103 Tendonopathy and Bursitis Flashcards
Tendons - connect bone to ?
muscle
Major precipitating causes of most tendinopathies - 2
mechanical overload
repetitive microtrauma
What intrinsic factors can result in high or frequency mechanical loads on tendons?
age
gender
blood type o
adiposity
tobacco use
malalignment
joint laxity
m weakness
imbalance
What extrinsic factors can result in high or frequency mechanical loads on tendons?
ergonomics
abnormal movements
excessive duration of activity
incr frequency/intensity of activity
envrionmental conditions
What abx cause incr risk of tendon rupture?
Fluoroquinolones
DDX tendinopathy
tendon rupture
ligamentous injury
inflammatory arthritis
fractures
tumors
tenosynovitis
osteochondrosis
bursitis
septic arthritis
OA
FB
rhabdo
OM
nerve entrapment syndromes
tendon sheath infections
Acute healing of tendons: Stage I: hemorrhagic phase
Blood accumulates and clots at site
Acute healing of tendons: Stage II: inflammatory phase
neutrophils and macrophages initiate phagocytosis, removing existing necrotic material
Acute healing of tendons: Stage III: proliferative phase
extrinsic cells (tendon sheath, fascia, periosteum) and intrinsic cells migrate and proliferate at injured tendon
collagen type III synthesized
Acute healing of tendons: Stage IV: formative stage
type III collagen stronger to handle tension forces
Acute healing of tendons: Stage V: remodeling phase
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
General tendinopathy -characteristic hx features
recent repetitive motions
hx fq use, statin, infectious disease, systemic illness, hx of RA/infections
Dismcomfort of tendons typically __ after rest
more
What structures might cause impingement of the shoulder?
Bursa, sits muscles, glenohumeral ligaments,
Greater to varsity impinges the tendons of usually the supraspinatus the anterior third of the acromiun
What is the pain of a rotator cuff tear described like?
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
Second stage of impingement syndrome leading to rotator cure:
Mechanical trauma continues, fibrosis, and thickening of the tendon and subacromial bursa can continue
Pain is constant at worse night
Third stage of impingement causing
Second stage, but also history of prolong shoulder problems
What test is best for assessing supraspinatus tenderness?
empty can/jobe test
sn 62%, sp 54%
Tests for rotator cuff tendinitis: Neer test
pain at end arc
sn 75-86%
sp 48-49%
Tests for rotator cuff tendinitis: Hawkins-Kennedy
sn 75-82%
sp 44-48%
Tests for complete rotator cuff tear: drop arm test
sn 74% but actually only 10% full thicknes
sp 98%
Tests for complete rotator cuff tear: shrug test - what is this?
[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)
Bicipital tendinopathy: what is this?
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
Bicipital tendinopathy: Yergason test
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
Bicipital tendinopathy: Speed’s test
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%
Calcific tendinopathy: what is this?
acute or chronic pain assoc with deposition of ca crystals in or around tendons
mc in rotator cuff
Underlying causes?
tissue hypoxia and degen from overuse
ca deposition overtime then when resorption occurs, causes pain
Calcific tendinopathy: risks (comorbidites?)
females
dm
thyroid disorder
nephrolithiasis
Calcific tendinopathy: dx
pain at site with xr showing calcification - ultrasound actually better and can tx with percutaneous needle lavage
Lateral epicondylitis: what tendons does this involve/their insertion?
common extensor tendon - ext carpi radialis brevis onto latera epicondyle
Cozen’s test for lateral epicondylitis:
grasp forearm with one hand and R pt wrist extension on affected side with other hand
+ means reproduction of pain at lateral epicondyle
Maudsley’s test/active extension of middle finger: for lateral epicondylitis:
pain over lateral epicondyle
poor sp and sn
DDX lateral epicondylitis
fractures
PIN entrapment (mo of radial n), plica lesions, synovitis, chondromalacia, adolescent osteochondral defects
Medial epicondylitis: where is this?
insertion at flexor carpi radialis on medial epicondyle
de Quervain’s tenosynovitis: what is this?
synovial lining of abductor pollicis longus and extensor pollicis brevis tendons - likely thickening of the extensor retinaculum covering first dorsal compartment of the wrist
de Quervain’s tenosynovitis: type of pain/presentation
often gradual onset
over radial styloid process
radiation pain forearm or distally down thumb
pain generally constant grasping, abd of thumb, ulnar deviation
de Quervain’s tenosynovitis: physical examination
crepitus over abductor pollicis longus and epb
swelling over radial styloid
finkelstein’s test pathognomonic
Finkelstein’s test what is this?
most pathognomonic physical sign - thumb in neutral position, patient deviates wrist toward ulna
pain near radial styloid
either of these are +
Eichoff’s test - what is this?
patient thumb in fist, then deviating wrist toward ulna
DDX of de Quervain’s tenosynovitis:
scaphoid fracture
OA of CMC joint
TB
disseminated gonococcal infections
Patellar tendinopathy: symptoms?
pain at inferior pole of patella
typically jumping sport
Patellar tendinopathy: exam
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
DDX for patellar tendinopathy
patellofemoral syndrome
arises from imablance of forces of patella tracking during flexion and extension
Achilles tendionopathy: result of systemic disease RF
dm
renal disease
ankylosing
spond
reactive arthritis
gout
pseudogout
FQ and statins
moderate etoh (not heavy though interestingly)
Achilles tendon rupture - common sx
“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.
PE of tendon rupture:
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
+ diagnosis of Achilles rupture:
2 ore more:
palpable defect 2cm to 6cm proximal to its insertion
+ thomspon test
increased passive ankle DF
decreased PF strength
100% npv if which 3 factors are absent:
palpable defect 2cm to 6cm proximal to its insertion
+ thomspon test
increased passive ankle DF
Acute or chronic tendinopathy: what might be seen on POCUS?
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
Management of a general tendinopathy
- cause
- eliminate cause
- NSAID
- protect
- relative rest
- optimal load/ergonomics
- application of ICE
- education and modify
- enhance diet
- refer if needed
What 2 tendons should CS injection particularly be avoided in?
achilles
patellar
What tendinopathies apparently do well with NTG patch?
medial lat epicondylitis - but also may incr risk of nonop tx failure
noninsertional achilles
rotator cuff tendinopathy
Platelet rich plasma injections - literature on this for tendinopathies?
variable!
Calcific tendinopathy tx
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
de Quervain’s tx
immob with thumb spica splint
antiinflamm meds
prompt referral
CS good
Management of an achilles rupture
posterior lower leg splint in 20 deg of PF
if not feasible consider walkingboot with 2 inch heel lift
NWB until seen by specialist
What is a bursa?
closed sac lined by synovial membrane which helps to lubricate tow areas of tissue/friction
Bursitis causes
trauma
systemic inflamm - gout, pseudogout, RA, psoriatic arthritis
infection - staph
idiopathi
Septic bursitis common symptoms
pain
tender
erythema
warmth
spetic is almost always proceeded by some kind of trauma
RF for septic arthritis
dm
etoh abuse
chronic skin cond like atopic dermatitis
RA/gout ie prior noninfectious
What movement issues would indicate more of a septic arthritis picture than septic bursitis?
significant decr rom
generalized joint swelling
joint pain? warmth? effusion?
Subacromial bursitis
similar to supraspinatus tendinopathy
Trochanteric bursa - where is deep and superficial?
deep bursa is between greater trochanter and tensor fasciae latae
super: between greater trochanter and skin
Trochanteric bursitis: symptoms? signs?
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
Iliopsoas bursitis: manigests as what?
anterior hip pain radiating down medial thigh to knee, exacerbated by hip extension
Pes Anserine bursitis
sartorius, gracilis and semitendinosis all come here - medial knee pain 2-3cm distal to join line
DDX of atraumatic nonseptic bursitis
ra
pseudogout
ank spond
hypertrophic pulmonary osteoarthropathy
oxalosis
gout
scleroderma
sle
whipple disease
idopathic hypereosinophilic syndrome
Bursitis - consider diagnostic testing with?
aspiration 18-20g needle
septic = purulent
send wbc an d diff, gram stain, crystals, appropriate cultures and sn, glucose level
labs for bursitis
cbc
crp
glucose
Bursa wbc > ? suggests infection
5000
Septic arthritis - oral abx for 14d - what options?
dcloxacillin 500mg PO qid
septra 1-2 tabs po twice daily
clinda 300mg po qid if pen allergic
IV options for septic bursitis
vancomycin 20-35mg/kg actual bw, then 15-20mg/kg actual bw q8-12h
Nonseptic bursitis tx
nsaid
compression
occas
- 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
d
- 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
d
- What is the causative organism in the majority of cases of septic
bursitis?
a. Beta-hemolyticstreptococci b. Pseudomonas aeruginosa
c. Staphylococcusaureus
d. Prototheca wickerhamii
c
- 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 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.
b
- 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.
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.
