Regional Peri-Articular Pain Flashcards
What is enthesopathy and how does it present?
It is inflammation of the tendinous insertions on to bone.
It presents as pain an stiffness around the joint but not in it. Typically it can present in:
- Heel
- Knee
- Hip
- Elbow
- Toes and fingers
- Sole of the foot
It can be caused by overuse injuries but can often be associated with inflammatory arthritidies:
- Psoriatic
- Rheumatoid
- Ankylosing spondylitis
How are enthesopathies managed?
Treatment is with NSAIDs and treating any underlying inflammatory arthritis.
What is tendinitis and tenosynovitis?
Tendinitis is inflammation of the tendon.
Tenosynovitis is inflammation of the surrounding synovial sheath.
What are the common causes of tendinitis and tenosynovitis?
Overuse conditions often occupational (typing, dentists, surgeons, tailors)
Can be sporting related or gaming (de quervain’s affecting the thumb)
How is tendinitis/tenosynovitis managed?
If it exacerbated by a paticular activity: rest it!
NSAIDs for analgesia.
What is bursitis and what are the areas which can be affected?
A bursa is a small sac of fibrous tissue with a thin synovial lining that is filled with fluid. They are found around joints to reduce friction.
When they become inflamed it is known as bursitis it can be caused by trauma, recurrent minor trauma (housemaids knee) or in infection.
Common areas which it can affect:
- Subacromial (shoulder)
- Trochanteric
- Prepatellar (housemaids)
- Olecranon
- Achilles
- Subcalcaneal
Describe how bursitis is treated?
Non infected:
- Avoid aggravating activities.
- Ice.
- Physiotherapy particularly if there is a reduced range of movement.
- OTC analgesia.
- Can use steroid injections
Infected:
- As above
- Aspirate fluid for culture and cytology
- Antibiotic therapy
- If not improving with abx within 36-48hrs incision and drainage is indicated.
Rarely in recurrent refractive bursitis surgical bursectomy can be performed.
What is medial epicondylitis?
Also known as Golfer’s elbow
It is a tendinopathy of the common flexor tendon which inserts at the medial epicondyle.
It is caused by recurrent microtrauma due to overuse.
Can get shooting pains, paraesthesiae and weakness due to ulnar nn entrapment.
What are the specific examination findings in a patient with medial epincindylitis?
Tenderness over the medial epicondyle.
Increased pain on resisted: wrist flexion or elbow pronation.
What is lateral epicondylitis?
Also known as tennis elbow.
It is a tendiopathy of the common extensor tendon which inserts next to the lateral epicondyle.
It is caused by microtrauma due to overuse.
What are the specific examination findings in lateral epicondylitis?
Tenderness over the lateral epicondyle.
Increased pain on resisted wrist extension/ finger extension
Describe how both medial and lateral epicondylitis are managed?
- Analgesia and rest
- Physiotherapy
- Steroid/anaesthetic injection
- Surgery*
*Tennis/golfer’s elbow release involves excision of the abnormal tissue from the extensor tendon (tennis elbow) or flexor tendon (golfer’s elbow). Only indicated in failed conservative management.
Name the rotator cuff muscles and there functions?
Supraspinatus (shoulder abduction)
Infraspinatus and teres minor (external rotators)
Subscapularis (internal rotator and humeral head depressor)
What are the main causes of rotator cuff tears?
Acute: younger patients likely traumatic high impact injury (Jenkins in rugby)
Chronic: older patients: degenerative disease due to repetive microtrauma common in manual labourers.
Acute on chronic: may have a degree of degeneration followed by an acute traumatic injury causing a tear.
Describe how rotator cuff tears present?
Acute: traumatic event shoulder is painful and there is weakness in one or more of the rotator cuffs.
Chronic: gradual onset of pain, weakness and a marked reduction in function most commonly being able to lift arms above head. (Supraspinatus is most commonly affected)
Pain is usually felt anterioirly and superiorly with no radiation down the arm.
What are some of the differentials or a rotator cuff tear?
Supraspinatus tendonitis: on testing supraspinatus there will be good power but it will be painful
Supraspinatus impingement: impingement of the supraspiantus tendon as it passes through the subacromial space (can lead to a degenerative chronic rotator cuff tear).
OA/RA:
- Will see global wasting and reduced ROM, there may be weakness due to the pain.
- Differentaiting features are reduced ROM in the arc actively and passively, features such as earl morning stiffness.
Describe the management of rotator cuff tears?
Conservative:
- Simple analgesia.
- Avoid imobilisation as can get frozen shoulder.
- Steroid injections can be used to reduce pain.
- Physiotherapy
- Much more likely to work in patients with tendon fibrosis or tendonitis.
Surgical:
- Indicated in patients with significant pain or functional restriction
- Only for patients with an imaging confirmed full thickness tear.
- Usually arthroscopic repair.
Describe the different stages of tendon degenration?
Stage 1 - Tendon oedema
Stage 2 - Fibrosis and tendinitis
Stage 3 - Partial and full thickness tears
What is plantar fascitis?
It is a condition in which there is pain on the sole of the foot/heel, it is often worsed after the 1st few steps after a prolonged rest.
It is caused by microtears in the plantar fascia due to overuse and is therefore common in runners
How is plantar fascitis managed?
- Resting of the foot as much as possible.
- Loss of weight if obese.
- Analgesia.
- If a runner reccommend running on softer surfaces.
- Specifc stretching exercises.
- Deep sole massage (can be done by rolling foot on a hard cylindrical object.
