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Rosens > 103 Tendonopathy and Bursitis > Flashcards

103 Tendonopathy and Bursitis Flashcards

1
Q

Tendons - connect bone to ?

A

muscle

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2
Q

Major precipitating causes of most tendinopathies - 2

A

mechanical overload
repetitive microtrauma

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3
Q

What intrinsic factors can result in high or frequency mechanical loads on tendons?

A

age
gender
blood type o
adiposity
tobacco use
malalignment
joint laxity
m weakness
imbalance

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4
Q

What extrinsic factors can result in high or frequency mechanical loads on tendons?

A

ergonomics
abnormal movements
excessive duration of activity
incr frequency/intensity of activity
envrionmental conditions

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5
Q

What abx cause incr risk of tendon rupture?

A

Fluoroquinolones

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6
Q

DDX tendinopathy

A

tendon rupture
ligamentous injury
inflammatory arthritis
fractures
tumors
tenosynovitis
osteochondrosis
bursitis
septic arthritis
OA
FB
rhabdo
OM
nerve entrapment syndromes
tendon sheath infections

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7
Q

Acute healing of tendons: Stage I: hemorrhagic phase

A

Blood accumulates and clots at site

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8
Q

Acute healing of tendons: Stage II: inflammatory phase

A

neutrophils and macrophages initiate phagocytosis, removing existing necrotic material

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9
Q

Acute healing of tendons: Stage III: proliferative phase

A

extrinsic cells (tendon sheath, fascia, periosteum) and intrinsic cells migrate and proliferate at injured tendon

collagen type III synthesized

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10
Q

Acute healing of tendons: Stage IV: formative stage

A

type III collagen stronger to handle tension forces

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11
Q

Acute healing of tendons: Stage V: remodeling phase

A

normalization of ratio between type I and III collagen followed by reintroduction of physiologic load into tendon

  • up to 12 weeks for tendon to regain former strength
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12
Q

General tendinopathy -characteristic hx features

A

recent repetitive motions

hx fq use, statin, infectious disease, systemic illness, hx of RA/infections

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13
Q

Dismcomfort of tendons typically __ after rest

A

more

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14
Q
A
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15
Q

What structures might cause impingement of the shoulder?

A

Bursa, sits muscles, glenohumeral ligaments,

Greater to varsity impinges the tendons of usually the supraspinatus the anterior third of the acromiun

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16
Q

What is the pain of a rotator cuff tear described like?

A

Dull ache over the anterolateral part of the shoulder, extending from the shoulder to the middle upper arm, often after an activity involving flexion and abduction of the arm

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17
Q

Second stage of impingement syndrome leading to rotator cure:

A

Mechanical trauma continues, fibrosis, and thickening of the tendon and subacromial bursa can continue

Pain is constant at worse night

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18
Q

Third stage of impingement causing

A

Second stage, but also history of prolong shoulder problems

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19
Q

What test is best for assessing supraspinatus tenderness?

A

empty can/jobe test
sn 62%, sp 54%

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20
Q

Tests for rotator cuff tendinitis: Neer test

A

pain at end arc
sn 75-86%

sp 48-49%

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21
Q

Tests for rotator cuff tendinitis: Hawkins-Kennedy

A

sn 75-82%

sp 44-48%

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22
Q

Tests for complete rotator cuff tear: drop arm test

A

sn 74% but actually only 10% full thicknes
sp 98%

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23
Q

Tests for complete rotator cuff tear: shrug test - what is this?

A

[t with acute macrotrauma to rotator cuf asked to abduct arm to 90 deg and appears o shrug with that side (as inability of cuff to hold abduction cause torn)

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24
Q

Bicipital tendinopathy: what is this?

A

tendon in long head of bicep is between supra and subscap tendons in anterior shoulder

pain radiating anterior shoulder to elbow, discomfort at night, reach into pocke, door handle

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25
Q

Bicipital tendinopathy: Yergason test

A

pt flex elbow to 90 deg with arm against body, then provider R ind forearm in supination

sn low at 37 but sp 83%, +LR 2.2

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26
Q

Bicipital tendinopathy: Speed’s test

A

elbow extended and forearm supinated, shoulder adducted at 60 deg pt R forward flexion of shoulder - pain positive at groove

sn 61-83%
sp 33-71%

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27
Q

Calcific tendinopathy: what is this?

A

acute or chronic pain assoc with deposition of ca crystals in or around tendons

mc in rotator cuff

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28
Q

Underlying causes?

A

tissue hypoxia and degen from overuse

ca deposition overtime then when resorption occurs, causes pain

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29
Q

Calcific tendinopathy: risks (comorbidites?)

A

females
dm
thyroid disorder
nephrolithiasis

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30
Q

Calcific tendinopathy: dx

A

pain at site with xr showing calcification - ultrasound actually better and can tx with percutaneous needle lavage

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31
Q

Lateral epicondylitis: what tendons does this involve/their insertion?

A

common extensor tendon - ext carpi radialis brevis onto latera epicondyle

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32
Q

Cozen’s test for lateral epicondylitis:

A

grasp forearm with one hand and R pt wrist extension on affected side with other hand

+ means reproduction of pain at lateral epicondyle

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33
Q

Maudsley’s test/active extension of middle finger: for lateral epicondylitis:

A

pain over lateral epicondyle

poor sp and sn

34
Q

DDX lateral epicondylitis

A

fractures
PIN entrapment (mo of radial n), plica lesions, synovitis, chondromalacia, adolescent osteochondral defects

35
Q

Medial epicondylitis: where is this?

A

insertion at flexor carpi radialis on medial epicondyle

36
Q

de Quervain’s tenosynovitis: what is this?

A

synovial lining of abductor pollicis longus and extensor pollicis brevis tendons - likely thickening of the extensor retinaculum covering first dorsal compartment of the wrist

37
Q

de Quervain’s tenosynovitis: type of pain/presentation

A

often gradual onset
over radial styloid process
radiation pain forearm or distally down thumb
pain generally constant grasping, abd of thumb, ulnar deviation

38
Q

de Quervain’s tenosynovitis: physical examination

A

crepitus over abductor pollicis longus and epb
swelling over radial styloid
finkelstein’s test pathognomonic

39
Q

Finkelstein’s test what is this?

A

most pathognomonic physical sign - thumb in neutral position, patient deviates wrist toward ulna
pain near radial styloid

either of these are +

40
Q

Eichoff’s test - what is this?

A

patient thumb in fist, then deviating wrist toward ulna

41
Q

DDX of de Quervain’s tenosynovitis:

A

scaphoid fracture
OA of CMC joint
TB
disseminated gonococcal infections

42
Q

Patellar tendinopathy: symptoms?

A

pain at inferior pole of patella
typically jumping sport

43
Q

Patellar tendinopathy: exam

A

quads musculature relaxed with knee flexed at 30 deg, tenderness may be localized to deep surface of proximal attachment of patellar tendon at inferior pole

44
Q

DDX for patellar tendinopathy

A

patellofemoral syndrome
arises from imablance of forces of patella tracking during flexion and extension

45
Q

Achilles tendionopathy: result of systemic disease RF

A

dm
renal disease
ankylosing
spond
reactive arthritis
gout
pseudogout
FQ and statins
moderate etoh (not heavy though interestingly)

46
Q

Achilles tendon rupture - common sx

A

“pop” followed by acute weakness and an inability to continue with activity. Patients may report feeling as though they were “struck” in the posterior ankle.

47
Q

PE of tendon rupture:

A

defect palpated in tendon possible
hematoma may feel boggy
decreased PF (Normal 20-30 deg)
thomspon test - evaluate for a complete rupture - no PF means + test

48
Q

+ diagnosis of Achilles rupture:

A

2 ore more:
palpable defect 2cm to 6cm proximal to its insertion
+ thomspon test
increased passive ankle DF
decreased PF strength

49
Q

100% npv if which 3 factors are absent:

A

palpable defect 2cm to 6cm proximal to its insertion
+ thomspon test
increased passive ankle DF

50
Q

Acute or chronic tendinopathy: what might be seen on POCUS?

A

loss of fibrillar echotexture
focal tendon thickening
diffuse thicekning focal hypoechoic areas
extended hypoecho
irregular and ill defined borders
microruptures
intratendinous calcification
peritendinous inflamm edema

51
Q

Management of a general tendinopathy

A
  1. cause
  2. eliminate cause
  3. NSAID
  4. protect
  5. relative rest
  6. optimal load/ergonomics
  7. application of ICE
  8. education and modify
  9. enhance diet
  10. refer if needed
52
Q

What 2 tendons should CS injection particularly be avoided in?

A

achilles
patellar

53
Q

What tendinopathies apparently do well with NTG patch?

A

medial lat epicondylitis - but also may incr risk of nonop tx failure
noninsertional achilles
rotator cuff tendinopathy

54
Q

Platelet rich plasma injections - literature on this for tendinopathies?

A

variable!

55
Q

Calcific tendinopathy tx

A

mainly conservative and consists of analgesia and brief immobilization (e.g., a shoulder sling for rotator cuff calcific tendinopathy) because prolonged immobilization may result in decreased range of motion. Both extracorporeal shock wave therapy (akin to that which is used for nephrolithiasis) and ultrasound-guided needle lavage and aspiration (Fig. 103.9) are effective treatments for this condition

56
Q

de Quervain’s tx

A

immob with thumb spica splint
antiinflamm meds
prompt referral
CS good

57
Q

Management of an achilles rupture

A

posterior lower leg splint in 20 deg of PF
if not feasible consider walkingboot with 2 inch heel lift
NWB until seen by specialist

58
Q

What is a bursa?

A

closed sac lined by synovial membrane which helps to lubricate tow areas of tissue/friction

59
Q

Bursitis causes

A

trauma
systemic inflamm - gout, pseudogout, RA, psoriatic arthritis
infection - staph
idiopathi

60
Q

Septic bursitis common symptoms

A

pain
tender
erythema
warmth
spetic is almost always proceeded by some kind of trauma

61
Q

RF for septic arthritis

A

dm
etoh abuse
chronic skin cond like atopic dermatitis
RA/gout ie prior noninfectious

62
Q

What movement issues would indicate more of a septic arthritis picture than septic bursitis?

A

significant decr rom
generalized joint swelling
joint pain? warmth? effusion?

63
Q

Subacromial bursitis

A

similar to supraspinatus tendinopathy

64
Q

Trochanteric bursa - where is deep and superficial?

A

deep bursa is between greater trochanter and tensor fasciae latae

super: between greater trochanter and skin

65
Q

Trochanteric bursitis: symptoms? signs?

A

mc middle aged woman, lying on hip and walking may make worse, complication of RA

palpation direct on site and hip adduction while pain of deep trochanteric bursitis may be reporudced with abd, normal hip ROM

66
Q

Iliopsoas bursitis: manigests as what?

A

anterior hip pain radiating down medial thigh to knee, exacerbated by hip extension

67
Q

Pes Anserine bursitis

A

sartorius, gracilis and semitendinosis all come here - medial knee pain 2-3cm distal to join line

68
Q

DDX of atraumatic nonseptic bursitis

A

ra
pseudogout
ank spond
hypertrophic pulmonary osteoarthropathy
oxalosis
gout
scleroderma
sle
whipple disease
idopathic hypereosinophilic syndrome

69
Q

Bursitis - consider diagnostic testing with?

A

aspiration 18-20g needle

septic = purulent
send wbc an d diff, gram stain, crystals, appropriate cultures and sn, glucose level

70
Q

labs for bursitis

A

cbc

crp
glucose

71
Q

Bursa wbc > ? suggests infection

A

5000

72
Q

Septic arthritis - oral abx for 14d - what options?

A

dcloxacillin 500mg PO qid
septra 1-2 tabs po twice daily
clinda 300mg po qid if pen allergic

73
Q

IV options for septic bursitis

A

vancomycin 20-35mg/kg actual bw, then 15-20mg/kg actual bw q8-12h

74
Q

Nonseptic bursitis tx

A

nsaid
compression
occas

75
Q
  1. What is the etiology of most tendinopathies?
    a. Direct blow to the tendon
    b. Recent or previous complete tendon rupture
    c. High-grade inflammation of the tendon
    d. Mechanical overload and repetitive microtrauma
A

d

76
Q
  1. What is the most important predisposing factor in septic bursitis? a. Chronic obstructive pulmonary disease
    b. Diabetes mellitus
    c. Human immunodeficiency virus (HIV)
    d. Trauma
A

d

77
Q
  1. What is the causative organism in the majority of cases of septic
    bursitis?
    a. Beta-hemolyticstreptococci b. Pseudomonas aeruginosa
    c. Staphylococcusaureus
    d. Prototheca wickerhamii
A

c

78
Q
  1. Which of the following interventions should routinely be used
    when treating patients with tendinopathies?
    a. Activitymodification
    b. NSAIDs
    c. Intratendinous corticosteroid injection
    d. Immobilization of the affected tendon/joint
A

a

79
Q
  1. A 38-year-old male presents after feeling a “pop,” followed by pain to the back of his leg while playing basketball. You note a defect to his Achilles tendon, decreased resting plantar flexion of the ankle, and a positive Thompson test on examination. What should be the next step in the patient’s management?
    a. Provide crutches and advise the patient to remain non- weightbearing until follow-up.
    b. Splint the affected leg in an equinus position and refer for prompt follow-up.
    c. Obtain emergent magnetic resonance imaging (MRI).
    d. Perform a steroid injection to the affected tendon.
A

b

80
Q
  1. A 42-year-old female without significant past medical history pres- ents with 4 days of edema, mild warmth, and mild erythema in the area of the right olecranon bursa. She is afebrile and has minimal tenderness to palpation of the bursa. Aspiration of the bursa reveals a white blood cell count of 1500/μL.3 What is the most appropriate
    next step in the patient’s management?
    a. Admit for intravenous (IV) antibiotics.
    b. Apply a compression dressing and give ibuprofen.
    c. Discharge the patient to home with oral antibiotics.
    d. Obtain magnetic resonance imaging (MRI) for further evalua-
    tion.
A

Answer: B. The clinical presentation and results of the fluid analysis highly suggest a nonseptic bursitis. Cases of nonseptic bursitis can be managed with a compressive dressing, nonsteroidal antiinflammatory drugs (NSAIDs), avoidance of local trauma, and close follow-up.

Rosens (40 decks)

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