t brace for too long with CMC arthritis because muscle wasting and joint stiffness may result!

Trigger Finger 

Prescribe a cute little splint for the finger to prevent flexion and allow inflammation of the tendon to resolve. Steroid injections work well. Surgery to cut the first “pulley” is the last resort, but usually results in a cure.

Carpal Tunnel Syndrome

Pathophysiology

The carpal tunnel has limited space. Thus, any swelling can lead to compression with distal ischemia and symptoms in the thumb, index finger, and radial second digit.

Clinical Clues

Dr. Parks points out that bilateral hand symptoms with an atypical distribution (e.g. involving all fingers on both hands) might originate from the neck, especially if their symptoms travel proximally to the wrist. Consider alternate diagnoses and EMG for patients with atypical symptoms or those who don’t respond to treatment.

Multiple systemic diseases are associated with carpal tunnel syndrome including hypothyroidism, rheumatoid arthritis, and diabetes (Cleveland Clinic). Notably, bilateral carpal tunnel syndrome can be a herald of later cardiac amyloidosis preceding it by several years (Donnelly, 2019).

Thenar wasting is a late finding that implies permanent damage and identifies folks less likely to respond to treatment. 

Treatment is bracing, steroid injections (diagnostic and therapeutic), or carpal tunnel release surgery. 

Episode #351 LIVE! Foot and Ankle Pain

Featuring Joan Ritter and production and graphics by Paul Williams

Ankle Sprains

These are common and can be managed in primary care with PRICE therapy and NSAIDs. 

Ankle braces can restrict movement in one plane (stirrup splint), multiple planes (lace-up brace), or immobilize the ankle (walking boot). Dr. Ritter cautioned against long-term immobilization, which can diminish proprioception, weaken muscles that stabilize the joint, and lead to recurrent ankle injuries. Recall our discussion of the “glass ankle.” 

Rehab exercises should be done as soon as possible, and include Achilles stretches and tracing the letters of the alphabet with the toes. Maintain a low threshold for referral to formal physical therapy.

Achilles tendon pathology

• Achilles tendon rupture presents with abrupt pain and is often dramatic. Patients initially think they were attacked or kicked. 
• Absent plantar flexion on the calf squeeze test (“Thompson test”) is indicative of Achilles tendon rupture (Maffulli 1998).
• Heel pain that is worse while wearing shoes may represent retrocalcaneal bursitis or Haglund’s deformity (bony enlargement at the Achilles tendon insertion).
• Achilles tendonitis may be more painful with the first steps taken after waking up as the Achilles stretches with dorsiflexion of the foot.
• Heel lifts might alleviate pain in some patients with Achilles tendonitis (Rabusin et al 2019).
• Don’t inject the Achilles tendon with steroids due to the increased risk of rupture (Vallone, 2014).

Posterior tibial tendon dysfunction (PTTD)

Anatomy

• PTTD is a potential cause of acquired flat foot deformity (Ka-Kin Ling, 2017).
• Posterior tibial tendon runs around the medial malleolus and supports the arch of the foot.

Evaluation

• Classically seen in middle-aged women. Being overweight and wearing poorly supportive shoes are additional risk factors.
• Presents with burning, medial ankle pain that radiates up the leg.
• Patient may demonstrate the “too many toes sign”
  • The patient stands barefoot facing away from you
  • A positive sign is more than 2 ½ toes seen laterally “peeking out” from behind the leg

Management

• Conservative management involves activity modification, orthotics, and NSAIDs, physical therapy +/- immobilization with casting or a walking boot (Ka-Kin Ling, 2017).
• More severe cases may be referred to orthopedics for surgical eval (Yao et al 2015).

Episode #348 Myositis and Myopathy

Featuring Lisa Christopher-Stine, production by Matthew Watto and graphics by Andréa Perdigão

Terms and terminology

• Myositis is commonly referred to as Idiopathic Inflammatory Myopathy (IIM).  
• The IIMs are a heterogeneous group of rare autoimmune disorders with varying combinations of muscle weakness and extramuscular manifestations like skin involvement, arthritis, and interstitial lung disease (Lundberg 2021).  
• Myositis-specific auto-antibodies (MSAs) are associated with specific clinical phenotypes and can help predict organ involvement and prognosis (Lundberg 2021).  
• Classically, we were taught of the IIMs as polymyositis (PM) or dermatomyositis (DM), but they are now split into “clinico-serological subtypes” of DM, antisynthetase syndrome (AS), overlap myositis (OM), immune-mediated necrotizing myopathy (IMNM), and inclusion body myositis (Khadilkar 2020).

When to suspect myositis?

• Myositis usually has a subacute onset and many patients incorrectly attribute their symptoms to aging.  
• Fatigue and difficulty rising from deep-seated chairs are common complaints (Christopher-Stine UpToDate 2022).  She asks questions like, “If there was a fire in a crowded theater, could you get out of your seat to run away from the fire?” to differentiate true weakness from fatigue.
• Classically, myopathy is painless, but pain can accompany weakness in inflammatory myopathies (Lundberg 2021).  Pain WITHOUT weakness is highly atypical (expert opinion). 
• Ask about rashes (especially of the eyelids, MCP, and PIP joints), pruritus, fevers, weight loss, and new onset Raynaud’s phenomenon.  
• Pruritis or burning pain of the scalp can be present (Christopher-Stine UpToDate 2022).   
• Overt cardiac involvement is uncommon (but may be subclinical), so be sure to ask about signs and symptoms of cardiopulmonary disease. 

Diagnostics

1. Test for neck and hip flexor weakness with the patient supine. Test hip extension with the patient prone. 
2. Flex the PIP and DIP joints (to the first palmar crease) and try to “pry them up” to test for distal weakness. This prevents the recruitment of intrinsic hand muscles. 
3. Initial testing for the patient with suspected myositis should include ESR, CRP, TSH, CBC, CMP, and ANA. Surprisingly, anemia is uncommon and inflammatory markers are often normal in dermatomyositis!
4. The following studies might be useful based on the clinical phenotype: skin biopsy, swallowing evaluation, pulmonary function testing with DLCO, neurology referral, and/or EMG/nerve conduction study. 
5. Imaging: MRI of the thigh muscles can identify muscle inflammation/biopsy sites,  and a high-resolution CT should be ordered (given the high association with interstitial lung disease).
6. Age-appropriate cancer screening is recommended for patients with myositis. Additionally, Dr. Christopher-Stine generally checks an initial CT chest/abdomen/pelvis for most patients and recommends PSA testing for middle-aged males (expert opinion). 

Counseling and Management

7. Evidence indicates that exercise is helpful and not deleterious for patients with myositis. 
8. Statins are safe to continue for patients with non-HMG-CoA reductase-related myositis.
9. Recall Paul’s hat story. Sun protection with high SPF (e.g. SPF 70) is recommended. 
10. Monitor bone density
11. Ensure timely vaccinations

Goal

Listeners will recall key pearls from recent Curbsiders episodes

Learning objectives

After listening to this episode listeners will…

1. Recall key pearls about wrist and hand pain
2. Recall key pearls about foot and ankle pain
3. Recognize features of myositis and perform appropriate initial testing

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Watto MF. “#369 Hand, Foot, Wrist and Ankle Pain, Myositis and Myopathy: A Rapid Review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date November 30, 2022.