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UCTD: undifferentiated connective tissue

Mandira Patel OMS III
disease

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The Patient presents.

cc: My right knee has been bothering me.

HPI: 51yo F with h/o Stage 2 Osteoarthritis, Juvenile

Rheumatoid Arthritis, and Undifferentiated Connective
Tissue Disease p/w chronic R knee pain and sacroiliac
pain for the past 2 years. The R knee pain is located
along the lateral and medial sides of the R knee, and is
a constant pain. The R knee pain is described as 12/10 throbbing pain while sitting that worsens
throughout the day. By the end of the day, the R knee
pain is at 6-7/10. There is swelling around R knee that
is accompanied with the R knee pain. The R knee
swelling worsens as the day progresses, and therefore
is worse at night. The R knee pain becomes better with
rest and elevation. Occasionally, the R knee joint will
lock in a flexed position for a short duration so that the
pt cannot extend the R knee and will feel a 9/10 pain.

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HPI continued

Pt explains the R knee pain masks the pain from her

sacroiliac joint. The sacroiliac joint pain is a 2-3/10
achy, intermittent pain for past 1.5 years. The
sacroiliac joint pain radiates as a sharp, shooting pain
down R posterior thigh and the R leg to the lateral R
foot. It also radiates to R lateral trochanter graded as a
5/10 pressure pain, which wakes her up at night and
aggravates her insomnia. The sacroiliac pain becomes
worse with walking and standing up from sitting
position.

Due to the pain through her R lower extremity, pt has

difficulty taking a standing shower, driving, and getting
up from sitting position such as when using the toilet
and standing up from bed or chair. Pt admits to limping
on R side and compensates while walking with R foot

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History continue
PMHx

Juvenile Rheumatoid Arthritis:

(1964) affecting her L knee
and R elbow
TMJ secondary to JRA
(1973)
flare up in 1984 affecting
her knees and ankles b/l.
Endometriosis (1977).
Interstitial cystitis with ulcers
(1984-present).
Depression and Anxiety
(1984-1994).
Insomnia for past 30 years
Iritis (1990).
Fibromyalgia (2015).
Sleep apnea (2015).

PSHx

Tracheostomy (1956)
Tonsillectomy (1971)
Laparoscopic removal of
endometriosis from fallopian
tubes and posterior uterus (1977)
Hymenectomy (1985) resulted in
increased scar tissue constricting
vaginal wall
Spinal fusion surgery due to C4/5
and C5/6 disc herniation (2007)
Lap-band (2009) resulted in chest
fascial tightening, scar tissue
around the port, and intraabdominal hernia
Hysterectomy due to fibroids
(2011)

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History continue
Trauma Hx

MVA in December 1988.

Pt was driving a Nissan
that was rear-ended at
red-light. Pt states she
fractured her sternum.

FamHx

Dad is deceased in 1991

at 66yo due to
lymphoma

Pt states she fractures

her coccyx from falling
down the stairs in 1984.

h/o JRA and RA

Mom is alive and healthy

at 81yo

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History continued.
Meds & Allergies

Meds:
Ambien 12mg PO 1 tab qhs.
Cymbalta 120mg PO 1 tab qhs.
Elavil qhs, unknown dose and
frequency.
Ativan unknown dose PO 1 tab
qhs prn.
Alg:
Penicillin causes erythema and
high fever.
Sulfa-drugs causes upset
stomach with nausea and
vomiting.
Paxil causes hallucinations

SocHx
Follows Metagenics diet,
which helps her lose
weight, but then regains it
due to her sugar addiction

Denies smoking

Occasional cocktail

Tried cannabis indica once

for the sacroiliac pain

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ROS

Gen: Pt admits to recent changes in weight (212lbs to 224lbs).

Pt denies appetite, sleeping patterns, fevers, chills, night sweats,
or weakness.
Derm: Pt admits to malar rash on face that is worse with
sunlight and rash on lateral sides of her arms at the elbows
bilaterally that is worse with sunlight. Pt denies h/o pruritis,
color, pigmentation changes or bleeding tendencies.
Head: Pt admits to h/o headache at temporal region b/l, which
she attributes to her herniated disc in her neck.
Eyes: Pt admits to small cataracts b/l. Pt denies hx of
changes/disturbances, infection, or glaucoma photophobia.
Throat: Pt admits h/o soreness. Pt denies hx of dysphagia, or
hoarseness.
Neck: Pt admits to radiating pain to trapezius and suboccipital
muscles. Pt denies hx of goiter, thyroiditis, lymphadenopathy,
lumps, or radiation exposure.
Resp: Pt admits to cough when lying on her back and h/o URI. Pt
denies wheezes, asthma, TB, dyspnea, SOB, hemoptysis,
nocturnal dyspnea or orthopnea.

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ROS

CV: Pt admits to DOE, edema of ankles b/l, and dysrhythmias,

which she describes as skipping a beat occasionally with no
associated symptoms. Pt denies palpitations, murmurs, angina, or
HTN.
GU: Pt admits to dysuria due to interstitial cystitis, urgency, mild
incontinence with sneezing, and difficulty starting stream. Pt
denies frequency, nocturia, difficulty stopping stream, bleeding,
hematuria, d/c, stones, or UTI.
Endo: Pt admits to heat intolerance and cold intolerance only in
her feet b/l. Pt denies any polyuria, polydipsia, or polyphagia.
MSK: Pt admits to arthritis, joint pain, swelling, muscle cramps,
and fractures. Pt denies gout or dislocations. Pt denies hx of Lyme
dz.
Vasc: Pt admits to persistent bilateral ankle edema. Pt admits to
varicose veins located at inner thigh b/l, inner mid leg b/l, and L
posterior upper leg. Pt denies thrombophlebitis, claudication,
Raynauds.
Psych: Pt admits to h/o depression and anxiety 20 years ago prior
to raising her child as single mother. Pt denies h/o extreme mood
swings, delusions, insomnia, anxiety, psychiatric care or suicidal
ideation.

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Physical Exam
Vitals:
Gen:

BP 110/80 Ht 66 3/4 in, Wt: 217 lbs, BMI 35

Pt is a WDWN/obese 51y/o female

Derm:

Warm, dry, color, pigmentation, with mild malar rash on

face and on lateral aspects of elbow b/l.

HEENT:

NCAT, PERRLA, EOMI, subconjunctival hemorrhage of L

eye, External auditory canals are patent, TM intact, nasal
septum midline, Oral mucosa is pink and moist

Neck:

Trachea midline. Thyroid not enlarged but visible upon

inspection. No LAD

Heart: RRR without murmurs, gallops, rubs or thrills

Lungs:
Abd:

CTA bilaterally.

Soft, non-tender without masses or organomegaly.

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Physical Exam

MSK/OST: Gait analysis shows more weight bearing on L

leg with inversion of R foot and increased weight bearing
on lateral R foot. No scoliosis noted. No tenderness to
palpation on posterior cervical, thoracic or lumbar spine.
Restriction in cervical C1-2 rotation to R, 60 o rotation to
right and 70o rotation to left. No restriction in ROM on
thoracic or lumbar spine. R knee flexion at 110 o and R
knee loss of 5o extension. R elbow restricted in extension
at 160o. R forearm supination at 85 o and R forearm
pronation at 110o. There is good ROM in L LE and L UE.

Neuro: Muscle strength is +4/5 in R quadriceps. Muscle

strength is +5/5 in b/l UE. Slightly decreased sensory
functions in R anterior upper arm and forearm and R
dorsum of foot. DTRs 2+ biceps bilaterally and 2+ patellar
bilaterally. CN II-XII grossly intact. Normal speech, A&O x 3.
Babinski toes down. Cerebellum intact as demonstrated by
finger-to-nose

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Osteopathic exam

L Sibebending rotation strain, OAFRLSR

C2-C3 FRRSR, AA RL

T1-2 RRSR, T5-10 NRLSR

R 2-7 ISD on L

Diaphragm restricted to L

L1-L3 FRRSR, L4-L5 FRLSL.

(+) R standing flexion. Posteriorly rotated R innominate. R sided

inflare.

Hyperextended L knee, slightly flexed R knee. Flat, wide feet b/l,

More weight bearing on b/l 5th metatarsal, R 5th metatarsal more
than L. B/L 5th metatarsal externally rotated. R 3 rd toe distal digit
has 1cm round, firm, fluid filled cyst. R supra-patellar +2 edema
and L supra-patellar +1 edema.

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Diagnosis and Differential

Working Diagnosis

Osteoarthritis of R knee

Sciatic neuritis

Somatic Dysfunction

Differential Diagnosis

Rheumatoid Arthritis

Systemic lupus erythematous

Scleroderma

Sjogrens Syndrome

Dermatomyositis/polymyositis

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Rheumatoid Arthritis

Systemic disorder associated with chronic joint

inflammation that most commonly affects the
peripheral joints

Pathogenesis of joint involvements

Type III reaction: Inflamed synovial cells express an antigen

that triggers B cells B cells produce RF, which is IgM
antibody against Fc portion of IgG immunocomplexes
formation activate complement system attracts
leukocytes into joint space chronic synovitis and pannus
formation

Pannus: granulation tissue, which releases cytokines that

destroy articular cartilage

Type IV reaction: activated CD4+ T cells release

proinflammatory agents

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Rheumatoid Arthritis

Clinical findings:

B/L Ulnar deviation of hands

Swan neck deformity of the fingers (flexion of DIP and extension of

PIP)

Common joints involved: knees, cervical spine, hips, shoulders,

elbows

Involvement of hip referring pain to the knee with movement and

standing

Baker (popliteal) cyst behind the knee joint

Carpal tunnel syndrome

Subluxation of atlantoaxial joint

Rheumatoid nodules on extensor surfaces

Heart: fibrinous pericarditis, small vessel vasculitis

Lungs: Chronic pleuritis with effusions

Hematologic changes: AIHA or ACD

Eyes: Iritis

Kidney: Focal glomerulonephritis

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Rheumatoid Arthritis

Lab findings

ACPA

Serum RF

Increased serum C3, decreased synovial C3

Elevated ESR

Imaging

Joint space narrowing

Bony erosions

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Systemic Lupus Erythematous

Chronic, multisystem, autoimmune disease that

primarily involves skin, joints, serosal membranes,
bloods cells, nervous system, and kidneys

Pathogenesis:

Immune complexes (type III HSR) cause inflammation in

skin, glomeruli, joints, and small vessels

Autoantibodies (type II HSR) cause cytopenias of RBC,

neutrophils, lymphocytes, and platelets

Diagnosis:

Serum ANA

Anti-dsDNA and anti-Sm antibodies

IF testing: band like distribution of immune complexes

along dermal-epidermal junction

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Systemic Lupus Erythematous

Clinical findings:

Constitutional symtoms: fatigue, fever, arthralgia, weight loss

Hematologic findings: AIHA, thrombocytopenia, leukopenia

Generalized LAD

Arthritis (symmetric, non-erosive, nondeforming)

Butterfly-shaped malar rash over cheeks and nose due to UV

light exposure

Diffuse proliferative glomerulonephritis

Fibrous pericarditis

Libman-Sacks endocarditis: vegetation over the mitral valve

Pleuritic chest pain

Headaches

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Scleroderma

Multisystem disease characterized by vascular

dysfunction, excessive production of collagen that
primarily targets the skin and visceral organs

Pathogenesis:

Increased in CD4+ cells reacting against an unknown

antigen

Increase in autoantibody production against DNA

topoisomerase (anti-Scl-70) and centromeres

Endothelial dysfunction due to vascular injury by cytokines,

decrease in vasodilators (NO), and damaged endothelial
cells release PDGF and TGF-b attracts fibroblast
perivascular fibrosis narrowing of vessels ischemic
injury

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Scleroderma

Clinical findings:

Fatigue

Stiff joints, joint pain and contractures due to fibrosis around tendons

Raynauds phenomenon

Edema of fingers and hands

Skin thickening

Esophageal hypomotility

Interstitial lung disease results in dyspnea on exertion

Pulmonary Hypertension results in dyspnea on exertion

Pericarditis

Neuropathies
Sexual dysfunction due to constriction of vaginal introitus

Diagnosis

Skin thickening plus additional findings supporting SSc

Sine scleroderma: fibrotic changes of SSc without skin involvment

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Sjorens Syndrome

Autoimmune destruction of minor salivary glands and lacrimal

glands

Female dominant disease

Clinical findings:

RA

Keratoconjunctivitis sicca: dry eyes

Xerostomia: dry mouth

Increased risk for thyroid disease

Xerosis: dry, scaly pruritic skin affecting the LE and axillary creases

Increased risk of interstitial cystitis

GI symptoms such as dysphagia, nausea, epigastric pain

Depression

Painful neuropathies

Fibromyalgia

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Sjorens Syndrome

Lab findings

Serum ANA

Serum RF

Anti-SS-A (anti-Ro) antibodies

Anti-SS-B (anti-La) antibodies

Diagnostic testing

Sailometry: measure rate of saliva production

Schirmer test: reflex tear production

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Dermatomyositis/Polymyositis

Immune-mediated disorders with symmetrical muscle

involvement and involvement of other organs

Pathogenesis:

Activated CD4+ T cells primarily target the capillaries in

skeletal muscle

Antibodies and complement involvement of capillary

damage

CD8 T cells and CD4 T cells activate macrophage damage

of unidentified antigens in myocyte fibers of skeletal
muscles

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Dermatomyositis/Polymyositis

Clinical findings

Muscle weakness: symmetric and proximal

Gottrons papules: reddish purple papules over knuckles and PIP

Heliotrope eruption: reddish purple eyelid discoloration

Facial erythema that can mimic malar erythema seen in SLE

Photodistributed poikiloderma: hypo/hyperpigmentation in

photo-exposed sites

Interstitial lung disease

Weakness of upper one-third of esophagus

Diagnosis

Increased serum creatine kinase and aldolase

Anti-transfer RNA synthase (anti-Jo-1) antibodies

Myopathic dysfunction on electromyography

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UCTD

Patients with signs and symptoms suggestive of systemic

autoimmune disease but not fulfilling the classification
criteria for defined diseases

In 1980, LeRoy et al proposed concept of UCTD:

Further complicated by overlapping of different conditions

Early phases of connective tissue diseases indefinite at their

onset

In 2003, Bodolay et al described UCTD as:

Presence of clinical symptoms and serological abnormalities

suggestive of an autoimmune disease, but are not sufficient to
fulfill the diagnostic criteria of defined CTD

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Treatment of Arthritic Pain
Goals:
Control

of pain
Improvement of function and quality
of life with minimal toxic effects from
therapy

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Pharmacologic modalities

Anti-inflammatory

Acetaminophen: purely analgesic for those who want to avoid NSAIDs

NSAIDs: superior than acetaminophen in severe pain, but more side

effects

Topical analgesics

Adjunctive modes of therapy for pt who cannot take systemic antiinflammatory therapy

Capsaicin cream

Opiate Analgesics

Short acting or immediate release opiates

Adjunct to anti-inflammatory therapy

Glucosamine chondrotin

amino sugar from shellfish that works to stimulate synthesis of

glycosaminoglycan, proteoglycan, and hyaluronic acid

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Non-pharmacologic modalities
Surgical
Procedural
Intra-articular

steroid injections
Relief lasting for months, but possibly increase the
progression of OA
Hyaluronic acid replacement by injecting HA into
painful joint to provide lubrication
Patient education
Weight loss
Aerobic exercise: swimming pool exercises
Physical therapy
Occupational therapy
Assistive devices for ADL
OMT!

Connective tissue is osteopathic

tissue.
OMT decongests CT from gel-like character to a healthy, fluid quality
allowing the blood, lymph, and nerves to function appropriately

Muscle Energy

Muscle contraction results in the transport and metabolism of waste

products by restoring normal circulation and influencing the surrounding
fasciae, CT ground substance, and interstitial fluids

Myofascial Release

Underlying metabolic disturbances can be corrected by treating the

muscle, joint, or bone dysfunction present

Combination of traction, compression, and twisting which releases bundle

of energy that stimulates the formation of free fluid and lubrication
between fascial layers to allow release of circulatory restriction and
freedom of movement

Balanced Ligamentous Tension

Release the improper configuration of collagen fibers and structure of the

joint to reduce the tensions within and surrounding joint and facilitate the
bodys inherent healing forces

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Resources

UptoDate

Medscape

Best Practice & Research Clinical Rheumatology Journal

Journal of American Osteopathic Association

Robbins Basic Pathology

OMT manual