BURSITIS & TENDONITIS Flashcards
What are non-articular sources of pain
Sources of pain originating in structures surrounding the joint e.g. tendons, ligaments, bursae, muscles
How can you tell the difference on examination between non-articular problems and articular problems?
Non-articular - localised pain, pain worsens with active but not passive joint motion
Articular - diffuse or deep pain, painful range of movement active + passive, creptitation, swelling, joint instability or deformity possible
What is a bursitis?
Inflammation of the bursae which causes thickening of the synovial membrane and increase fluid production causing swelling
Common types of bursitis?
Prepatellar
Olecranon
Trochanteric
Retrocalcaneal
What is a bursa?
is a closed synovial fluid-filled sac created by synovial membrane that works as a cushion and gliding surface to reduce friction between tissues of the body. Found at bony prominences
What can cause bursitis?
Friction from repetitive movements or leaning on the elbow
Trauma
Inflammatory conditions (e.g., rheumatoid arthritis or gout)
Infection - septic bursitis e.g. following a penetrating injury
What is olecranon bursitis sometimes known as?
Students elbow as students may lean on their elbow for prolonged periods while studying causing friction and mild trauma
Miners elbow
Draftmans elbow
Who do olecranon bursitis typically affect?
Middle aged males
What is the olecranon bursa?
A sac overlying the olecranon process of the elbow beneath the skin
It has a synovial lining but does not communicate with the joint
What are most causes of septic olecranon bursitis caused by?
Staph aureus up to 90%
Strep
Presentation of olecranon bursitis?
Swelling over the olecranon process that appears over hours-days, is fluctuating, tender and warm
Movement at the elbow joint is painless except at full flexion when the swollen bursa is compressed
Features that might indicate septic bursitis rather than non-septic bursitis?
Increased tenderness or painful, red, hot swelling of the bursa which is progressively worsening.
Local cellulitis.
Abrasion or laceration over the bursa.
Fever.
Immunocompromised state.
Tachycardia, low bp, change in mental status
What should you do if you suspect septic bursitis?
Aspirate bursal fluid using a sterile aspiration technique before antibiotics are started
If pus is aspirated or fluid is blood stained then septic arthritis is possible. Note straw coloured fluid means infection less likely and milky fluid indicates gout
Send bursal fluid to lab for gram staining, culture and crystal examination
Management of non-septic olecranon bursitis?
Rest, ice, reduced activity, avoid trauma, compressive bandaging and analgesia
If clinically confident that the bursitis is non-septic then reassure person that most people will respond to this.
If effusion is last you may consider aspiration to improve function
Management of septic olecranon bursitis?
Aspirate bursal fluid
Treat empirically with oral antibiotic that covers staph and strep until culture results are known (flucloxacillin)
If swelling, tenderness and erythema recurs consider repeated aspiration
What is trochanteric bursitis known as?
Greater trochanteric pain syndrome
What is greater trochanteric pain syndrome?
A regional pain syndrome in which chronic intermittent pain is felt around the greater trochanter
It has been found that the trochanteric bursae plays a smaller role than previously thought and inflammation is not always present which is why the term traochnateric bursitis is no longer used
What causes greater trochanteric pain syndrome?
Pass med - “Repeated movement of the fibroelastic iliotibial band”
CKS - Inflammation or physical trauma in the muscles. Most commonly a tendinopathyor muscular tear of the gluteus medius, minimus or trochanteric bursitis
Other causes are iliotibial band thickening and infection of the trochanteric bursa
Who is greater trochanteric pain syndrome most common in?
Women aged 40-60
Can occur in younger people - especially runners, footballers and dancers
How does greater trochanteric pain syndrome present?
Chronic lateral hip/thigh/buttock pain which can be intermittent or persistent
Onset is gradual and may progressively worsen over time
An aching or burning pain that may radiate down the lateral aspect of the thigh
Pain is typically aggravated by physical activity and with pressure eon that side of the body e.g. sitting cross-legged, sleeping on that side
Pain on palpation of the greater trochanter
Special tests to establish the diagnosis of greater trochanteric pain syndrome?
Palpate the greater trochanter
Trendelenburg test - pelvis drops down on the contralateral side
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip
How does iliotibial band syndrome/snapping hip syndrome present?
Lateral hip pain on walking, running or cycling with or without snapped
Lateral knee pain aggravated by repetitive activity
How does iliopsoas bursitis present?
Reproducible painful snapping sensations in the anterior hip
Pain is often worsened by activity’s such as walking, climbing stairs or crossing legs
Management of greater trochanteric pain syndrome?
Reassure it is self limiting
Rest, ice, analgesia, weight loss, smoking cessation
Assess needs for aids and devices
If this fails… peri-trochanteric corticosteroid injections and referral to PT
What is the pre-patellar bursa?
A closed fluid-filled sac which lies between the anterior surface of the patella and the skin
It reduces friction on movement between the skin, tendon, ligaments and bone, allowing them to glide smoothly over one another
What is pre-patellar bursitis also known as?
Housemaids knee
Carpet layers knee
Miners knee
Beat knee
Causes of non-septic pre-patellar bursitis?
Acute trauma e.,g. Fall on knee
Chronic trauma e.g. prolonged kneeling
Crystal-depositing conditions - less common
Systemic inflammatory conditions
Who is pre-patellar bursitis most common in?
Men aged 40-60
People whose occupation involves prolonged kneeling or leaning against the knees, for example cleaners, coal miners, carpet layers, gardeners, and roofers.
People who play sports which involve repetitive movement of the knees or direct impact to the knees, such as basket ball and wrestling.
Symptoms of pre-patellar bursitis?
Pain, fluctuating swelling, redness of knees
Difficulty walking or kneeling
Does not affect range of motion of knee but may cause discomfort at extreme flexion of the knee
May have signs of infection if septic bursitis
Management of non-septic pre-patellar bursitis?
Rest, ice, activity modification, simple analgesia
Reassurance
Consider bursal aspiration to improve function and comfort if effusion is large
If no response to conservative management - corticosteroid injection into the bursa
What is a retrocalcaneal bursitis?
Inflammation of the bursa located between the calcaneus and the anterior surface of the Achilles tendon
What causes calcaneal bursitis?
Almost always shows that dig into the back of the heel
Risk factors for Achilles tendon disorders?
Quinolone use e.g. ciprofloxacin
Hypercholesterolaemia as predisposes to tendon xanthomata
Diabetes
Sports that stress the Achilles e.g. basketball or track
What is a tendinopathy?
A term to describe pain, swelling and impaired function of a tendon
It does not necessary mean inflammation
Function of the Achilles tendon?
Connects the gastrocnemius and soles to the calcaneus bone
Flexion of the calf muscles pulls on the Achilles and causes plantar flexion of the ankle
What are the 2 types of Achilles tendinopathy?
Insertion tendinopathy and mid-portion tendinopathy
What is insertion Achilles tendinopathy?
Damage to the Achilles tendon within 2cm of the insertion point on the calcaneus
25% of cases
What is mid-portion Achilles tendinopathy?
This is when it affects the area of the Achilles tendon 2-6cm above its insertion on the calcaneus
This area is vulnerable to damage because it has a relatively poor blood supply
60% of cases
Symptoms of Achilles tendinopathy?
gradual onset of posterior heel aching pain that is worse following activity or pressure to the area
morning pain and stiffness are common after a period of prolonged sitting or in the morning
Management of Achilles tendinopathy?
Simple analgesia
Reduction in precipitating activities
Calf muscle eccentric actives - self-directed or under the guidance of PT
Symptoms of Achilles tendon rupture?
Whilst playing a sport or running… hearing an audible pop in the ankle, sudden onset significant pain in calf/ankle and difficulty with weight bearing
What can you use to exclude Achilles tendon rupture?
Simmonds triad - look for an abnormal angle of declination, palpation for a gap in the tendon and the calf squeeze test to see if foot moves or not
Performed by the pt lying prone with their feet over the edge of the bed
Investigation for Achilles tendon rupture?
US
Management of suspected Achilles tendon rupture?
Acute referral to orthopaedic specialist
May be surgery or wearing a specialist boot to immobilise the ankle
What is tennis elbow?
Lateral epicondylitis
Tendinosis that affects the common attachment of the tendons on the extensor muscles of the forearm to the lateral epicondyle of the humerus
Most commonly affects the extensor carpi radialis
Causes of tennis elbow?
Minor or unrecognised trauma e.g. in repetitive overuse which cause micro-tears
Activities associated: repetitive wrist extension and grip-intensive activities
Symptoms of tennis elbow?
pain/burning and tenderness localised to the lateral epicondyle with radiation down the extensor forearm
pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
Grip weakness
Resisted middle finger extension may be painful
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
Management of tennis elbow?
Heat or ice
Rest
Consider using an orthosis e.g. forearm strap
Analgesia
Reassess after 6 weeks. If no response to treatment 6-12 months later than consider referral to an orthopaedic surgeon
What is Golfers elbow?
Medial epicondylitis - tendon inflammation where they insert into the medial epicondyle of the humerus
Symptoms of medial epicondylitis?
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
What is patellar tendinopathy?
I.e. jumpers knee
This is when there is pain in the tendon bellow the patella due to overuse or overload which may cause micro injuries or changes to its structure
Symptoms of patellar tendinopathy?
Chronic pain and tenderness at the front of the knee
Pain often worse after running
The tendon may feel thickened and some may experience tightness or weakness in quadriceps
Stiffness in knee
Mild swelling around the knee
Who is patellar tendinitis most common in?
Athletic teenage boys
What is swimmers shoulder?
Aka subacromial impingement or painful arc syndrome
This is inflammation and irritation of the supraspinateus tendon, particuarly due to impingement at the point where it passes between the humeral head and the acromion
What test can be done for supraspintaus tendinopathy?
The empty can test aka jobe test
Pt abducts the shoulder to 90 degrees and fully internally rotates their arm as though emptying a can of water
The examiner pushes down on the arm whilst the pt resists
Test is positive if this elicits pain or the arm gives way
Symptoms of supraspinatus tendinitis?
Pain on outside of upper arm when abducting 60-120 degrees
Pain often common with twisting movements e.g. putting on coats
Tenderness over the anterior acromion
What is De Quervain’s tenosynovitis?
A common condition in which the sheath containing the extensor policies brevis and abductor pollicis longus tendons is inflamed
Who does De Quervain’s tenosynovitis typically affect?
Females 30-50
Cause of De Quervain’s tenosynovitis?
Chronic overuse of the wrist E.g. lifting a baby or gardening
Symptoms of De Quervain’s tenosynovitis?
Pain on the radial side of the wrist
Tenderness over the radial styloid process
Abduction of thumb against resistance is painful
What test can be done to test for De Quervain’s tenosynovitis?
Finkelstein’s test: examiner pulls the thumb of the pt in ulnar deviation and longitudinal traction
In a pt with tenosynovitis this causes pain over the radial styloid process and along the length of extensor pollicis brevis and abductor pollicis longus
Management of De Quervain’s tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
