Epicondylitis/Bursitis Flashcards
Elbow Anatomy
Synovial hinge joint
Consists of 3 joints, which form a functional unit enclosed within a single articular capsule
Humeroulnar joint
Humeroradial joint
Proximal radioulnar joint
Motions of the elbow:
Extension and flexion
Pronation and supination of the forearm
Lateral Epicondylitis
general
Commonly referred to as tennis elbow
Most common cause for elbow symptoms in patients with elbow pain
Overuse injury normally affecting the dominant arm
Caused by eccentric overload at the origin of the common extensor tendon → tendinosis and inflammation of the extensor carpi radialis brevis (ECRB)
Activities that require repetitive wrist extension, radial deviation, and/or forearm supination
lateral epicondylitis
Clin Med
PE / tests
Insidious onset of pain
Patient describes an overuse history without a specific inciting traumatic event
Pain over the lateral elbow
Maximum over the lateral epicondyle
Increased or reproducible pain with:
Resisted wrist extension with the elbow extended and the forearm pronated (Cozen’s Test)
Resisted extension of the middle finger (Maudsley Test)
Connecting muscle(s) may exhibit tightness
No radicular symptoms
No numbness/tingling
lateral epicondylitis
Dx
Made clinically
X-rays of the elbow to access for arthritis or rule out other etiologies
MRI to grade the severity of the tendon damage
lateral epicondylitis
Tx
Rest from offending activity
Oral/topical NSAIDs
Icing
Stretching exercises
Forearm counterforce straps to relieve tension
Physical therapy
Surgery – after 6-12 months of failed conservative treatment
Medial Epicondylitis
general
Commonly known as golfer’s elbow or pitcher’s elbow
90% of cases are not sports-related
Caused by overuse or overload of the medial common flexor tendon that inserts on the medial epicondyle
5 muscles conjoin to form the common flexor tendon
Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis – innervated by the median nerve
Flexor carpi ulnaris – innervated by the ulnar nerve
Medial Epicondylitis
Clin man
Associated w what complication
Insidious onset of pain
Patient describes an acute traumatic blow or repetitive elbow use, gripping, or valgus stress to the elbow
Pain over the medial elbow
Aching with radiation down the anterior dominant forearm
Increased or reproducible pain with:
Resisted pronation or flexion of the wrist
Resolves with cessation of activity
May have associated elbow stiffness, weakness, and/or numbness and tingling in an ulnar distribution
Swelling, erythema, or warmth in acute cases
medial epicondylitis
Dx
Made clinically
X-rays of the elbow to access for arthritis or rule out other etiologies
Electromyogram and nerve conduction studies if there is concern for ulnar nerve involvement
medial epicondylitis
Tx
Rest from offending activity
Oral/topical NSAIDs
Icing
Physical therapy
Ultrasound or palpation-guided corticosteroid injections
Electrical stimulation or iontophoresis
Surgery for failed conservative treatment
Bursitis
general
Swelling or inflammation of a bursa
Bursa
Synovium-lined, sac-like structure containing a small amount of fluid found throughout the body
Acts as a cushion and gliding surface to reduce friction
150 bursae in the body
Located near bony prominences or between bones, muscles, tendons, or ligaments
bursitis
etiology
Prolonged pressure – most common
Trauma
Repetitive motion
Autoimmune conditions – SLE, RA
Systemic inflammatory conditions – gout, pseudogout
Acute bursitis
clin man
Trauma, infection, crystalline joint disease (gout)
Pain with palpation of the bursa
ROM often ↓ due to pain
Active motion elicits pain
chronic bursitis
clin man
Inflammatory arthropathies, repetitive pressure/overuse
Minimal pain or painless – bursa has had time to expand to accommodate the increase in fluid → significant swelling
Olecranon bursitis
Pain with..
Caused by injury or repetitive pressure on the elbow; pain with flexion
Trochanteric bursitis
pain/complain
cause
Caused by injury, overuse, arthritis, or surgery;
pain with lying or sleeping on the affected side
Most common in middle-aged and older women
Prepatellar bursitis
Cause
Caused by repetitive pressure on the knees
Retrocalcaneal bursitis
Cause
Caused by uphill running or wearing tight-fitting shoes
bursitis
Dx imaging
Certain types can be diagnosed clinically
Imaging:
Plain film x-rays of the affected joint
Trauma to evaluate for possible fracture
Concern for foreign body
Ultrasound
Differentiate cellulitis from infectious bursitis
Assess the amount of fluid accumulated
Aspiration of the inflamed bursa:
Used for diagnosis and to alleviate pain
Send for cell count, Gram stain and culture, glucose, and analysis for crystals
White blood cell count < 500/mm3 is consistent with a noninfectious etiology
bursitis
Tx
Majority of cases resolve without treatment
Conservative management:
Rest, ice, compression, and elevation (RICE)
Analgesia:
NSAIDs and/or acetaminophen
Corticosteroid injections for deep bursitis
Protective padding for elbows and knees
Donut seat for ischial bursitis
Treatment of underlying autoimmune or inflammatory conditions
Systemic antibiotics with gram-positive coverage for septic bursitis
Surgical bursectomy is a treatment of last resort
A 66-year-old diabetic female presents to the ER for evaluation of a productive cough, SOB, fever, chills, and fatigue over the past two days. Today, the patient reports having a coughing episode that produced a moderate amount of bright red blood. CXR shows a right middle lobe consolidation with an associated cavitating lesion. Given this presentation, you should be most concerned for pneumonia caused by which organism?
A. Chlamydia pneumoniae
B. Human metapneumovirus
C. Community-acquired methicillin-resistant Staphylococcus aureus
D. Streptococcus pneumoniae
E. Mycobacterium tuberculosis
MRSA
