Tendinopathy Flashcards
tendinopathy
- tendon entrapment and stenosis, inflammatory conditions or noninflammatory process
- most likely idiopathic
- contributing factors - include trauma, reptitive activity - systemic conditions such as diabetes
- most patients have success with non surgical treatment
extensor tendinopathies
usually noninflammatory - conflict of the thickening tendon to the pulley or other anatomical structures - restriction of its normal gliding - proliferation of the tightened structures - ongoing damage of the tendon
relationship between special work and tendinopathy could not be established in literature
risks:
- jobs with repetitive activity
- high grip strength
- age over 40
- body mass index over 30
- history of CTS
- complaints of shoulder and neck discomfort
- jobs with a higher shoulder posture rating
most common in extensors are the Quervain’s tendinopathy followed by the tendinopathy of the 6th compartement
de Quervain’s tendinopathy
risk factors:
- period around pregnancy
- repetitive ulnar and radial deviation of the wrist
- nursing and carrying children under 2y
- greater 40y
- female sex
- black rade
- APL has normally 2 - 3 slips - one inserted on the base on the thumb the other into the trapezium
- EPL - usually have a single slip to the proximal phalanx of the thumb - maybe an additional slip to the EPL
- 35-45% have a subcompartment for the EPB
- gold standard is the Finkelstein test
- test for seperated EPB compartment is extension of the MCP joint against resistance - palmary abduction is less painful
- often there is a CMC arthritis or previous distal radius fracture
- ultrasound should be used
- radiographs or MRI usually not necessary only with special circumstances
treatment:
splinting, hand therapy, NSAIDs, activity modification and corticosteroid injections
injections have good success - splinting for 4-6 weeks with the first injection - 2. injection after 2-3 month - if there are still symptoms than surgical release
tourniquet or WALANT
Intersections syndrome
tenosynovitis of the 2. compartement - ECRL and ECRB - tendons of the 1. compartment crosses the 2. about 7cm proximal to run through the radial thumb
patiens have pain, swelling and sometimes grinding or squeaking sensation localized to the area
atheltic population - rowers
treatment:
as Quervain - injection with a splint in extension of 15° for 4-6 weeks - second injection in 2-3 month - than maybe surgery - direct release over the 2. compartment at the radius
- compartment tenosynovitis
extremely rare - except in special situations such as RA or non-displaced radius fractures - dorsal hardware or dorsal bony spurs from osteoarthritis
common are drummes from repetitve activities - in comparison to other tendons high risk of ruptur because of the tight tunnel and tight turn around the Lister tubercle
radiograph very helpful to see bone changes
treatment
high risk of rupture - so no conservative treatment is achieved
release of the tendon and subcutaneous transposition - in case of rupture - EI-transfer - local anaesthetic or WALANT
- compartment tenosynovitis
extremely rare in idiopathic setting - most common with RA or other inflammatory arthropathies
symptoms with active and digital and wrist motion - swelling over the compartment - tendon irritation maybe with dorsal wrist ganglion - swelling can be caught by the retinaculum extensorum - the so called “tuck sign”
EIP syndrome - distal muscle belly of the EIP gets trapped within the extensor retinaculum causes pain and triggering when active extend the index finger
treatment:
conservative not so successful as other compartments - but first try
surgery - step cut or z-plasty approach to the retinaculum
- compartment tenosynovitis
rare - localized sweling of the fifth compartment associated with active small finger extension
EDM tenosynovitis often associated with DRUG synovitis in RA patients radiographs are obtained
treatment
conservative is possible - if the tendon is ruptured a tendon transfer is performed
- compartment tenosynovitis
volar aspect of the tendon sheath is part of the TFCC for stabilization of the DRUG
ECU pathology with 2 main categories
tenosynovitis and instability
ECU subluxation
trauma (racquet sports), patients can be born with asymptomatic subluxation
tenosynovitis is often not identibiable, repetitive overuse
ECU subluxation is caused by loss of integrity of the subsheath - fraying (ausfransen), longitudinal tearing and tenosynovitis lead to subluxation
tenosynovitis shows pain and swelling - exacerbated by gripping, twisting, resisted forearm rotation and heavy lifting - painful snipping with supination
ECU synergy test
thumb abducted against resistance with counterpressure of the examiner against on the long finger - holding thumb and longfinger - than abduction of the thumb - leads to tension on FCU and ECU - reproduction of the test shows a ECU tenosynovitis
initial workup:
plain radiographs: ulnar-side wrist pain, DRUJ arthritis, ulnar positive variance and ulnocarpal impaction - fracture or dislocations
MRI could be helpful - dynamic ultrasound
treatment:
conservative with injections an splinting, surgery after 2 injections
surgery:
if there is subluxation - flap of the retinaculum can be used or - special refixation of the widened subsheath with bone anchors -
flexor tendinopathies
mostly the trigger finger of the long fingers - prevalence is about 3% with 20% of underlying comorbid medical condition such as diabetes
most common middle-aged femalis with the thumb and ringfinger of the dominant hand
maybe following is presented
- CTS
- de Quervain
- Dupuytren
- amyloidosis
- mucopolysaccharidosis
- RA
- sarcoidosis
exact cause is unclear - potential cause with repetitive power gripping lead to inflammation of the FDS and FDP tendon as they traverse the A1-Pulley - maybe the A1-pulley enlarges 3times of normal through inflammation - proliferation maybe occurs - intratendinous nodule may develop in tendon because of mechanical mismatch for smooth gliding within a stenotic sheath during digit flexion - myofibroblasts are seen in the A1-Pulley with contraction of the pulley
cave:
maybe associated with Dupuytren disease and trigger finger - HLA-B21 locus associated with “fibrotic pahtology”
Trigger finger subtypes:
WET:
- PIP-contracture
- very painful
- positive FDS test (limited FDS motion)
- tenosynovialitis
- surgery: FDS slip resection - A1-pulley and tenosynovectomy - maybe a greater approach
DRY:
- locking of finger
- no tenosynovitis
- not so painful
- surgery: only A1-Pulley
classfication of green
grade 1 - pre-triggering
grade 2 - triggering that actively can be reduced
grade 3 - triggering that passively can be reduced
grade 4 - fixed flexed position and contracture - not reduction possible
other reasons for triggering:
- palmar aponeurosis - contracture - M. Dupuytren
- partial FDS laceration which “flaps” back
- foreign bodies in tendon sheath
- no A1-Pulley release in RA - ulnar deviation gets worse
- psoriatic patients often have tenosynovitis
treatment
nonsurgical treatment
NSAIDs, hand therapy, splinting corticosteroids injections - splinting - different concepts with nighttime splinting or full time use for 3-12 weeks - 13% recurrence - injections have been described successful for 60 to 90%
complications:
skin depigmentation, skin thinning, fat necrosis, tendon weakening to rupture, elevated glucose level
not more than two injections - than surgery
surgery:
can be done open or percutaneous (than in hyperextension of MCP Joint for bringing the NV-Bundle more radially and ulnarly - open is the gold standard
paediatric trigger finger - resection of a little FDS slip - studies have shown that full release of the A1 pulley and 50% of the A2 pulley leads to normal function
FCR tendinitis
is uncommon - repetitive overuse or acute stretching - inserted on the base of the 2. metacarpal primary and trapezial tuberosity and the 3. metacarpal secondary - narrow fibro-osseus tunnel adjacent to the trapezium - with osteoarthritis of the CMD or the STT joints it is possible to compromise the tendon in this area
high rate of FCR tendinits with trapeziectomy and APL suspension
rupture is possible and improves symptoms, good diagnosis is performed with:
ganglions
scaphoid fractures
trapezial fractures
CMC arthritis
STT arthritis
treatment
nonsurgical - splinting with NSAIDs for 4-6 weeks - maybe than corticosteroid injections - if this fail than surgery - decompression of the osteo-fibrous canal as well as the causing pathology - good results with 90% in literature
compications:
damage to the palmar cutaneous branch of the median nerve and the superficial radial nerve
FCU tendinitis
uncommon cause of ulnar writs pain - repetitive overuse or acute stretching - calcification!!! - often seen in athletics seen with clubs or raquets - inserted to the pisiform, hamate and the 5. metacarpal
pain with resisted wrist flexion and ulnar deviation
DD: pisiform fracture, pisotriqutral arthritis and TFCC tears volary
maybe special is the calcification of the FCU - initial presentation with dramatic and extreme tenderness, loss of motion, swelling and erythema - radiographs show the calcium deposition around the FCU tendon in an oblique plane
treatment
period of splinting for 4-6 weeks with NSAIDs - than corticosteroid injections, calcification normally self-limiting, very rare with surgery - maybe with calcification - punctum maximum 3cm proximal to the pisiform - with a pisitriquetral arthritis maybe a pisectomy should be performed
congenital trigger thumb
child with thumb locked in flexion -
- congenital clasped thumb
- absent or aberrant extensor tendons
- arthrogryposis
- spasticity
often seen a nodular thickening in the tendon “Notta’s node” after the individual who was described in 1850 - no specific association with congenital anomalies - normally there is a thickening of the FPL Tendon an the A1-pulley
age of presentation mostly 18-24 month
20 - 33% bilateral
30-40% resolve - may take years
surgical release is safe and effective (wait until age 6month - if possible wait until age is 3y or painful)
mostly wait - most of the children resolve 70% after 7y and 90% after 9y
congenital trigger digit
mostly rare and have similar condition to the trigger thumb - release of the A1-Pulley alone is not satisfactory - always resect slip of the FDS Tendon to give more space to the tendons
use an extensile approach - maybe occur with storage syndromes such as Hurler’s syndrome which can aquire trigger digits and CTS from mucopolysaccharides around the tendons in the carpal canal
