Поражение околосуставных мягких тканей (ПОМТ) является распространенной патологией, вызывающей выраженную боль и нарушение функции опорно-двигательного аппарата. Цель исследования. Определить частоту, характер и клинические особенности ПОМТ в реальной клинической практике, а также эффективность нестероидных противовоспалительных препаратов (НПВП) в дебюте лечения этой патологии. Материалы и методы. В ходе наблюдательного исследования оценивалась частота ПОМТ в структуре обращений к 68 амбулаторным хирургам-ортопедам в разных городах России в течение 1 мес. Проведена оценка характера и динамики клинических проявлений в ходе лечения у 1227 пациентов с ПОМТ. В качестве средства «первой линии» для лечения ПОМТ использовались НПВП, в основном оригинальный мелоксикам. Результаты лечения оценивались через 10–14 дней при повторном визите пациентов. Результаты. Доля пациентов с ПОМТ составила 15,8% от общего числа лиц, обращавшихся за амбулаторной помощью. Среди 1227 больных (мужчин 57,5%, средний возраст 51,3±15,5 года), которые наблюдались в динамике, преобладали лица с ПОМТ области коленного сустава (энтезопатия коленного сустава, препателлярный бурсит, тендинит/бурсит области «гусиной лапки») – 21,2%, стопы (плантарный фасциит, «пяточная шпора») – 16,9%, плеча (тендинит мышц ротаторов плеча) – 16,4% и локтя (латеральный и медиальный эпикондилит) – 15,3%. На фоне лечения отмечалось существенное уменьшение суммарной выраженности боли – с 6,58±1,61 до 2,48±1,60 балла по 11-балльной числовой рейтинговой шкале (p<0,001), снижение интенсивности боли при движении, в покое, ночью и при пальпации, а также выраженности функциональных нарушений. Необходимость в локальной инъекции глюкокортикоидов возникла у 22,1% больных. Существенное улучшение отмечалось при всех локализациях ПОМТ, при этом 68,1% больных оценили результат лечения как «хороший» и «отличный». Нежелательные реакции отмечены у 15,0% пациентов, серьезных осложнений не зафиксировано. Заключение. ПОМТ занимает третье место по частоте обращений после травм и остеоартрита крупных суставов в практике амбулаторных хирургов-ортопедов. Использование НПВП в максимальной терапевтической дозе в течение 10–14 дней позволяет добиться существенного улучшения при ПОМТ различной локализации.
Damage to periarticular soft tissues is a common pathology that causes severe pain and impaired function of the musculoskeletal system. Aim. To determine the frequency, nature and clinical features of damage to periarticular soft tissues in real clinical practice, as well as the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) in the debut of treatment of this pathology. Materials and methods. During the observational study, the frequency of defeat of the periarticular soft tissues in the structure of visits to 68 outpatient orthopedic surgeons in different cities of Russia for 1 month was estimated. Assessed the nature and dynamics of clinical manifestations during treatment in 1227 patients with defeat of the periarticular soft tissues. NSAIDs, mainly the original meloxicam, were used as a “first line” treatment for damage of the periarticular soft tissues. The results of treatment were evaluated after 10–14 days at a repeat visit of patients. Results. The proportion of patients with damage of the periarticular soft tissues was 15.8% of the total number of people who applied for outpatient care. Among 1227 patients (men 57.5%, average age 51.3±15.5 years) who were observed in the dynamics, prevailed were those with damage of the periarticular soft tissues of the knee joint area (knee joint enthesopathy, prepatellar bursitis, tendonitis/ bursitis of the goose foot area) – 21.2%, feet (plantar fasciitis, calcaneal spur) – 16.9%, shoulder (tendonitis of the muscles of the shoulder rotators) – 16.4% and the elbow (lateral and medial epicondylitis) – 15.3%. During treatment, there was a significant decrease in the total severity of pain – from 6.58±1.61 to 2.48±1.60 points on an 11-point numerical rating scale (p<0.001), a decrease in the intensity of pain during movement, at rest, at night and palpation, as well as the severity of functional disorders. The need for local injection of glucocorticoids arose in 22.1% of patients. Significant improvement was noted with all defeat of the periarticular soft tissues localizations, with 68.1% of patients rated the treatment result as “good” and “excellent”. Adverse reactions were noted in 15.0% of patients; no serious complications were recorded. Conclusion defeat of the periarticular soft tissues ranks third in the frequency of visits after injuries and osteoarthritis of large joints in the practice of outpatient orthopedic surgeons. The use of NSAIDs in the maximum therapeutic dose for 10–14 days allows for significant improvement in defeat of the periarticular soft tissues of various localization.
Keywords: damage to the periarticular soft tissues, tendonitis, bursitis, enthesitis, non-steroidal anti-inflammatory drugs, meloxicam.
Список литературы
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21. Boudreault J, Desmeules F, Roy JS, et al. The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis. J Rehabil Med. 2014 Apr;46(4):294-306. doi: 10.2340/16501977-1800
22. Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. doi: 10.2340/16501977-1800
23. Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group. Arch Fam Med. 1997 May-Jun;6(3):257-62. doi: 10.1001/archfami.6.3.257
24. Jakobsen TJ, Petersen L, Christiansen S, et al. Should athletic injuries be treated with non-steroidal anti-rheumatic agents (NSAID)? Tenoxicam, piroxicam and placebo in the treatment of acute stress-induced injuries. Ugeskr Laeger. 1991 Jul 8;153(28):2003-5. PMID: 1862584
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31. Nawai A, Leveille SG, Shmerling RH, et al. Pain severity and pharmacologic pain management among community-living older adults: the MOBILIZE Boston study. Aging Clin Exp Res. 2017 Feb 21. doi: 10.1007/s40520-016-0700-9 [Epub ahead of print].
32. Larsson C, Hansson EE, Sundquist K, Jakobsson U. Chronic pain in older adults: prevalence, incidence, and risk factors. Scand J Rheumatol. 2016 Nov 25:1-9. doi: 10.1080/03009742.2016.1218543 [Epub ahead of print].
33. Courties A, Gualillo O, Berenbaum F, Sellam J. Metabolic stress-induced joint inflammation and osteoarthritis. Osteoarthritis Cartilage. 2015 Nov;23(11):1955-65. doi: 10.1016/j.joca.2015.05.016. Epub 2015 May 30.
34. Belluzzi E, El Hadi H, Granzotto M, et al. Systemic and Local Adipose Tissue in Knee Osteoarthritis. J Cell Physiol. 2017 Aug;232(8):1971-8. doi: 10.1002/jcp.25716. Epub 2017 Mar 3.
35. Staud R. Evidence for shared pain mechanisms in osteoarthritis, low back pain, and fibromyalgia. Curr Rheumatol Rep. 2011 Dec;13(6):513-20. doi: 10.1007/s11926-011-0206-6
36. Haviv B, Bronak S, Thein R. The complexity of pain around the knee in patients with osteoarthritis. Isr Med Assoc J. 2013 Apr;15(4):178-81. PMID: 23781753
________________________________________________
1. Abat F, Alfredson H, Cucchiarini M, et al. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. J Exp Orthop. 2017 Dec;4(1):18. doi: 10.1186/s40634-017-0092-6. Epub 2017 May 30.
2. [Belenky AG. Pathology of the shoulder joint. Periarthritis of the shoulder blade. Farewell to the term: from approximation to specific nosological forms. Consilium Medicum. 2004;6(2):15-20 (In Russ.)].
3. [Belenky AG. Epicondylitis. Russian Medical Journal. 2006;14(25):1786-9 (In Russ.)].
4. [Belenky AG. Diseases of the periarticular tissues of the area of the brush. Consilium Medicum. 2005;7(2):95-8 (In Russ.)].
5. [Karateev AE, Karateev DE, Orlova ES, Ermakova YuA. “Small” rheumatology: non-systemic rheumatic pathology of the periarticular soft tissues of the upper limb. Part 1. Modern Rheumatology. 2015;9(2):4-15 (In Russ.)]. doi: 10.14412/1996-7012-2015-2-4-15
6. [Karateev AE, Karateev DE, Ermakova YuA. “Small rheumatology”: non-systemic rheumatic pathology of the periarticular soft tissues of the upper limb. Part 2. Drug and non-drug methods of treatment. Modern Rheumatology. 2015;9(3):33-42 (In Russ.)]. doi: 10.14412/1996-7012-2015-3-33-42
7. Abat F, Alfredson H, Cucchiarini M, et al. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. J Exp Orthop. 2018 Sep 24;5(1):38. doi: 10.1186/s40634-018-0145-5
8. Kia C, Baldino J, Bell R, et al. Platelet-Rich Plasma: Review of Current Literature on its Use for Tendon and Ligament Pathology. Curr Rev Musculoskelet Med. 2018 Dec;11(4):566-72. doi: 10.1007/s12178-018-9515-y
9. Dougados M, Le Henanff A, Logeart I, Ravaud P. Short-term efficacy of rofecoxib and diclofenac in acute shoulder pain: a placebo-controlled randomized trial. PLoS Clin Trials. 2007 Mar 9;2(3):e9. doi: 10.1371/journal.pctr.0020009
10 [Shirokov VA. Shoulder pain: pathogenesis, diagnosis, treatment: Monograph. 2nd ed. Moscow: MEDpress-inform, 2012 (In Russ.)].
11. [Shirokov VA. Shoulder pain: problems of diagnosis and treatment. Effective Pharmacotherapy. 2016;35:38-46 (In Russ.)].
12. Malavolta EA, Gracitelli MEC, Assunção JH, et al. Shoulder disorders in an outpatient clinic: an epidemiological study. Acta Ortop Bras. 2017 May-Jun;25(3):78-80. doi: 10.1590/1413-785220172503170849
13. Alvarez-Nemegyei J, Peláez-Ballestas I, Goñi M, et al. Prevalence of rheumatic regional pain syndromes in Latin-American indigenous groups: a census study based on COPCORD methodology and syndrome-specific diagnostic criteria. Clin Rheumatol. 2016 Jul;35 Suppl 1:63-70. doi: 10.1007/s10067-016-3188-y. Epub 2016 Feb 1.
14. Walker-Bone K, Palmer KT, Reading I, et al. Prevalance and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004;4(54):642-51. doi: 10.1002/art.20535
15. Shen PC, Chang PC, Jou IM, et al. Hand tendinopathy risk factors in Taiwan: A population-based cohort study. Medicine (Baltimore). 2019 Jan;98(1):e13795. doi: 10.1097/MD.0000000000013795
16. Albers IS, Zwerver J, Diercks RL, et al. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC Musculoskelet Disord. 2016 Jan 13;17:16. doi: 10.1186/s12891-016-0885-2
17. Moon DK, Park YJ, Song SY, et al. Common Upper Extremity Disorders and Function Affect Upper Extremity-Related Quality of Life: A Community-Based Sample from Rural Areas. Yonsei Med J. 2018 Jul;59(5):669-76. doi: 10.3349/ymj.2018.59.5.669
18. Grobet C, Marks M, Tecklenburg L, Audigé L. Application and measurement properties of EQ-5D to measure quality of life in patients with upper extremity orthopaedic disorders: a systematic literature review. Arch Orthop Trauma Surg. 2018 Jul;138(7):953-61. doi: 10.1007/s00402-018-2933-x. Epub 2018 Apr 13.
19. Ferreira AA, Malavolta EA, Assunção JH, et al. Quality of life in patients with rotator cuff arthropathy. Acta Ortop Bras. 2017 Nov-Dec;25(6):275-8. doi: 10.1590/1413-785220172506173893
20. Palomo-López P, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, et al. Impact of plantar fasciitis on the quality of life of male and female patients according to the Foot Health Status Questionnaire. J Pain Res. 2018 Apr 27;11:875-80. doi: 10.2147/JPR.S159918. eCollection 2018.
21. Boudreault J, Desmeules F, Roy JS, et al. The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis. J Rehabil Med. 2014 Apr;46(4):294-306. doi: 10.2340/16501977-1800
22. Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. doi: 10.2340/16501977-1800
23. Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group. Arch Fam Med. 1997 May-Jun;6(3):257-62. doi: 10.1001/archfami.6.3.257
24. Jakobsen TJ, Petersen L, Christiansen S, et al. Should athletic injuries be treated with non-steroidal anti-rheumatic agents (NSAID)? Tenoxicam, piroxicam and placebo in the treatment of acute stress-induced injuries. Ugeskr Laeger. 1991 Jul 8;153(28):2003-5. PMID: 1862584
25. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001;(2):CD000232. doi: 10.1002/14651858.CD000232
26. Nalamachu S, Crockett RS, Gammaitoni AR, Gould EM. A comparison of the lidocaine patch 5% vs naproxen 500 mg twice daily for the relief of pain associated with carpal tunnel syndrome: a 6-week, randomized, parallel-group study. Med Gen Med. 2006 Aug 9;8(3):33. PMID: 17406167
27. Vidal L, Kneer W, Baturone M, Sigmund R. Meloxicam in acute episodes of soft-tissue rheumatism of the shoulder. Inflamm Res. 2001 Mar;50 Suppl 1:S24-9. doi: 10.1007/PL00022376
28. Yang M, Wang HT, Zhao M, et al. Network Meta-Analysis Comparing Relatively Selective COX-2 Inhibitors Versus Coxibs for the Prevention of NSAID-Induced Gastrointestinal Injury. Medicine (Baltimore). 2015 Oct;94(40):e1592. doi: 10.1097/MD.0000000000001592
29. Asghar W, Jamali F. The effect of COX-2-selective meloxicam on the myocardial, vascular and renal risks: a systematic review. Inflammopharmacology. 2015 Feb;23(1):1-16. doi: 10.1007/s10787-014-0225-9
30. [Karateev AE, Nasonov EL. Meloxicam in Russia: 20 years together. Therapeutic Archive. 2016;88(12):149-58 (In Russ.)]. doi: 10.17116/terarkh20168812149-158
31. Nawai A, Leveille SG, Shmerling RH, et al. Pain severity and pharmacologic pain management among community-living older adults: the MOBILIZE Boston study. Aging Clin Exp Res. 2017 Feb 21. doi: 10.1007/s40520-016-0700-9 [Epub ahead of print].
32. Larsson C, Hansson EE, Sundquist K, Jakobsson U. Chronic pain in older adults: prevalence, incidence, and risk factors. Scand J Rheumatol. 2016 Nov 25:1-9. doi: 10.1080/03009742.2016.1218543 [Epub ahead of print].
33. Courties A, Gualillo O, Berenbaum F, Sellam J. Metabolic stress-induced joint inflammation and osteoarthritis. Osteoarthritis Cartilage. 2015 Nov;23(11):1955-65. doi: 10.1016/j.joca.2015.05.016. Epub 2015 May 30.
34. Belluzzi E, El Hadi H, Granzotto M, et al. Systemic and Local Adipose Tissue in Knee Osteoarthritis. J Cell Physiol. 2017 Aug;232(8):1971-8. doi: 10.1002/jcp.25716. Epub 2017 Mar 3.
35. Staud R. Evidence for shared pain mechanisms in osteoarthritis, low back pain, and fibromyalgia. Curr Rheumatol Rep. 2011 Dec;13(6):513-20. doi: 10.1007/s11926-011-0206-6
36. Haviv B, Bronak S, Thein R. The complexity of pain around the knee in patients with osteoarthritis. Isr Med Assoc J. 2013 Apr;15(4):178-81. PMID: 23781753
1 ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой», Москва, Россия;
2 ФГБУ «Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова» Минздрава России, Москва, Россия
1 Nasonova Research Institute of Rheumatology, Moscow, Russia;
2 Priorov National Medical Research Center of Traumatology and Orthopedics, Moscow, Russia