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An inflammatory cause for arm pain – Musculoskeletal case of the month

Myositis

Myositis is the name for a group of conditions where there is muscle inflammatory changes and break down. It is usually autoimmune in nature. The main symptoms are weakness, painful or aching muscles which sometimes can be confused with joint or nerve related pain.

There are different types of myositis, including:

  • Polymyositis, which affects many different muscles, particularly the shoulders, hips and thigh muscles. It’s more common in women and tends to affect people aged 30 to 60. This is the most common cause of myositis. 
  • Dermatomyositis, which affects several muscles and causes a rash. It’s more common in women and can also affect children (juvenile dermatomyositis).
  • Inclusion body myositis (IBM), which causes weakness in the thigh muscles, forearm muscles and the muscles below the knee. It may also cause problems with swallowing (dysphagia). IBM is more common in men and tends to affect people over 50.

Polymyositis

Polymyositis affects many different muscles, particularly around the neck, shoulders, back, hips and thighs.

Symptoms of polymyositis include:

  • muscle weakness
  • aching or painful muscles and feeling very tired
  • finding it hard to sit up, or stand after a fall
  • swallowing problems, or finding it hard to hold your head up
  • associations with poor mental health

Patients may find it difficult to get up from a chair, climb stairs, lift objects, and comb your hair. The muscle weakness can become so severe that even picking up a cup of tea can be difficult. The muscle weakness may change from week to week or month to month, although it tends to steadily get worse if treatment is not given early.

Case Presentation

Clinical history;

  • 30 year old lady presents with left arm, shoulder and neck pain over the past 6 months
  • Pain comes in flares every few weeks and described as a dull ache
  • Left arm feels heavy and pain on lifting and carrying, initially carrying weight in gym, progressing to household objects e.g., kettle
  • Mild tingling in the left hand on occasions
  • Night pain present during flares
  • No temperatures, fevers or night sweats
  • No blood in urine (to indicate haemoglobinuria)

Previous treatment and investigation

  • GP organised MRI scan of neck which showed no evidence of cervical nerve root impingement. 
  • Patient had physiotherapy to treat neck symptoms which helped marginally

Past Medical history;

  • BMI 22
  • Non-smoker
  • History of inflammatory bowel disease (IBD), previously been on immunosupressants mercaptopurine and asacol (stopped 6 years ago and no recent flares)
  • Hypothyroidism – taking thyroxine 50mcg for underactive thyroid

Exercise history;

  • Enjoys keeping fit with exercise classes and gym training
  • No execessive heavy loading history or history of endurance sports

Social history;

  • Teacher
  • Non drinker or smoker

Clinical examination;

  • Moderate discomfort on shoulder movements particulary, adduction and abduction and wrist movements
  • Full power in all myotomes in left upper limb and normal sensation in all dermatomes
  • Moderate/severe pain on palpation of certain muscle groups including deltoid, forearm
  • Neural tension tests mildly positive in median and radial nerve bias

Point of Care Ultrasound 

Normal appearences of the shoulder, rotator cuff, deltoid, elbow and wrist

Clincial suspicions, differentials and reasoning;

  1. Myositis. The past medical history of inflammatory bowel disease should raise suspicion for inflammatory causes of muscle pain and should be excluded before a musculoskeletal diagnosis in made. Localised tenderness over muscle groups is high suggestive of muscle pathology (inflammation or otherwise). 
  2. Rhabdomyolosis. Rhabdomyolysis can be defined as a clinical syndrome associated with the breakdown of skeletal muscle fibres and myocyte cell membranes, leading to release of muscle contents into the circulation, resulting in multiple complications, including electrolyte disturbance. This can occur in patients with extreme loading e.g. ultramarathon, or exercising in a dehydrated state. Unlikely in this patient due to the low training volume. Note, severe myositis can lead to rhabdomyolosis. 
  3. Shoulder related pain. Both glenohumeral and subacromial pain can present as referred symptoms down the arm but usually have restriction/pain in shoulder range rather than global muscle aching and fatigue, although this can be difficult to differentiate. Tenderness to the muscles in arm would also suggest there is localised pathology.
  4. Nerve related pain. Although previous MRI of the cervical spine came back as normal, neural tension and nerve related pain can arise in the neck, brachial plexus or in upper/lower arm. Normal neurological examination of myotomes/dermatomes would suggest otherwise in this case. Pain is also out of proportion to fit with neural tension with no median or radial nerve disturbance.

Imaging and Investigation

MRI scan left shoulder, left upper arm and foream 

T2 weighted images show florid muscle oedema and myositis in teres major (left image), posterior delotid (middle image), brachoradialis and forearm compartments (right image)

Blood tests

  • Elevated ESR of 56
  • Elevated creatine kinase (CK) of 560 (CK is a marked of muscle breakdown)
  • Positive Myositis autoantibodies
  • Normal kidney, liver and blood count

Diagnosis

Polymyositis, affecting muscle groups in the left upper liimb. Likely association with patient’s previous inflammatory bowel disease and hypothyroidism.

Management

Exercise therapy

  • Patient given an appropriate loading programme with aerobic, anaerobic and strength stimuli
  • When treating inflammatory myositis, exercise is safe and very beneficial in the reduction of inflammation
  • This is different to overuse muscle breakdown conditions (e.g. rhabdomyolsis) where peroids of rest may be advised to aid muscle recovery

Medical treatment

  • Patient urgently referred to NHS rheumatology service and started on immunosuppressants
  • Patients symptoms settled rapidly once started on the correct treatment

Key Summary and learning points

  • Be mindful of pain localised to muscles, particularly in the proximal upper and lower limb girdles
  • A good inflammatory history is key if suspecting myositis, although there is not always a clear association between inflammatory bowel disease and inflammatory joint or muscle disease
  • Blood tests and autoantibodies have an important role when diagnosing myositis, particularly ESR and and Creatine Kinase.
  • Aerobic or static exercise is safe and will not cause damage to the muscles or joints in people with myositis
  • Regular physical activity can also reduce the risk of chronic diseases that are possible complications of myositis, including type II diabetes, osteoporosis, cardiovascular disease and hypertension
  • Exercise is particularly important for patients with inclusion body myositis (IBM), as this type of myositis does not respond to medication
  • Ultrasound often cannot detect muscle oedema, whereas MRI is much more sensitive
  • Useful link for patients and clinicians https://www.myositis.org.uk/ 
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.