Garrod’s pads or knuckle pads
These are lumps on the dorsal (back) of the finger joints, mainly affecting the PIP joint (the finger joint closest to the hand), and less often the knuckle! They can look like calluses or plaques on the skin, where the skin thickens and loses its elasticity. They are caused by fibrous tissue in or under the skin. The thumb does not tend to be affected.
People who have Garrod’s pads often have Dupuytren’s Contracture as well, but Garrod’s pads can also be unrelated and caused by repeated trauma to the joint (for instance repeated sports or work trauma). All calluses on a finger joint are called Garrod’s pads, but not all are Dupuytren’s related.
Usually the pads do not cause any problems and do not need any treatment, but sometimes they can be painful . Steroid injections or in rare cases radiotherapy might help. Surgery to remove the pads is likely to result in scarring, and is usually not recommended. Keratolytics (e.g. salicylic acid or urea) to soften the skin can also be helpful.
Recent research suggests that it is possible that Garrod’s Pads are totally unrelated to Dupuytren’s and that the supposed correlation has been a result of misdiagnosed dorsal Dupuytren’s nodes.
Dorsal Dupuytren’s Nodules
These nodes on the back of the fingers were first described in the 1980’s. They are NOT Garrod’s pads, although they are often found in the same place, on joints in the finger. Dorsal nodules are found mainly on the PIP joint (the joint in the finger closest to the hand) of the index finger, with the little finger affected less often, the others even less, and the thumb does not tend to be affected. One study showed these lumps in about 20% of Dupuytren’s patients. Like all Dupuytren’s nodules they may be painful or cause contracture.
As they cause contracture on the tendon on the back of the hand, first the finger will feel tight when making a fist, and a fist will become harder to make over time. As dorsal nodules progress they can make it painful and sometimes impossible to form a fist at all, whereas nodules on the front of the hand make the finger bend towards the palm.
If the finger is bent further, it can lead to a rare condition called a ‘swan neck deformity’(see picture) where the first joint is permanently bent backwards because of the nodule contracting over the tendon, and the last finger joint forwards.
If these nodules cause a problem, surgery is a possibility, but as with all Dupuytren’s related condition the possibility of conditions worsening and scarring of the finger should be taken into consideration. There is little information on treatment, but treatments that work for palmar Dupuytren’s are the most likely ones to be considered for dorsal nodules.
Frozen Shoulder or adhesive capsulitis
Frozen shoulder is an inflammation in the lining (capsule) of the shoulder joint. The exact relationship between frozen shoulder and Dupuytren’s Disease is not known, but patients with one condition have a higher risk of developing the other. Dupuytren’s patients have an 8 times higher chance of getting a frozen shoulder, and 18-50% of frozen shoulder patients have or develop Dupuytren’s Disease as well.
However Frozen Shoulder is unlike other Dupuytren’s related diseases in that there are no obvious nodules and no contracture. The connection may be something to do with collagen or calcium deposits in or on tendons or the joint capsule.
Frozen shoulders are seen more in women age 40-60. An estimated 2-5% of the population will get some degree of frozen shoulder. Usually only one shoulder is affected. It is more common in people with a history of Dupuytren’s Disease, Diabetes Mellitus, overactive thyroid and Parkinson’s. Phenobarbitone ( epilepsy medication) can also increase the incidence of frozen shoulders.
The shoulder joint capsule becomes inflamed and scar tissue forms in the capsule, thus thickening it and making it less flexible.
It has three phases:
- the freezing phase where the shoulder becomes increasingly more painful and less mobile.
- the frozen phase where the pain is less but movements are very limited.
- the thawing or recovery phase where slowly the range of movement increases again.The whole process can take 2-3 years, sometimes more.
Pain Relief - anti-inflammatory drugs such as ibuprofen, naproxen, co-codamol, paracetamol and similar medications.
Physiotherapy - mobilising exercises, as described by your physiotherapist, done four times daily for 20-30 minutes at the time to prevent freezing up completely and slowly increase mobility.
There are many reports of success with the Niel-Asher technique performed by a qualified practitioner, but we are not aware of independent clinical trials comparing this method to regular physiotherapy.
Steroid injection into the shoulder joint - This can be done to reduce pain and inflammation, and to make exercising easier. Normally the injection will contain a steroid and a local anaesthetic to give fast pain relief. On its own it is not a cure, exercise is still essential.
Hydrodilatation - saline fluid mixed in with the steroid injection, to stretch the joint capsule and increase mobility. Not widely used in the UK. Can be painful in the short term (don’t drive afterwards).
Arthrosopic joint release - A procedure done under general anaesthetic, where scar tissue in the capsule is released using an arthroscope. (An arthroscope is a tiny camera in a tube and scalpels, etc. can also be passed down the tube. This is keyhole surgery.
Mobilisation under anaesthetic - In these cases where exercises are not having the desired effect, the patient can be given a general anaesthetic and the surgeon will manipulate the arm to break down the scar tissue in the joint capsule. Used as last resort but can give good results very quickly.
Collagenase injections - Auxilium has announced the first human trials of Xiapex (Xiaflex in the US) injection as potential treatment for frozen shoulder. Further information here.
Keloid formation is a condition where people produce a lot of hard scar tissue for a relatively minor wound, over a larger area than the original wound. Scar tissue contains collagen, and this has caused speculation as to whether keloids are related to Dupuytren’s.
There are similarities to the formation of excess collagenous scar tissue but the dis-similarities are large.
Keloid formation is seen more in people of African origin (unlike Dupuytren’s which is rare in Africans). Also, keloids affect the head and neck more than the limbs.
Keloid scarring is associated with unexplained carotid atherosclerosis (plaque formation in the arteries to the brain), which is not typical for Dupuytren’s patients.
Most doctors consider keloid formation to be unrelated to Dupuytren’s, even though studying one problem can give insights into the disease process of the other. For this reason some doctors have a special interest in both diseases.