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Concept: Diseases involving the fasciae


Generalized joint hypermobility (GJH) is highly prevalent among patients diagnosed with chronic pain. When GJH is accompanied by pain in ≥4 joints over a period ≥3 months in the absence of other conditions that cause chronic pain, the hypermobility syndrome (HMS) may be diagnosed. In addition, GJH is also a clinical sign that is frequently present in hereditary diseases of the connective tissue, such as the Marfan syndrome, osteogenesis imperfecta, and the Ehlers-Danlos syndrome. However, within the Ehlers-Danlos spectrum, a similar subcategory of patients having similar clinical features as HMS but lacking a specific genetic profile was identified: Ehlers-Danlos syndrome hypermobility type (EDS-HT). Researchers and clinicians have struggled for decades with the highly diverse clinical presentation within the HMS and EDS-HT phenotypes (Challenge 1) and the lack of understanding of the pathological mechanisms that underlie the development of pain and its persistence (Challenge 2). In addition, within the HMS/EDS-HT phenotype, there is a high prevalence of psychosocial factors, which again presents a difficult issue that needs to be addressed (Challenge 3). Despite recent scientific advances, many obstacles for clinical care and research still remain. To gain further insight into the phenotype of HMS/EDS-HT and its mechanisms, clearer descriptions of these populations should be made available. Future research and clinical care should revise and create consensus on the diagnostic criteria for HMS/EDS-HT (Solution 1), account for clinical heterogeneity by the classification of subtypes within the HMS/EDS-HT spectrum (Solution 2), and create a clinical core set (Solution 3).

Concepts: Collagen, Syndromes, Marfan syndrome, Genetic disorders, Connective tissue, Ehlers-Danlos syndrome, Hypermobility, Diseases involving the fasciae


A patient with a known biopsy of polyarteritis nodosa diagnosis presented with cyclic fevers, acute kidney injury, and progression of rash from macular to pustular, worsening despite being on antibiotics, without evidence of infection on multiple cultures. The patient had a pathological diagnosis from a skin biopsy of acute generalized exanthematous pustulosis syndrome, with a total resolution of rash, fevers, and acute kidney injury on treatment with pulse steroids.

Concepts: Inflammation, Biopsy, Pathology, Rheumatology, Vasculitis, Acute kidney injury, Polyarteritis nodosa, Diseases involving the fasciae


Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. Although function improves overtime, full and pain free range, may not be restored in everyone. Frozen shoulder is also known as adhesive capsulitis, however the evidence for capsular adhesions is refuted and arguably, this term should be abandoned. The aim of this Masterclass is to synthesise evidence to provide a framework for assessment and management for Frozen Shoulder. Although used in the treatment of this condition, manipulation under anaesthetic has been associated with joint damage and may be no more effective than physiotherapy. Capsular release is another surgical procedure that is supported by expert opinion and published case series, but currently high quality research is not available. Recommendations that supervised neglect is preferable to physiotherapy have been based on a quasi-experimental study associated with a high risk of bias. Physiotherapists in the United Kingdom have developed dedicated care pathways that provide; assessment, referral for imaging, education, health screening, ultrasound guided corticosteroid and hydro-distension injections, embedded within physiotherapy rehabilitation. The entire pathway is provided by physiotherapists and evidence exists to support each stage of the pathway. Substantial on-going research is required to better understand; epidemiology, patho-aetiology, assessment, best management, health economics, patient satisfaction and if possible prevention.

Concepts: United Kingdom, Shoulder, Joint manipulation, Adhesive capsulitis of shoulder, Hydrodilatation, Diseases involving the fasciae


Systemic vasculitides are great masqueraders and at times their presenting manifestations can be very different from the usual recognized patterns. Such uncommon presentations of granulomatosis with polyangiitis (Wegener’s granulomatosis), classical polyarteritis nodosa and unclassifiable vasculitides are described here with the relevant review of literature.

Concepts: Rheumatology, Vasculitis, Wegener's granulomatosis, Arthritis, Polyarteritis nodosa, Vascular-related cutaneous conditions, Microscopic polyangiitis, Diseases involving the fasciae



Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.

Concepts: Syndromes, Marfan syndrome, Genetic disorders, Ehlers-Danlos syndrome, Hypermobility, Loeys-Dietz syndrome, Flat feet, Diseases involving the fasciae


Lowered pressure pain thresholds have been demonstrated in adults with Ehlers-Danlos Hypermobility type(EDS-HT), however it remains unclear if these findings are also present in children. Therefore, the objectives of the study were to: (1)determine if generalized hyperalgesia is present in Hypermobility syndrome (HMS)/EDS-HT children, (2)explore potential differences in pressure pain thresholds between HMS/EDS-HT children and adults, and (3)determine the discriminative value of generalized hyperalgesia.

Concepts: Syndromes, Marfan syndrome, Ehlers-Danlos syndrome, Hypermobility, Contortion, Diseases involving the fasciae


To investigate whether orthostatic intolerance (OI) is a significant predictor for fatigue in Ehlers-Danlos Syndrome, hypermobility type (EDS-HT).

Concepts: Syndromes, Marfan syndrome, Postural orthostatic tachycardia syndrome, Ehlers-Danlos syndrome, Hypermobility, Orthostatic intolerance, Contortion, Diseases involving the fasciae


This study provides insight into the profile and importance of autonomic symptoms in the hypermobility type (HT) of Ehlers-Danlos syndrome (EDS). The impact of these symptoms is put into perspective by comparing with fibromyalgia (FM) and two other EDS types.

Concepts: Syndromes, Marfan syndrome, Fatigue, Ehlers-Danlos syndrome, Hypermobility, Contortion, Diseases involving the fasciae


A 68-year-old woman was admitted to our hospital with fever and pleural effusion. Her thoracentesis showed eosinophilic pleural effusion (EPE) without any evidence of malignancy, infection, or trauma. Pleural biopsy revealed pleuritis and intercostal myositis. Characteristic skin manifestations, including Gottron’s sign, interstitial lung disease, and pericardial effusion, appeared later in the clinical course. She was finally diagnosed with anti-PL-7 antisynthetase syndrome (ASS) based on the presence of anti-PL-7 antibody, and she fulfilled the diagnostic criteria for dermatomyositis. These clinical manifestations improved with immunosuppressive therapy. EPE might therefore be one of the characteristic features of anti-PL-7 ASS.

Concepts: Immune system, Inflammation, Cancer, Pulmonology, Medical terms, Diagnosis, Pleural effusion, Diseases involving the fasciae