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Intro to Ortho > Tendinitis > Flashcards

Tendinitis Flashcards

1
Q

Tendinitis

Inflammation of a tendon

A

Inflammation of a tendon:

Tendons are made of regularly arranged, dense collagen fibrils

They attach muscle to bone and are part of the musculotendinous unit

Tendons appear in two shapes: cord-like structures and broad, sheet-like called aponeuroses

A tendon that moves in a straight line is surrounded by a paratendon-blood vessels are coiled in the loose alveolar tissue which stretches along with the tendon

A tendon that runs across a bony prominence is surrounded by a tendon sheath-this double-layered tubular structure is filled with synovial fluid

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2
Q

Tendons

A

The dense CT of tendons has a limited blood supply originating from muscles and bones

Tendons are subject to great tensile stress

When a load is placed on a tendon, the waves of its collagen fibres straighten out

The collagen fibres then temporarily deform

Over time, a tendon can experience micro-tearing, partial tearing or complete rupture, usually at the point of most reduced blood supply

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3
Q

Causes of Tendinitis

A

Chronic overload of the tendon, leading to microtearing and an inflammatory response in the tendon

  • Contributing Factors:

Muscle imbalances, lack of flexibility, improper equipment and training errors

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4
Q

Types of Tendon Overuse Injuries

A

Tendon overuse injuries have all been termed “tendinitis”

  • Tendinitis
  • Paratendinitis:
  1. Inflammation of the paratendon or the tendon sheath where these structures are associated with a tendon, either of which may be irritated by the tendon as it rubs over a bony prominence
  2. Associated with tendon injuries
  3. Also called tenosynovitis or tenovaginitis
  4. Tenosynovitis is irritation of the inner surface of the tendon sheath by the roughened surface of the tendon
  5. Tendovaginitis is irritation and thickening of the sheath itself
  • Tendinosis:
  1. Degenerative changes occurring with chronic overuse tendon injuries, such as “tennis elbow”
  2. Aging and avascularity may be contributing factors to tissue degeneration
  3. There are no signs of inflammation in the tendon itself, but biopsies have shown
    angiofibroblastic degenerative changes occurring (invasion of organized vascular tissue and a disorganization of collagen tissue in the tendon)
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5
Q

Grades of Tendinitis

A

Grade 1-pain after activity only

Grade 2-pain at the beginning of activity which disappears during activity then returns after activity

Grade 3-pain at the beginning of activity, during activity and after activity. Pain may restrict activity

Grade 4-pain with ADL’s and pain continues to get worse

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6
Q

Common Tendinitis Locations and Causes

A
  1. Supraspinatus tendon
  2. Infraspinatus tendon
  3. Subscapularis tendon
  4. Biceps long head tendon
  5. Common extensor tendon
  6. Common flexor tendon
  7. Abductor pollicis longus and Extensor pollicis brevis tendons
  8. Patellar tendon
  9. Popliteus tendon
  10. Tibialis posterior tendon
  11. Achilles tendon
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7
Q
  1. Supraspinatus Tendon
A

To palpate:

The client is seated with their arm held behind the back and the elbow in flexion

The humerus is maximally internally rotated and maximally extended, bringing the humeral attachment of supraspinatus out from under the acromion

The tendon is palpated immediately inferior to the AC joint

The therapist palpates through deltoid in the indentation between the anterior and middle fibres

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8
Q
  1. Infraspinatus Tendon
A

To palpate: (infraspinatus and teres minor)

The client is seated or prone with the humerus flexed to 90 degrees, adducted 10 degrees and externally rotated 20 degrees

This position brings the tendon out from under the acromion

The tendon is palpated immediately inferior to the AC joint and the lateral portion of the spine of the scapula

The therapist palpates the tendon through the posterior fibres of the deltoid muscle

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9
Q
  1. Subscapularis Tendon
A

To palpate:

The client is seated with the humerus at their side and the elbow flexed to 90 degrees

The tendon is palpated inferior to the clavicle, lateral to the coracoid process (medial to anterior deltoid)

The tendon is palpated deep in the deltopectoral triangle, between the tendons of the long and short heads of biceps

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10
Q
  1. Rotator Cuff Tendons
A

Supraspinatus, infraspinatus, teres minor and subscapularis are prone to tendonitis with sports such as swimming, tennis, golf or any throwing sport

Occupations or activities that stress the shoulder muscles with the arms in an overhead position, such as drywall installation or assembly line work

Pain is usually experienced when the arm is in more than 90 degrees of abduction

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11
Q
  1. Biceps Long Head Tendon
A

To palpate:

The client is seated with the humerus internally rotated 20 degrees or to a “hands on lap” position

The tendon is palpated inferior to the clavicle, lateral to the coracoid process in the same areas as the subscapularis tendon

Swimming and throwing sports where the arm is adducted, compressing the tendon can cause bicep tendinitis

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12
Q
  1. Common Extensor Tendon
A

To palpate:

The client is seated with the elbow in slight flexion

The tendon is located distal to the lateral epicondyle

It may extend over top of the radial head which can be located by the client pronating and supinating the hand while the therapist palpates for the moving head

Repetitive forceful extension, supination and radial deviation are the movements lost likely to provoke extensor tendinosis

Wheelchair athletes and meat cutters are also susceptible

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13
Q
  1. Common Flexor Tendon
A

To palpate:

The client is seated with the elbow in flexion and the wrist supinated

The tendon is located distal to the medial epicondyle

Repetitive activity such as hammering or using a screwdriver may cause injury to the CFT

Sports involving wrist flexion and pronation such as golfing and overhead serving in tennis are other causes

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14
Q
  1. Abductor Pollicis Longus & Extensor Pollicis Brevis Tendons
A

To palpate:

The sheaths of these two muscles is palpated at the radial side of the wrist

Activities requiring repetitive thumb use, repetitive radial and ulnar deviation and forceful gripping cause De Quervain’s tenosynovitis

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15
Q
  1. Patellar Tendon
A

To palpate:

Palpated immediately inferior to the patella

Pain is localized to the tendon

Activities include running or jumping such as track and field are causes

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16
Q
  1. Popliteus Tendon
A

To palpate:

Palpated just inferior to the lateral femoral condyle, directly posterior to the lateral collateral ligament and biceps femoris tendon

It is palpated through the lateral gastrocnemius muscle

Activities such as downhill running or downhill walking combined with foot pronation cause this tendinitis

Can be confused with ITB friction syndrome

17
Q
  1. Tibialis Posterior Tendon
A

To palpate:

The foot is placed in plantarflexion

The tendon in its sheath is palpated just posterior and inferior to the medial malleolus

Pain runs along the medial border of the tibia and along the course of the tendon

Activities such as running, using step machines or doing step aerobics combined with excessive pronation can cause this tendinitis

18
Q
  1. Achilles Tendon
A

To palpate:

The tendon lies between the gastrocnemius-soleus complex and the calcaneus

Pain is felt along the tendon

Activities such as running combined with pronation, poor footwear or tight gastrocnemius-soleus muscles cause this condition

19
Q

Medical Treatment of Tendinitis & Tendon Tears

A

For acute tendinitis, inflammation is controlled through rest, ice and NSAIDs

Stretching, strengthening and a gradual return to activity are recommended

Surgical repair is necessary with a total tendon rupture

20
Q

Other Tendon Pathologies

A

Rotator cuff tendons may suffer:

  1. Impingement syndrome
  2. Partial or complete tears
  3. Calcific tendinitis
  4. Trigger Finger
21
Q
  1. Impingement Syndrome
A

Inflammation, pain and edema in the tissues within the coracoacromial arch and between the acromioclavicular and glenohumeral joints

Painful compression of the tendons, especially supraspinatus, may occur when the humerus is abducted against the acromion

The biceps tendon and the subacromial bursa may be affected as well

Stage 1-edema and hemorrhage of the subacromial bursa

Stage 2-tendinitis and fibrosis are present. Both stages are reversible with conservative care such as rest, stretching and progressive strengthening

Stage 3-incomplete tears or complete tendinous rupture occurs. There may be associated bony changes in the acromion and the AC joint. Surgery is usually indicated

22
Q
  1. Rotator Cuff Tears
A

Overuse, impingement and normal aging can lead to painful tearing of the rotator cuff tendons

Tears may be partial or full thickness with supraspinatus the most frequently injured

Medically, tears are treated by open rotator cuff repair surgery in which the rotator cuff is exposed

23
Q
  1. Calcific Tendinitis
A

A late-occurring stage of rotator cuff tendinitis, usually developing in the supraspinatus tendon

Supraspinatus functions to hold the head of the humerus in place and this constant pressure of the head of the humerus seems to “wring out” the blood supply to the poorly supplied tendon

The tendon’s fibrocytes change to chondrocytes, collagen disintegrates and calcific deposits accumulate in the cells

Over time, these deposits are set free into the intercellular spaces
The deposits can be soft, toothpaste-like material or hard and chalky

24
Q
  1. Trigger Finger
A

Through overuse, flexor tendons of any finger may develop a thickened, nodular swelling

This swelling is unable to move through the tendon sheath and gets caught

The finger is stuck in flexion until it is passively extended by an external force

Rest, NSAIDs and stretching are the usual treatments

25
Q

Symptom Picture

A

By nature, tendinitis is a chronic condition with an initial acute inflammatory stage

  1. Acute:
  • Gradual onset with tenderness local to the tendon, one or two days after activity
  • Initially, pain diminishes with renewed activity which progresses to pain during activity as the severity increases
  • Microtearing occurs with adhesion formation as the tendon attempts to heal
  • Repetitive use tears these new adhesions, causing more inflammation and a cycle of reinjury
  • Inflammation, heat and swelling develop along the tendon or tendon sheath
  • Crepitus may develop with tenosynovitis and paratendinitis
  • Decreased ROM of the affected muscle
  1. Chronic:
  • Pain occurs during and after activity
  • Chronic inflammation, fibrosis and adhesions are present
  • Chronic swelling or thickening may be observed if the tendon is superficial enough, as with the Achilles tendon
  • Crepitus may be present
  • Decreased ROM and decreased strength
  • Flare-ups to the acute stage may occur with repeated overuse
  • Tendon may degenerate to such a degree that tendon rupture occurs
26
Q

Health History Questions

A

What activities or movements cause pain?

Where is the pain located?

What are your current symptoms? How long have these symptoms been present?

What is the client’s recreational or occupational posture?

Have you begun a new activity or increased duration or speed of a previous activity?

Was there a previous injury to the affected limb?

Has the condition been diagnosed by a physician?

What parallel therapies are you taking?

Are supports or braces being used during activities?

Are you taking any meds?

27
Q

Observations

A
  1. Acute:
  • Antalgic posture or antalgic gait may be present
  • Swelling and redness may be noticeable if the tendon is superficial
  1. Chronic;
  • A postural assessment may be performed to determine sources of muscle imbalance
  • Thickening of the tendon may be observed
  • Muscle wasting and disuse atrophy occur with complete tendon tears
28
Q

Palpation

A
  1. Acute:
  • Point tenderness occurs over the tendon
  • Heat and swelling may be palpated at the tendon
  • HT and TPs are present in the affected muscle and its antagonists
  1. Chronic:
  • Pain occurs over or near the tendon
  • Swelling adhesions are present. The tendon may feel granular or hard at the adhesion site
  • HT and TPs occur as in the acute stage
  • Crepitus may be palpated on movement of the tendon in its sheath
  • A snapping sensation may be felt due to tight tendons that snap over bony prominences or bursae
29
Q

Testing

A

Acute & Chronic:

AF ROM of the affected limb is usually painless

PR ROM may reveal pain on actions that fully stretch the affected tendon

AR isometric testing is painful on contraction of the muscle of the affected tendon, especially if the muscle is contracted in a stretched position. Pain is local to the tendon and increases with the force of the contraction. The therapist may have to move the muscle through its range, testing isometrically in different positions to provoke a positive test. If this fails, the client puts the limb in the position that causes pain and isometric resistance is applied in this position

30
Q

Treatment
Acute

A

Positioning depends on the location of the tendinitis and the client’s comfort

Hydrotherapy is cold

Reduce edema on the affected limb

Reduce HT and TPs in the proximal and antagonists muscles

Reduce HT in the affected muscle with GTO on the unaffected tendon

Distally, muscle squeezing and stroking are used

Maintain ROM with passive relaxed ROM on the proximal and affected joints

Mobilize hypomobile joints

31
Q

Treatment
Chronic

A

Positioning is chosen for comfort and for accessibility of the structures that are treated

Hydrotherapy proximal to the tendinitis and on the lesion site itself include deep moist heat to soften adhesions and to increase local circulation

Contrast hydrotherapy is useful to flush out edema

Reduce fascial restrictions and any chronic edema

Reduce HT and TPs in the proximal limb and antagonists and the affected muscle is treated working towards the lesion

Reduce adhesions that may have formed in the tendon and between. Fascial techniques and muscle stripping are used over the lesion site to break down as many adhesions as possible before frictions are used. After frictions are applied, stretch and ice

Mobilize hypomobile joints in the affected limb

Restore ROM with PR ROM

Stretch shortened muscles with passive stretches

32
Q

Self-care: Acute

A
  1. Acute:

Educate the client regarding relative rest with activities that cause the tendinitis

Hydrotherapy of ice immediately after activity

Stretch shortened muscles with slow, pain-free stretches

Strengthen weakened muscles with progressive strengthening that is pain-free, submaximal isometric exercises

  1. Chronic:

Educate the client regarding relative rest with activities that cause the tendinitis

Hydrotherapy of contrast bath is used

Self massage may be used on the antagonists and affected muscles

Stretch shortened muscles, progressing from isometric to isotonic exercise

Eccentric exercises can be effective for a strengthening effect on the tenon

Intro to Ortho (6 decks)

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