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Description : Check out this medical presentation on Orthopaedics, which is titled "Bursitis, Tendonitis, Fibromyalgia, and RSD", to know how bursitis and tendonitis are similar, how bursitis and tendonitis differ from from another, and phases in development and healing of bursitis and tendonitis.

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Slide 1-

Bursitis, Tendonitis, Fibromyalgia, and RSD Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA 1
Slide 2-

Objectives Explain how bursitis and tendonitis are similar Explain how bursitis and tendonitis differ from from another List phases in development and healing of bursitis and tendonitis 2
Slide 3-

Objectives List common types of bursitis and tendonitis found at the: Shoulder Elbow Wrist 5. List indications / contraindications for injection therapy of bursitis and tendonitis Hip Knee Ankle 3
Slide 4-

Objectives Describe typical findings in a patient with fibromyalgia Describe typical findings in a patient with reflex sympathetic dystrophy 4
Slide 5-

Sports Society more athletic Physical activity  health benefits Overuse syndromes increase 25% to 50% of participants will experience tendonitis or bursitis 5
Slide 6-

Workplace Musculoskeletal disorders from… …repetitive motions …localized contact stress …awkward positions …vibrations …forceful exertions Ergonomic design  incidence 6
Slide 7-

Bursae Closed, round, flat sacs Lined by synovium May or may not communicate with synovial cavity Occur at areas of friction between skin and underlying ligaments / bone 7
Slide 8-

Bursae Permit lubricated movement over areas of potential impingement Many are nameless ~78 on each side of body New bursae may form anywhere from frequent irritation 8
Slide 9-

Bursitis Inflamed by… …chronic friction …trauma …crystal deposition …infection …systemic disease: rheumatoid arthritis, psoriatic arthritis, gout ankylosing spondylitis 9
Slide 10-

Bursitis Inflammation causes bursal synovial cells to thicken Excess fluid accumulates inside and around affected bursae 10 Bemoeial (Wikipedia)
Slide 11-

Tendons Tendon sheaths composed of same synovial cells as bursae Inflamed in similar manner Tendonitis: inflammation of tendon only Tenosynovitis: inflammation of tendon plus its sheath 11
Slide 12-

Tendons Inflammatory changes involving sheath well documented Inflammatory lesions of tendon alone not well documented Distinction uncertain: terms tendonitis and tenosynovitis used interchangeably 12
Slide 13-

Tendons Most overuse syndromes are NOT inflammatory Biopsy: no inflammatory cells High glutamate concentrations NSAIDs / steroids: no advantage TendonITIS a misnomer 13
Slide 14-

14 Gray's Anatomy (Wikipedia)
Slide 15-

Bursitis / Tendonitis Most common causes: mechanical overload and repetitive microtrauma Most injuries multifactorial 15
Slide 16-

Bursitis / Tendonitis Intrinsic factors: malalignment, poor muscle flexibility, muscle weakness or imbalance Extrinsic factors: design of equipment or workplace and excessive duration, frequency, or intensity of activity 16
Slide 17-

Immediate Phase Release of chemotactic and vasoactive chemical mediators Vasodilation and cellular edema PMNs perpetuate process Lasts 48 hours to 2 weeks Repetitive insults prolong inflammatory stage 17
Slide 18-

Healing Phase Classic inflammatory signs: pain, warmth, erythema, swelling Healing goes through proliferative and maturation 6 to 12 weeks: organization and collagen cross-linking mature to preinjury strength 18
Slide 19-

History Changes in sports activity, work activities, or workplace Cause not always found Pregnancy, quinolone therapy, connective tissue disorders, systemic illness 19
Slide 20-

History Most common complaint: PAIN Acute or chronic Frequently more severe after periods of rest May resolve quickly after initial movement only to become throbbing pain after exercise 20
Slide 21-

Articular vs. Periarticular In joint capsule Joint pain / warmth / swelling Worse with active & passive movement All parts of joint involved Periarticular Pain not uniform across joint Pain only certain movements Pain character & radiation vary 21
Slide 22-

Physical Exam Careful palpation Range of motion Heat, warmth, redness 22
Slide 23-

Lab Studies Screening tests: CBC, CRP, ESR Chronic rheumatic disease: mild anemia Rheumatoid factor, antinuclear antibody, antistreptolysin O titers, and Lyme serologies for follow-up Serum uric acid: not helpful 23
Slide 24-

Synovial Fluid Especially crystalline, suppurative etiology Appearance, cell count and diff, crystal analysis, Gram’s stain Positive Gram’s: diagnostic Negative Gram’s: cannot rule out 24
Slide 25-

Management Rest Pain relief: meds, heat, cold No advantage to NSAIDs Exceptions: olecranon bursitis and prepatellar bursitis have a moderate risk of being infected (Staphylococcus aureus) 25
Slide 26-

Management Shoulder: immobilize few days Risk of adhesive capsulitis Lateral epicondylitis: forearm brace Olecranon bursitis: compression dressing 26
Slide 27-

Management De Quervain’s: splint wrist and thumb in 20o dorsiflexion Achilles tendonitis: heel lift or splint in slight plantar flexion 27
Slide 28-

Local Injection 28
Slide 29-

Local Injection Lidocaine or steroid injection can overcome refractory pain Steroids universally given, often with great success No good prospective data to support or refute therapeutic benefit 29
Slide 30-

Local Injection Short course of oral steroid may produce statistically similar results Primary goal of steroid injection: relieve pain so patient can participate in physical rehab 30
Slide 31-

Local Injection Adjunct to other modalities: pain control, PT, exercise, OT, relative rest, immobilization Additional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, electrical nerve stimulation 31
Slide 32-

Local Injection Analgesics + exercise: better results than exercise alone Eliminate provoking factors Avoid repeat steroid injection unless good prior response Wait at least 6 weeks between injections in same site 32
Slide 33-

Indications Diagnosis Obtain fluid for analysis Eliminate referred pain Therapy Give pain relief Deliver therapeutic agents 33
Slide 34-

Contraindication: Absolute Bacteremia Infectious arthritis Periarticular cellulitis Adjacent osteomyelitis Significant bleeding disorder Hypersensitivity to steroid Osteochondral fracture 34
Slide 35-

Contraindication: Relative Violation of skin integrity Chronic local infection Anticoagulant use Poorly controlled diabetes Internal joint derangement Hemarthrosis Preexisting tendon injury Partial tendon rupture 35
Slide 36-

Preparations Local anesthetic Hydrocortisone / corticosteroid Rapid anti-inflammatory effect Categorized by solubility and relative potency High solubility  short duration Absorbed, dispersed more rapidly 36
Slide 37-

Preparations Triamcinolone hexacetonide: least soluble, longest duration Potential for subcutaneous atrophy Intra-articular injections only Methylprednisolone acetate (Depo-Medrol®): reasonable first choice for most ED indications 37
Slide 38-

Dosage Large bursa: subacromial, olecranon, trochanteric: 40 – 60 mg methylprednisolone Medium or wrist, knee, heel ganglion: 10 – 20 mg Tendon sheath: de Quervain, flexor tenosynovitis: 5 – 15 mg 38
Slide 39-

Site Preparation Use careful aseptic technique Mark landmarks with skin pencil, tincture of iodine, or thimerosal (Merthiolate®) (sterile Q-tip) Clean point of entry: povidone-iodine (Betadine®) and alcohol Do not need sterile drapes 39
Slide 40-

Technique Make skin wheal: 1% lidocaine or 0.25% bupivacaine OR… …use topical vapocoolant: e.g., Fluori-Methane® Use Z-tract technique: limits risk of soft tissue fistula Agitate syringe prior to injection: steroid can precipitate or layer 40
Slide 41-

Complications: Acute Reaction to anesthetic: rare Treat as in standard textbooks Accidental IV injection Vagal reaction: have patient flat Nerve injury: pain, paresthesias Post injection flare: starts in hours, gone in days (~2%) 41
Slide 42-

Complications: Delayed Localized subcutaneous or cutaneous atrophy at injection site Small depression in skin with depigmentation, transparency, and occasional telangiectasia Evident in 6 weeks to 3 months Usually resolve within 6 months Can be permanent 42
Slide 43-

Complications: Delayed Tendon rupture: low risk (<1%) Dose-related Related to direct tendon injection? Limit injections to no more than once every 3 to 4 months Avoid major stress-bearing tendons: Achilles, patellar 43
Slide 44-

Complications: Delayed Systemic absorption slower than with oral steroids Can suppress hypopituitary-adrenal axis for 2 to 7 days Can exacerbate hyperglycemia in diabetes Abnormal uterine bleeding reported 44
Slide 45-

Some specific entities… 45
Slide 46-

Shoulder Region 46 Gray's Anatomy (Wikipedia)
Slide 47-

Shoulder Region 47 “Bursitis of the shoulder” Supraspinatus tendon and subdeltoid bursa “Bicipital tendonitis” Tendon of long head of biceps
Slide 48-

Bicipital Tendonitis Risk: repeatedly flex elbow against resistance: weightlifter, swimmer Tendon goes through bicipital (intertubercular) groove Pain with elbow at 90° flexion, arm internally / externally rotated 48
Slide 49-

Bicipital Tendonitis Range of motion: normal or restricted Strength: normal Tenderness: bicipital groove Pain: elevate shoulder, reach hip pocket, pull a back zipper 49
Slide 50-

Bicipital Tendonitis Lipman test: "rolling" bicipital tendon produces localized tenderness Yergason test: pain along bicipital groove when patient attempts supination of forearm against resistance, holding elbow flexed at 90° against side of body 50
Slide 51-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Calcific (calcareous) tendonitis: hydroxyapatite deposits in one or more rotator cuff tendons Commonly supraspinatus Sometimes rupture into adjacent subacromial bursa Acute deltoid pain, tenderness 51
Slide 52-

52 Calcific Tendonitis
Slide 53-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Clinically similar: difficult to differentiate Rotator cuff: teres minor, supraspinatus, infraspinatus, subscapularis Insert as conjoined tendon into greater tuberosity of humerus 53
Slide 54-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Jobe’s sign, AKA “empty can test” Abduct arm to 90o in the scapular plane, then internally rotate arms to thumbs pointed downward Place downward force on arms: weakness or pain if supraspinatus 54
Slide 55-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Other tests: Neer, Hawkins Passively abduct arm to 90°, then passively lower arm to 0° and ask patient to actively abduct arm to 30° 55
Slide 56-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis If can abduct to 30° but no further, suspect deltoid If cannot get to 30°, but if placed at 30° can actively abduct arm further, suspect supraspinatus If uses hip to propel arm from 0° to beyond 30°, suspect supraspinatus 56
Slide 57-

Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Subacromial bursa: superior and lateral to supraspinatus tendon Tendon and bursa in space between acromion process and head of humerus Prone to impingement 57
Slide 58-

Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis Patient holds arm protectively against chest wall May be incapacitating All ROM disturbed, but internal rotation markedly limited Diffuse perihumeral tenderness X-ray: hazy shadow 58
Slide 59-

Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis 59 Drongo (Wikipedia)
Slide 60-

Rotator Cuff Tear 60 Nucleus Communications (Wikimedia Commons)
Slide 61-

Rotator Cuff Tear Drop arm test: arm passively abducted at 90o, patient asked to maintain  dropped arm represents large rotator cuff tear Shrug sign: attempt to abduct arm results in shrug only 61
Slide 62-

Elbow and Wrist 62 “Student’s elbow” Olecranon bursa “Tennis Elbow” Extendor tendons posteriorly at ischial tuberosity De Quervain’s tenosynovitis Tendons of extensor pollicis brevis and abductor pollicis longus “Acute tendonitis of the wrist” Flexor carpi ulnaris and other wrist flexor tendons
Slide 63-

Elbow and Wrist 63 Pngbot (Wikipedia)
Slide 64-

Lateral Epicondylitis Pain at insertion of extensor carpi radialis and extensor digitorum muscles Radiohumeral bursitis: tender over radiohumeral groove Tennis elbow: tender over lateral epicondyle 64
Slide 65-

Lateral Epicondylitis 65 Gray's Anatomy (Wikipedia)
Slide 66-

Lateral Epicondylitis History repetitive overhead motion: golfing, gardening, using tools Worse when middle finger extended against resistance with wrist and the elbow in extension Worse when wrist extended against resistance 66
Slide 67-

Radial Tunnel Syndrome 67 Gray's Anatomy (Wikipedia)
Slide 68-

Medial Epicondylitis “Golfer's elbow” or “pitcher’s elbow” similar Much less common Worse when wrist flexed against resistance Tender medial epicondyle 68
Slide 69-

Cubital Tunnel Syndrome Ulnar nerve passes through cubital tunnel just behind ulnar elbow Numbness and pain small and ring fingers Initial treatment: rest, splint 69
Slide 70-

Cubital Tunnel Syndrome 70 Area of Pain Area of Numbness Schplook (Open Clipart) Schplook (Open Clipart)
Slide 71-

Olecranon Bursitis “Student's” or “barfly elbow” Most frequent site of septic bursitis Aseptic: motion at elbow joint complete and painless Septic: all motion usually painful 71
Slide 72-

Olecranon Bursitis Aseptic olecranon bursitis Cosmetically bothersome, usually resolves spontaneously If bothersome, aspiration and steroid injection speed resolution Oral NSAID after steroid injection does not affect outcome 72
Slide 73-

Olecranon Bursitis 73 Source Undetermined
Slide 74-

Septic Olecranon Bursitis Most common septic bursitis: olecranon and prepatellar 2o to acute trauma / skin breakage Impossible to differentiate acute gouty olecranon bursitis from septic bursitis without laboratory analysis 74
Slide 75-

75 Arcadian (Wikimedia Commons)
Slide 76-

Ganglion Cysts Swelling on dorsal wrist ~60% of wrist and hand soft tissue tumors Etiology obscure Lined with mesothelium or synovium Arise from tendon sheaths or near joint capsule 76
Slide 77-

Ganglion Cysts 77 Source Undetermined
Slide 78-

Ganglion Cysts 78 Cieslaw (Wikipedia)
Slide 79-

79 Source Undetermined Source Undetermined Source Undetermined
Slide 80-

Carpal Tunnel Syndrome Median nerve compression in fibro-osseous tunnel of wrist Pain at wrist that sometimes radiates upward into forearm Associated with tingling and paresthesias of palmar side of index and middle fingers and radial half of the ring finger 80
Slide 81-

Carpal Tunnel Syndrome 81 BruceBlaus (Wikipedia)
Slide 82-

Carpal Tunnel Syndrome 82 Numbness Pain Schplook (Open Clipart) Schplook (Open Clipart)
Slide 83-

Carpal Tunnel Syndrome Patient wakes during night with burning or aching pain, numbness, and tingling Positive Tinel sign: reproduce tingling and paresthesias by tapping over median nerve at volar crease of wrist 83
Slide 84-

Carpal Tunnel Syndrome 84 www.hulc.co.uk (Wikimedia Commons)
Slide 85-

Carpal Tunnel Syndrome Positive Phalen test: flexed wrists held against each other for several minutes in effort to provoke symptoms in median nerve distribution 85
Slide 86-

Carpal Tunnel Syndrome 86 Source Undetermined
Slide 87-

Carpal Tunnel Syndrome May be idiopathic Known causes: rheumatoid arthritis pregnancy, diabetes, hypothyroidism, acromegaly 87
Slide 88-

Carpal Tunnel Syndrome Insert needle just radial or ulnar to palmaris longus and proximal to distal wrist crease Ulnar preferred: avoids nerve Direct needle at 60° to skin surface, point toward tip of middle finger 88
Slide 89-

de Quervain’s Disease Chronic teno-synovitis due to narrowed tendon sheaths around abductor policis longus and extensor pollicis brevis muscles 89 Gray’s Anatomy (Wikipedia)
Slide 90-

de Quervain’s Disease 1st dorsal compartment Radial border of anatomic snuffbox 1st compartment may cross over 2nd compartment (ECRL/B) proximal to extensor retinaculum Steroid injections relieve most symptoms 90
Slide 91-

de Quervain’s Disease Finkelstein’s Test 91 Source Undetermined
Slide 92-

Trigger Finger Digital flexor tenosynovitis Stenosed tendon sheath Palmar surface over MC head Intermittent tendon “catch” “Locks” on awakening Most frequent: ring and middle 92
Slide 93-

Trigger Finger 93 www.med.und.edu
Slide 94-

Trigger Finger Tendon sheath walls lined with synovial cells Tendon unable to glide within sheath Initial treatment: splint, moist heat, NSAID Steroid for recalcitrant cases 94
Slide 95-

Hip and Groin 95 “ischial bursitis” Located medial to the sciatic nerve “trochanteric bursitis” Gluteus medius and minimus tendons “iliopectineal bursitis” Located lateral to femoral vessels
Slide 96-

Hip and Groin 96 Beth Ohara (Wikipedia)
Slide 97-

Hip and Groin 97 Anterior View Posterior View Gray's Anatomy (Wikipedia) Gray's Anatomy (Wikipedia)
Slide 98-

Trochanteric Bursitis Second leading cause of lateral hip pain after osteoarthritis Discrete tenderness to deep palpation Principal bursa between gluteus maximus and posterolateral prominence of greater trochanter 98
Slide 99-

Trochanteric Bursitis Pain usually chronic Pathology in hip abductors May radiate down thigh, lateral or posterior Worse with lying on side, stepping from curb, descending steps 99
Slide 100-

Trochanteric Bursitis Patrick fabere sign (flexion, abduction, external rotation, and extension) may be negative Passive ROM relatively painless Active abduction when lying on opposite side  pain Sharp external rotation  pain 100
Slide 101-

Ischiogluteal Bursitis Weaver's bottom / tailor’s seat: pain center of buttock radiating down back of leg Often mistaken for back strain, herniated disk Pain worse with sitting on hard surface, bending forward, standing on tiptoe 101
Slide 102-

Ischiogluteal Bursitis Tenderness over ischial tuberosity Ischiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / posterior femoral cutaneous nerves 102
Slide 103-

Some Other Back Pains 103 Low back pain: Spasm and tenderness of lumbosacral musculature and straightening of normal lumbar lordosis Trochanteric bursitis: localized pain over greater trochanter Coccygodynia: Pain localized to the coccyx Ischial bursitis: localized tenderness medial to the sciatic nerve Sciatica: localized tenderness at the sciatic notch 120 Gray's Anatomy (Wikipedia)
Slide 104-

Legs and Feet 104 “Housemaid’s knee” prepatellar bursa “Infrapatellar bursitis” infrapatellar bursa “Bursitis of the heel” Achilles tendon “Anserine bursitis” anserine bursa Gray's Anatomy (Wikipedia) Gray's Anatomy (Wikipedia)
Slide 105-

Knee 105 BruceBlaus (Wikipedia)
Slide 106-

Prepatellar Bursitis Housemaid’s knee / nun’s knee: swelling with effusion of superficial bursa over lower pole of patella Passive motion fully preserved Pain mild except during extreme knee flexion or direct pressure 106
Slide 107-

Prepatellar Bursitis Pressure from repetitive kneeling on a firm surface: rug cutter's knee Rarely direct trauma Second most common site for septic bursitis 107
Slide 108-

Prepatellar Bursitis 108 Source Undetermined
Slide 109-

Prepatellar Bursitis 109 Source Undetermined
Slide 110-

Baker’s Cyst Pseudothrombophlebitis syndrome Herniated fluid-filled sacs of articular synovial membrane that extend into popliteal fossa Causes: trauma, rheumatoid arthritis, gout, osteoarthritis Pain worse with active knee flexion 110
Slide 111-

Baker’s Cyst Can mimic deep venous thrombosis Ultrasound eseential Many resolve over weeks May require surgery Steroid injections not performed: risk of neurovascular injury 111
Slide 112-

Baker’s Cyst 112 Source Undetermined
Slide 113-

Baker’s Cyst 113 Source Undetermined
Slide 114-

Anserine Bursitis Cavalryman's disease / pes bursitis / goosefoot bursitis: obese women with large thighs, athletes who run Anteromedial knee, inferior to joint line at insertion of sartorius, semitendinous, and gracilis tendon 114
Slide 115-

Anserine Bursitis Abrupt knee pain, local tenderness 4 to 5 cm below medial aspect of tibial plateau Knee flexion exacerbates 115
Slide 116-

Iliotibial Band Syndrome Lateral knee pain Cyclists, dancers, distance runners, football players Pain worse climbing stairs Tenderness when patient supine, knee flexed to 90o 116
Slide 117-

Ankle and Foot 117 Gray's Anatomy (Wikimedia Commons)
Slide 118-

Peroneal Tendonitis Peroneal tendons cross behind lateral malleolus Running, jumping, sprain Holding foot up and out against downward pressure causes pain 118
Slide 119-

Peroneal Tendon Rupture Torn retinaculum Have patient dorsiflex and plantar flex with foot in inversion Feel for “snapping” behind lateral malleolus 119
Slide 120-

Foot 120 Gray's Anatomy (Wikipedia) Gray's Anatomy (Wikipedia)
Slide 121-

Retrocalcaneal Bursitis Ankle overuse: excessive walking, running, or jumping Heel pain: especially with walking, running, palpation Haglund disease: bony ridge on posterosuperior calcaneus Treatment: open heels (clogs), bare feet, sandals, or heel lift 121
Slide 122-

Plantar Fasciitis Policeman's heel / soldier's heel: associated with heel spurs Degenerated plantar fascial band at origin on medial calcaneous Heel pain worse in morning and after long periods of rest May be relieved with activity 122
Slide 123-

Plantar Fasciitis 123 Davius (Wikipedia)
Slide 124-

Plantar Fasciitis Microtears in fascia from overuse? Eliminate precipitators, rest, strength and stretching exercises, arch supports, and night splints Sometimes need steroid injection Risk of plantar fascia rupture and fat pad atrophy 124
Slide 125-

Tarsal Tunnel Syndrome Between medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periods Tender along course of nerve 125
Slide 126-

Tarsal Tunnel Syndrome Between medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periods Tender along course of nerve 126
Slide 127-

Achilles Tendonitis 127 Grook Da Oger (Wikipedia)
Slide 128-

Fibromyalgia 128 Sav vas (Wikimedia Commons)
Slide 129-

Fibromyalgia 129 mitopencourseware (Flickr)
Slide 130-

130 Google
Slide 131-

131 Amazon
Slide 132-

Fibromyalgia Pain in muscles, joints, ligaments and tendons “Tender points“ Knees, elbows, hips, neck 5% of population, including kids Main symptom: sensitivity to pain 132
Slide 133-

Fibromyalgia Pain: chronic, deep or burning, migratory, intermittent Fatigue, poor sleep Numbness or tingling “Poor blood flow” Sensitivity to odors, bright lights, loud noises, medicines 133
Slide 134-

Fibromyalgia Jaw pain Dry eyes Difficulty focusing Dizziness Balance problems Chest pain Rapid or irregular heartbeat 134
Slide 135-

Fibromyalgia Shortness of breath Difficulty swallowing Heartburn Gas Cramping abdominal pain Alternating diarrhea & constipation Frequent urination 135
Slide 136-

Fibromyalgia Pain in bladder area Urgency Pelvic pain Painful menstrual periods Painful sexual intercourse Depression Anxiety 136
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Compare to Somatization 137
Slide 138-

Compare to Somatization 138
Slide 139-

Compare to Somatization 139
Slide 140-

Compare to Somatization 140
Slide 141-

Fibromyalgia Treatment ? 141
Slide 142-

Reflex Sympathetic Dystrophy Causalgia Shoulder-hand syndrome Sudeck's atrophy Post-traumatic pain syndrome Complex regional pain syndrome type I and type II Sympathetically maintained pain 142
Slide 143-

Reflex Sympathetic Dystrophy Distal extremity pain, tenderness Bone demineralization, trophic skin changes, vasomotor instability Precipitating event in 2/3: injury, stroke, MI, local trauma, fracture Associated with emotional liability, depression, anxiety 143
Slide 144-

Reflex Sympathetic Dystrophy Treatments: medication, physical therapy, sympathetic nerve blocks, psychological support Possible sympathectomy or dorsal column stimulator Pain Clinic with coordinated plan may be helpful 144