Tendon lesions and soft tissue rheumatism--great outback or great opportunity?

Soft tissue rheumatism in 1995 Musculoskeletal symptoms without frank arthritis are very common. Most of us suffer such symptoms each year. They usually occur in one region, in an individual who is otherwise well. These regional musculoskeletal disorders, which have commonly been overlooked in the planning and provision of health care, are disorders of major and increasing importance. Soft tissue rheumatism accounts for up to 25% of all hospital consultations for the rheumatic disorders. ' Shoulder pain is prevalent and often under reported, with symptoms or disability in at least 20% of the elderly hospital population.2 Data from United Kingdom general practitioners suggest that, each year, approximately 1:170 of the adult population will present to their general practitioner with a new episode of shoulder pain.3 Lateral epicondylitis is estimated to affect four adults per 1000 each year, particularly those aged 35-54 years. Most experience a recurrence of symptoms within 18 months.4 Soft tissue rheumatism is certainly still confusing. In clinical practice it is often difficult to ascertain the underlying disorder. Different tissues such as muscle, ligament, tendon, and tendon sheaths can be affected, and often minor injury and inflammation cause much pain and dysfunction. Disorders can be classified by clinicopathological process (tendinitis), by anatomical region (shoulder pain), or by aetiology (repetitive strain syndrome). The heterogeneity of soft tissue rheumatism poses considerable problems in arriving at a sensible programme of treatment and system of management. For example, more than 40 treatments have been proposed for lateral epicondylitis, reflecting the lack of consensus about how to treat this and other soft tissue conditions.5 Soft tissue rheumatism also remains costly; the lesions are chronic and have been estimated to result in the loss of up to 1 1 million working days annually. ' Most cases of lateral epicondylitis are managed in primary care, although the condition causes considerable loss from work and industrial compensation. Labelle et al6 reported that, among industrial workers, an average of 62 days per patient is lost from work. This group of diseases make up a high proportion of rheumatological practice in the UK, but traditionally little effort has been made to understand their underlying pathology. There are a number of reasons for this. Soft tissue lesions are not life threatening, unlike the much rarer immunological and inflammatory rheumatological diseases. Soft tissues are rarely biopsied, so samples are difficult to obtain and current animal models do not necessarily reflect the chronic degenerative lesions found in aging patients. However, while there is lack of pathological information on many of these lesions, there are usually adequate clinical features to allow identification of individual conditions. Perhaps the biggest hindrance to progress in our understanding of soft tissue rheumatism has been a negative attitude to the affected tissues, which are still thought of as inert, homogeneous structures. This is certainly true of diseases where tendon tissues are principally involved.