Orthopedic tx 400 -- Fracture. Tendinitis Flashcards
fx causes
Direct Violence - Fracture occurs at the site of trauma and sudden force.
Indirect Violence - Fracture occurs proximal to applied force, torque or twist.
Muscular Contraction - Sudden, violent.
Overuse - Repeated wear causing cracks.
Pathologies - Osteoporosis, tumor, local infection, cyst..
Symptomatic Picture
Unnatural mobility, deformity at the site.
Shock, P, Bleeding, inflammation, Edema.
Local erythema, bruising, MM spasms and splinting.
Loss of function, fatigue, weakness.
(SHARP)
complicated fracture
Complicated fracture – structures surrounding the fracture are injured. There may be damage to the veins, arteries or nerves, and there may also be injury to the lining of the bone (the periosteum).
E.g.
lungs
(Complicated: Broken bone has injured an internal organ.)
Dupuytren’s fx
Dupuytren’s- Similar/Same as Pott’s? Talus pushed superiorly.
complications of fx
May develop early or late
Possible increase in P levels, edema, bruising, paresthesia, heat local to the fracture etc.
early complications fx
Early – torn MM, Tendons, Ligament damage, compartment syndrome, NV injury, Vascular injury, Joint hemarthrosis, infections, DVT, ill fitting casting.
late complications
Late – Delayed/non/mal union, myositis ossificans, NV compression or entrapment, bone necrosis, Volkmann’s ischemic contracture, joint stiffness, disuse atrophy.
During immobilization
Local and possible distal P
Tissue repair and bony callus formation occur
Adhesions develop around the injury
<Circulation, edema, atrophy, contractures
<Cartilage health
HT and TP’s in compensatory
Complications can occur: Compartment syndrome, periferal nerve compression, infection, plaster sores, non-union.
After immobilization
Site is remodeling
<tissue health under casting: fragile, <tone
Adhesions have matured, contractures may be present
Initial P and stiffness may be present, loss of proprioception, scarring if open fracture
HT, TP’s, MM weakness and disuse atrophy
Occasionally a pocket of chronic inflammation can remain locally
Long term complications may occur.
note terms
—> (ALL ARE RSI/OVERUSE —> TENDINOPATHY (general category encompassing various types))
tendinitis
tendinopathy (term we will be concerned with – general term encompassing various types)
tendinosis (term that pathology class is concerned with)
calcific tendinitis (only consider as a possibility that you warn pt about)
tenosynovitis (paratendinitis)
with tendinitis (tendinopathy) — is there an acute or subacute stage?
there is no acute phase, no subacute phase — ALL considered CHRONIC
heat and tendinitis
heat makes it feel better
E.g.
—> Hot shower
4 stages / types of tendinitis
1) only discomfort after activity
2) discomfort before, that fades during activity, and returns after activity
3) discomfort before, during, and after activity
4) discomfort in general during ADLs (not just the specific activity/sport)
impingemnet syndrome
Impingement Syndrome is inflammation, pain, and edema in the tissues within the coracoacromail arch and between the acromiaoclavicular and glenohumeral joints. Painful compression of the tendons, especially supraspinatus. There are three progressive stages of impingement:
Stage 1 – there is edema and hemorrhage of the subacromial bursa. (reversible)
Stage 2 – tendinitis and fibrosis are present. (reversible)
Stage 3 – incomplete tears or complete rupture occurs. (surgery indicated)
Repetitive Strain Injury (RSI):
Repetitive movements and poor posture lead to mm fatigue and damage to the mm, tendons, and nerves of the shoulders, neck, and arms. Pain, numbness, and weakness are experienced. Tendonitis, tenosynovitis, trigger points, myalgia, and nerve entrapments – including TOS and carpal tunnel syndrome – are some of the diagnosed conditions.
Calcific Tendonitis/Tendonopathy
is a late-occurring stage of rotator cuff tendonitis, usually developing in the supraspinatus tendon. Pressure on the tendon causes the fibrocytes to change to chondrocytes, collagen disintegrates and calcific deposits accumulate within the cells
Tendonitis: Symptomatic Picture
Acute: Gradual onset, with local tenderness one or two days after activity. Initially pain diminishes with renewed activity. It progresses to pain during activity as severity increases Inflammation, heat, and swelling present. Crepitus may develop with tenosynovitis and paratendonitis. There is decreased ROM of the affected mm.
Chronic: Pain during and after activity. Chronic inflammation, fibrosis, and adhesions are present. Chronic thickening may be observable if the tendon is superficial (achilles tendon). Crepitus may be present, decreased ROM and strength. Flare-ups to the acute stage may occur with repeated overuse. The tendon can rupture if allowed to degenerate.
History q
What activities or movements cause the pain?
How much is required to produce symptoms?
Where is the pain?
Present symptoms? How long?
First time?
New activities?
Previous injuries?
Observations
Acute: Antalgic posture/gait. Swelling and redness.
Chronic: MM imbalance. Thickening of the tendon. MM wasting and disuse atrophy occur with complete tears.
Palpation
Acute: Point tenderness, heat, swelling, HT, TP’s.
Chronic: Local pain, swelling, adhesions, granular feeling tendon or hard at the adhesion site. HT, TP’s, crepitus, a snapping sensation may be felt due to tight tendons that snap over a bony prominence or bursa.
Testing
AROM is usually painless.
PROM may reveal pain with full stretch.
RROM/Isometric testing is painful, especially when applied in a fully lengthened position. The pain increases with the force of contraction. You may have to test isometrically in different positions. If this fails, the client puts the limb in the position that causes pain and isometric resistance is applied. Weakness may be present. This is called the tendonitis differentiation test.
(P with palp, stretch, and RROM with no initial trauma…)
Tendonitis Treatment
Acute: Reduce inflammation with cold hydro. Reduce edema with MLD, nodal pumping. Reduce HT and TP’s(prox). Maintain ROM with PROM. Mobilize hypomobile joints. Modify symptomatic movements or volume if possible.
Chronic: Deep moist heat to soften adhesions and increase circulation (short duration). Reduce restrictions and edema with MFR and contrast hydro. Decrease HT and TP’s. To reduce adhesions skin rolling and separations are used generously before Frictions are applied. Isometrics or carefully dosed loading.
Homecare
Pt education is key! Discussions about pain vs progress, tendon response timing, and loading options to self manage
Symptomatic control:
1) Hydro: contrasts with chronic, ice with acute flare ups.
2) Stretch shortened MM.
3) Alter activities to put less strain on affected MM.
4) Self massage!!!! (separations, skin rolling)
Long term:
Increase capacity of tendon with loading
Modify loads for controlled rehab
Optimize movement patterns without introducing fear avoidance
BURSITIS
Bursitis is inflammation of a bursa.
bursa
A bursa is a small, flat sac lined with synovium. The word bursa means “purse”. A bursa reduces friction, usually between tendons and bones. Since it is flat, a bursa is not palpable unless inflamed.
bursa can…
A bursa can regrow in 6-24 months if surgically removed
bursitis is via
Bursitis is caused from overuse of structures surrounding the bursa, leading to excessive friction and inflammation of the bursal walls.
It is usually secondary to other conditions such as tendonitis.
bursitis contributing factors
Contributing factors include mm imbalance, poor biomechanics, & postural dysfunction such as scoliosis, other (?)
less common causes & risk factors for bursitis
Less common causes include
acute trauma,
infection,
osteoarthritis,
gout,
rheumatoid arthritis.
Common bursitis locations
Subscapular
Subacromial Aka Subdeltoid
Olecranon
Trochanteric
Iliopectineal
Ischial aka “bench warmers bursitis”
Pes anserine
Infrapatellar
Prepatellar
Retrocalcaneal
Subcutaneous calcaneal
Subscapular bursitis
lies between the scapula and subscapularis mm. It is not easily palpated.
subacromial bursa
lies between the acromion and supraspinatus tendon with a portion between the deltoid mm and humerus.
olecranon bursa
lies between the olecranon and the subcutaneous fascia (superficial) and is quite swollen and obvious when inflamed. It is irritated by repetitive weight bearing or trauma such as dragging the elbow across a surface.
Trochanteric bursa
There are two main bursa:
One lies between the gluteus maximus tendon and the trochanter,
the other between the gluteus medius tendon and the trochanter.
Pain is local to the lateral hip. The patient will not be able to sleep on that side.
Pain is worse on climbing stairs and getting out of a car.
Iliopectineal bursa
lies between the iliopsoas mm and the iliofemoral ligament.
Ischial Bursa
(“bench warmers bursitis”)
lies between glut max and the ischial tuberosity. It is palpated through glut max.
Pain is localized over the ischial tuberosity.
There may be referred pain down the posterior leg, and can appear like sciatic pain.
Pain can be alleviated when pressing the brake when driving the ischial tuberosity is rotated away from the seat.
pes anserine bursa
between the tendons of sartorius, gracilis, and semitendonosis, and the medial tibia.
Infrapatellar bursa
lies between the patellar ligament and the tibia.
Prepatellar
between the distal half of the patella, the patellar ligament, and the skin. It is easily palpated when inflamed. Pain is local.
up to how many bursae in knee
There are up to 11 bursae at the knee
Retrocalcaneal bursa
lies between the achilles tendon and the calcaneus. The bursa is palpated on either side of the tendon. Local pain when inflamed.
subcutaneous calcneal bursa
between the subcutaneous facia and achilles tendon (superficial)
Other similar (?) injuries
..
Baker’s cyst
is a synovial cyst that usually appears at the lateral side of the popliteal space. Can appear in children and adults. They tend to spontaneously resolve. With surgical removal, they usually reoccur within seven months.
Bunion
occurs at the first metatarsophalangeal joint capsule. Formed by excessive bone growth (exostosis), a callus, and inflamed thickened bursa developing over the joint.
