Limited Joint Mobility Syndrome

Jesus (Jesse) D. Bracamonte, DO
Assistant Professor of Family Medicine, Department of Family Medicine, Mayo Clinic Scottsdale, Arizona

Gretchen Anderson, FNP
Department of Family Medicine, Mayo Clinic Scottsdale, Arizona

Molly Kresin, DO
Assistant Professor of Family Medicine, Department of Family Medicine, Mayo Clinic Scottsdale, Arizona

Citation:
Bracamonte JD, Anderson G, Kresin M. Limited joint mobility syndrome. Consultant. 2020;60(3):91-93. doi:10.25270/con.2020.03.00007

A 42-year-old woman presented to our primary care clinic with a 1-year history of progressive hand pain manifested by stiffness, fullness of the digits, tight skin, and an inability to fully flex the digits. Her symptoms affected the small digits of both hands but spared the thumbs.

Her capillary refill was normal, and neurologic examination findings were unremarkable, but she was unable to fully extend the digits of both hands upon examination.

She had a history of poorly controlled diabetes type 1 due to nonadherence, with a hemoglobin A_1c level of 13.6%, which correlated with the onset of her symptoms. Her diabetes was being managed with basal insulin via an insulin pump. Her hypertension was adequately controlled with lisinopril and metoprolol, and her cholesterol was well treated with atorvastatin. She continued to smoke a half a pack of cigarettes a day and had done so for 20 years. She had tried acetaminophen without relief. She had no additional history of occupational risks or rheumatologic conditions, and there was no known family history of rheumatologic disease.

She had undergone extensive clinical evaluations by her primary care team and during subsequent specialty consultations with orthopedics, endocrinology, and plastic surgery specialists. Laboratory evaluation and specialty consultation excluded other potential etiologies including complex regional pain syndrome, Dupuytren contracture, flexor tenosynovitis, trigger finger, and other inflammatory conditions. Upon final consultation with a rheumatologist, LJMS was diagnosed based on the pathognomonic positive tabletop and prayer signs (Figures 1 and 2). Ultrasonography revealed fibrous thickening of the flexor tendon sheaths. She was informed that LJMS is a chronic condition, but that optimization of diabetes control and tobacco cessation may help to alleviate her symptoms.

Figure 1. The prayer sign, which tests the patient’s ability to flatten the palmar surfaces together as in the act of prayer; an inability to articulate the palmar surfaces of the digits or hands represents a positive result for LJMS.

Figure 2. The tabletop test is positive for LJMS when the patient is unable to fully place the palmar aspect of the hand against the surface of a table.