Rheumatoid Arthritic Tendons
Hello Rheumatology Fans!
I suspect tendons are rather overlooked in RA (I admit myself included)
I have always known tendons are affected by RA but looking deeper into the evidence I am surprised to the extent/prevalence of that affect.
Some Caveats
Almost all the information I have seen is regarding tenosynovitis of the hand, I was able to find some bits and pieces but nothing I could deem conclusive. As such I have decided to stick to the hand, I will follow up with a new article if I am able to find further information (or am sent some!) in the future.
Tendon Issues Associated With RA
Tendons are affected directly by RA. This initiates early and tenosynovitis has been shown to predict the onset of RA. As the course of the disease progresses tendon damage becomes surprisingly (to me anyway) prevalent and tendon rupture becomes a risk as well. Once clinical remission is achieved subclinical tenosynovitis can remain and is often used by Rheumatologists to ensure optimal management is reached. Deleterious effects can still be experienced if there is ongoing inflammation even if there is no reported symptoms.
Enthesitis is a much less likely occurrence in RA compared to other inflammatory arthropathies (such as Psoriatic Arthritis) as it is primarily a synovitic condition (the autoimmune issue is “targeted” at synovial tissue) whereas the other arthropathies are more enthesitic in nature (the autoimmune issue is “targeted” at enthesis sites). That being said there is significant overlap in the conditions and also an individualised nature of presentation so an enthesitis is not out of the question.
Tenosynovitis
Tenosynovitis, a condition characterised by inflammation of the tendon sheath, particularly involving the flexor and extensor tendons of the hand, has been identified as a prevalent issue among Rheumatoid Arthritis (RA) patients. Utilising advanced imaging techniques such as ultrasound and magnetic resonance imaging (MRI), studies have indicated that approximately 45%-50% of individuals with RA exhibit signs of tenosynovitis in these tendons.
The significance of this observation extends beyond its prevalence, as researchers have proposed a potential link between tenosynovitis and the severity of joint stiffness reported by RA patients. Joint stiffness is a common and often debilitating symptom of RA, contributing significantly to the overall burden of the disease. The hypothesis suggests that the presence and extent of tenosynovitis may play a crucial role in understanding the variability in reported joint stiffness among individuals with RA.
In simpler terms, the more pronounced the tenosynovitis in the flexor and extensor tendons, the greater the likelihood of experiencing heightened joint stiffness. It's essential to note that this association does not necessarily hinge on synovitis within the joints themselves, which is a more traditionally recognized aspect of RA pathology. Instead, the emphasis is on the inflammation of the tendon sheaths, implicating them as potential contributors to the overall symptomatology of the disease.
This insight is particularly valuable in the context of personalised medicine for RA patients. Understanding the impact of tenosynovitis on joint stiffness allows healthcare professionals to tailor treatment approaches more precisely. Targeted interventions addressing tenosynovitis may prove beneficial in managing and alleviating the specific symptom of joint stiffness, contributing to an improved quality of life for individuals with RA.
Tendon Ruptures?
The high prevalence of tenosynovitis in Rheumatoid Arthritis (RA) carries significant implications for the structural integrity of tendons within the affected hands. Prolonged inflammation of the tendons can lead to detrimental consequences, with potential damage or even rupture of the affected tendons. Notably, ultrasound, a valuable diagnostic tool in assessing musculoskeletal conditions, has revealed alarming findings.
A study reported that ultrasound detected tendon damage in at least one tendon in a staggering 75% of the recruited individuals with RA.
While the specific rate of tendon rupture remains elusive in the provided information, existing literature suggests that such occurrences are more frequent in the extensor tendons. The extensor tendons, responsible for extending the fingers and facilitating hand movements, appear to be particularly vulnerable to the deleterious effects of tenosynovitis. This vulnerability underscores the importance of proactive monitoring and early intervention in RA patients to mitigate the risk of tendon damage or rupture, contributing to a comprehensive understanding of the multifaceted impact of RA on the musculoskeletal system.
Advice
Evidence based advice is sparse here so please bear in mind the following is a combination of my experience and opinion…
Remember these tendons have a pathological cause based in an auto-immune condition, as mentioned there is a high rate of tendon damage in Rheumatoid Arthritis patients. Considering this I would urge therapists to firstly consider that their medical management has been optimised. This will likely involve collaborating with the Rheumatologist. In private practice your access will vary and discussion/education of the patient to feedback to their consultant is going to be key.
Once this process has either begun or concluded, if there are symptoms remaining then essentially, we are looking at treating them like we would any other tenosynovitis. My experience with these tendons is that their reaction to therapies is variable. My Occupational therapy colleagues have had some success with splinting to offload the tendon during high load activities.
Physiotherapy treatments specifically aimed at the tendon is our favourite “LOADING”. Gotta love loading a tendon. My experience with these specific tendons however is a dichotomous one. The tendons either react as you might expect them to or they react really badly. I try to be upfront with patients about this, it isn’t a true load-based tendon problem so the reaction to loading may well not have the same effect.
I think there is a lot of mileage in the person management in this scenario, sleep, general conditioning, stress management and so forth are really important as these not only have a significant impact on tendon health but also Rheumatoid Arthritis itself.
References
Iustina et al, Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage Rheumatology 2016;55:1042:1046
Sahbudin et al, The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development. Rheumatology 2018;57:1243-1252