Connective tissue conditions Flashcards
What cell is responsible for the repair of skeletal muscle?
Satellite cells
What is tendonitis and how is it caused?
Small tears causing localised inflammation in a tendon
Causes: overuse, collagen disorders, renal dialysis
How should tendonitis be treated?
RICE
Analgesics + NSAIDS
stretching
surgery
Where in the Achilles tendon does tendonitis usually occur?
Belly of the tendon
~2-6 cm above insertion point
What is heterotopic calcification/ossification? How often does it occur in tendon injuries? How can this be treated?
Formation of bone outside the skeleton (i.e. in soft tissue)
~30% of tendon injuries cause heterotopic ossification
NSAIDs such as indomethacin, aspirin and ibuprofen can prevent the ossification (not necessarily heal ossification that has already occurred)
State whether cast immobilisation and passive motion are beneficial or detrimental for:
a) tendon-to-bone healing
b) flexor tendon healing
a) tendon-to-bone healing
- cast immobilisation is beneficial
- passive movement is detrimental
b) flexor tendon healing
- cast immobilisation is detrimental
- passive movement is beneficial
Which tendons heal via extrinsic and intrinsic methods?
- Extrinsic (peripheral fibroblasts):
- Achilles
- Rotator cuff
- Tendons without a tendon sheath - Intrinsic (fibroblasts from tendon):
- Hand flexors
- any tendon with a sheath
What are the different phases of tendon healing? How long does tendon healing take and why?
Phase 1: INFLAMMATION
- pain, swelling, redness
- reduced collagen synthesis and increased inflammatory cells
Phase 2: PROLIFERATION/REPAIR
- collagen fibre production
- reduced collagen fibre organisation and reduced inflammatory cells
Phase 3: MATURATION/REMODELLING
- proper collagen fibre alignment
- increased tissue strength
Can take up to 1 year to heal fully - as tendons are relatively avascular
What are the two different types of enthesis?
- Fibrosus
- tendon/ligament not kinked by joint movement (long distance from insertion
- extends all the way up to bone
- aligned collagen fibres are going to insert and integrate on the outer edge
- tendon joins directly to bone - Fibrocartilaginous
- tendon/ligament is kinked by joint movement (close insertion)
- small section of fibrocartilage at attachment site
- tendon transitions through fibrocartilage before reaching the bone
- -> ensures that any bending of tendon/ligament is spread gently away from bone
What are Sharpey’s fibres?
insertion of tendons into periosteal layer of bone
look like trees in longitudinal section and circles in cross-section
What is enthesitis? How is it caused?
Inflammation of the enthesis (i.e. any point of attachment for tendon/ligament)
Causes:
1. recurring stress
2. autoimmune disease (i.e. spondyloarthritides, associated with HLA-B27 arthropathies)
What is the pathogenesis of enthesitis?
- mechanical injury
- stress-sensing at entheseal junction - vasodilatation
- transcortical vessels become inflamed - Inflammation
- cells (neutrophils) efflux through transcortical vessels
- enthesitis occurs - new bone formation
- mesenchymal proliferation and osteoblast differentiation
What is the main difference between tendonitis and enthesitis?
Tendonitis = inflammation in belly of tendon Enthesitis = inflammation at insertion point of tendon
Where do enthesophytes and ostephytes originate from?
Enthesophytes = from the insertion of joint capsule, ligaments or tendons; the articular border of cartilage is not involved
Osteophytes = originate from the border of articular cartilage
How should enthesitis be treated?
Mechanical: RICE and NSAIDs
Inflammatory: usually part of treatment of an asspocated polyarthritis
- sulfasalazine, MTX
- anti-TNFalpha therapy
- local radiotherapy
- corticosteroid injections
- injection of hyperosmolar dextrose
Why are injections of hyperosmolar dextrose used sometimes as treatment for enthesitis?
it is an irritant - causes proliferation of intrinsic fibroblasts
this speeds up the repair of the tendon before it becomes ossified
What are the main forms of tenosynovitis?
- De Quervain’s syndrome:
- fibrosis and narrowing of tendon sheath
- caused by tendons and sheath rubbing over radial styloid process
- inflammation of the tendon sheath of the first dorsal compartment - Trigger syndrome:
- enlargement of tendon within the sheath
- section of tendon/nodule outside the tendon gets stuck (finger is stuck in position)
What treatment options are there for De Quervain’s and Trigger syndrome?
RICE, splinting, anti-inflammatories, corticosteroid injections
Surgery:
Trigger finger: cut the annular ligament
DeQuervain’s: shave down the radial styloid process
What is a characteristic clinical feature of tendinopathies/enthesitis?
Pain on resisted movement
What tendons are involved in DeQuervain’s syndrome?
Extensor pollicus longus
Abductor pollicus longus
Extensor pollicus brevis
What are the differential diagnoses for carpal tunnel syndrome?
cervical radiculopathy
diabetic neuropathy
MS
Thenar eminence wasting is a sign of carpal tunnel syndrome, what other condition is it a sign of?
Pancoast tumour
- tumour in apex of lung
- can compress T1
What causes Dupuytren’s contracture?
Fibrosis of palmar aponeurosis
What causes the following types of pain at the elbow:
- referred pain
- peri-articular pain
- articular pain
- due to issue in the neck of shoulder
- epicondylitis or bursitis
- trauma or osteoarthritis
What is tennis elbow? How is it diagnosed and treated?
Also called lateral epicondylitis
affects the extensor muscles which attach to the lateral epicondyle
Diagnosis :
pt ‘cocks’ wrist back against resistance, if there is pain or tenderness then this indicates lateral epicondylitis
Treatment:
rest, topical NSAIDs, massage, injections, therapy
What could cause swellings and rashes over the extensor surface of the elbows?
olecranon bursitis rheumatoid nodule gout tophus psoriatic plaque vasculitis rash
What are the potential causes of pain in the shoulder?
rotator cuff tendonitis bicipital tendonitis frozen shoulder subacromial bursitis degenerative arthritis (Acromioclavicular joint)
What are the causes of these referred pain patterns in the arm?
- posterior arm/shoulder
- anterior arm/shoulder
- deltoid to elbow
- neck pain
- acromioclavicular joint pain
- true shoulder pain
What muscle is most likely to be the cause of shoulder impingement/tendinopathy and why?
Supraspinatus
because of how the muscle inserts –> passes under clavicle and acromion to insert onto the greater tubercle of humerus
What is the main clinical sign of rotator cuff tendonitis and how is it treated?
Sign: painful arc on active abduction, pain on resisted abduction
Treatment: physiotherapy, steroid injections, surgery
What causes the following types of pain at the hip:
- referred pain
- peri-articular pain
- articular pain
- pelvis, spine/SIJs, meralgia paraesthetica (paraesthesia of outer thigh)
- trochanteric bursitis, ischial bursitis, adductor tendinopathy, bone disease
- OA, inflammatory arthritis, irritable hip
What are potential causes of pain in the foot?
Plantar fasciitis
March fracture
Morton’s neuroma
