ITIS

A beautiful fall day and I have an aching left shoulder. Tendinitis or bursitis. Popping aspirin helps. I know exactly how this injury occurred. A poorly done weight training session, one day after turning 58, caused this "itis".

Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.

Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.

Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.

NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.

Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.

As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.

I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.

Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.

Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!