Tendon Problems Flashcards
Definition of tendinopathy?
Disease of a tendon (not all of these involve inflammation)
Definition of tendonitis?
Inflammation of a tendon
Definition of a tendonosis?
Chronic tendon injury with damage to a tendon at the cellular level
Definition of a tenosynovitis?
Inflammation of the tendon sheath
Definition of enthesopathy?
Disorder inv. the attachment or origin of a tendon into bone
Definition of enthesitis?
Inflammation of the tendon origin or insertion into bone (usually assoc. with spondyloarthropathies)
Function of tendons?
Link muscles to bones for joint motion
Shape of tendons?
Cylindrical in shape with widening/flattening at the musculotendinous junction and their bony insertions
Structure of tendons?
Hierarchial structure:
• Microfibrils make up subfibrils, which constitute fibrils
Many fibrils are within a fascicle; fascicles are separated by endotenon, which is covered by epitenon
Cells of a tendons?
Fibroblasts (predominantly) produce and maintain collagen and other proteins, which confer flexibility and tensile strength of tendons
Collagen is the primary component of tendons (mainly type I collagen)
Blood supply to tendons?
3 sources:
• Perimyseum
• Periosteal insertion of the tendon
• Paratenon
Intrinsic risk factors for tendon problems?
Age
Gender (females)
Obesity
Pre-disposing disease, e.g: RA
Anatomical factors, e.g: limb malalignment, pes cavus, hyperpronation and leg lenth discrepancy
Extrinsic risk factors for tendon problems?
Trauma, e.g: dislocations
Repetitive injury
Drugs:
• Steroids
• Antibiotics, e.g: Ciprofloxacin
Sports-related factors
Management of tendon problems?
Many are self-limiting and management is conservative:
• Rest
• Analgesics, e.g: anti-inflammatories for tendonitis
Injections:
• Rotator cuff pathology
• Tennis elbow
• Cannot be used for the achilles tendon or extensor knee mechanism (risk of rupture)
Splinting:
• Achilles tendon tears
Some may require surgical repair
Surgical methods used for tendon problems?
Debridement:
• Removal of diseased tissue
Decompression:
• Supraspinatus tendonitis & subacromial decompression
Synovectomy:
• Helps to prevent rupture
• Extensor tendons of wrist (RA)
• Tibialis posterior
Tendon transfer:
• Tibialis posterior
• Extensor pollicis longus
Muscles of the rotator cuff?
Supraspinatus (usually affected in rotator cuff pathology), infraspinatus, subscapularis and teres minor
Risk factors for rotator cuff pathology?
Intrinsic risk factors, e.g: degeneration, tendon vascularity
Extrinsic factors, e.g: morphology of the acromion and biomechanical factors, lie kinetics and performance:
• Athletes (throwing events)
• Manual workers (painters)
Symptoms and signs of rotator cuff pathology?
Aching pain (pain in the 4 tendons of the rotatory cuff)
Shoulder tenderness, around the GH and AC joints
Difficulty sleeping on the affected side, reaching overhead and lifting
Painful arc with rotator cuff weakness
+ve impingement tests, e.g: • Hawkins-Kennedy
• Scarf test
• Jobe’s test
Management of rotator cuff pathology?
Conservative (tend to be self-limiting) - rest, physiotherapy, steroids + local anaesthetic injections
Surgical - either arthroscopic OR open subacromial decompression and rotator cuff repair
Imaging of the rotator cuff?
US can show rotator cuff tears (gold standard) and a dynamic scan can detect impingement too
MRI can show rotator cuff tears
Types of biceps tendinopathy and causes?
Tendonitis, tendonosis, rupture or tenosynovitis
Causes inc. overuse, instability, impingement or trauma
Where does most inflammation of the biceps brachii occur?
Long head of the biceps, which passes through the BICIPITAL groove, located anteriorly on the proximal humerus
Inflammation here is usually friction-related
Occurrence of biceps tendinopathy?
Common in occupations where heavy lifting or overhead work is typical
Higher incidence in athletes inv. in throwing events, swimmers or gymnasts
Symptoms of biceps tendinopathy?
Anterior shoulder pain aggravated by:
• Shoulder flexion
• Forearm pronation
• Elbow flexion
Clicking/snapping sensations with shoulder movement
Ix of biceps tendinopathy?
Before Ix, do an examination
USS
Management of biceps tendinopathy?
Conservative
Surgical
Clinical signs of biceps rupture?
May rupture at the top of the bicipital groove OR at the biceps tuberosity
- POP-eye sign (proximal rupture)
- Extensive bruising (distal rupture)
Management of biceps ruptures?
Conservative (mainstay treatment) - rest and physiotherapy
Surgical - repair but there is high risk of neurovascular complications, esp. at the distal end of the tendon, stiffness or a flexor contracture
What is the most powerful supinator of the forearm?
Biceps brachii (weakness affects the screwdriver motion)
Describe lateral epicondylitis
AKA tennis elbow (which can be a repetitive strain injury); causes pain and tenderness over the lateral epicondyle, which is the origin of the forearm extensors
The pain is worse when stretching muscles, e.g: opening a jar
Clinical examination of tennis elbow?
+ve Mill’s test (pain is reproduced by resisted wrist extension, with the palm pronated whilst moving sideways in the direction of the thumb)
Pain is usually unilateral but it can be bilateral
Ix for tennis elbow?
Diagnosis is clinical but USS, MRI and nerve conduction studies (if there are nerve symptoms) can be carried out
Management of tennis elbow?
- Rest + physio
- Modify activities
- Orthotics
- Inject
- Surgical release
What is medial epicondylitis?
AKA Golfer’s elbow; inflammation of the flexor forearm muscles that causes medial elbow pain, with a tendow point over the origin of the flexors of the forearm (medial epicondyle)
Can be caused by repetitive stress at the muscle-tendon junctions, e.g: golf
Signs of medial epicondylitis?
Pain aggravated by wrist flexion and pronation and also upon grasping, e.g: opening a jar
Some cases are assoc. with ulnar neuropathy/muscle weakness
Occurrence of medial epicondylitis?
Peak incidence between 40-50 years
Ix for medial epicondylitis?
Diagnosis is clinical but USS, MRI and nerve conduction studies (if there are nerve symptoms) can be carried out
Management of medial epicondylitis?
Self-limiting conditions and the management is the same as for Tennis elbow/lateral epicondylitis
EXCEPT: avoid injection in medial epicondylitis, as the ulnar nerve may be damaged
What is DeQuervain’s tenosynovitis?
AKA Blackberry thumb, gamer’s thumb and mother’s wrist, etc
This is tenosynovitis affecting the 1st compartment, which contains APL and EPB; typically presents as a repetitive strain injury
Symptoms and signs of DeQuervain’s tenosynovitis?
Pain over the RADIAL STYLOID PROCESS at the wrist
+ve Finklestein’s test (patient makes a fist over the thumb and the hand is ulnar deviated to reproduce pain)
Occurrence of DeQuervain’s tenosynovitis?
Most common in women between 30-50 years
Assoc. with pregnancy and RA
Ix for DQ tenosynovitis?
USS
X-ray (to rule out CMC joint OA, which can mimic DQ)
Management of DQ tenosynovitis?
Conservative - splint, rest, physiotherapy and analgesics
Inject
Surgical decompression
How can RA cause extensor tendon rupture?
Autoimmune attack on the synovium causes tendon degeneration and rupture, leading to weakness of wrist extension
Signs of extensor tendon rupture?
DROP FINGER
Management of extensor tendon rupture?
Cannot repair a diseased tendon so a tendon transfer is done
Synovectomy can prevent extensor tendon rupture, e.g: if RA treatments are not prevent tendon degeneration, this can be used to prevent rupture
Causes of EPL rupture?
RA
After a Colles fracture
Signs of EPL rupture?
Drop thumb (loss of function)
Management of EPL rupture?
Tendon transfer (using EIP, i.e: extensor indicis proprius, which is one of the 2 tendons in the adjacent finger)
Pathophysiology of trigger finger?
Stenosing tenosynovitis produces a fibrocartilaginous metaplasia, leading to the formation of a nodule under the a flexor tendon
The nodule catches on the pullet, often A1, and causes triggering
Occurrence of trigger finger?
Any age (even children)
Management of trigger finger?
Tends to be self-limiting
Injection
Surgical release
Components of the extensor mechanism of the knee?
Quadriceps muscle
Quadriceps tendon
Patella
Patellar tendon
Cause of extensor knee problems?
Injury to any one of the components causes difficulty/inability to straight leg raise (SLR)
Tendonitits, rupture or traction apophysitis
Occurrence of extensor knee ruptures?
Tend to be partial or complete
More common in the middle-aged population, who play running/jumping sports
Clinical examination findings of extensor knee problems?
Palpable gap
No SLR (must always check this with an acute knee injury)
Ix for extensor knee problems?
X-rays (may show an effusion with the patella sitting in the wrong place)
USS or MRI (show a partial/complete tear)
Management of extensor knee problems?
Mostly surgical, with gradual increase in range of movement post-operatively with physiotherapy
Small partial tears of the quadriceps can be managed with immobilisation + physiotherapy
What is traction apophysitis?
E.g: Osgood-Schlatter’s disease
Inflammation of the patellar ligament as it inserts into the anterior tibial tuberosity
Occurrence of Osgood-Schlatter’s disease?
Adolescent active boys most commonly
What is Sever’s disease?
AKA calcaneal apophysitis; this is a type of traction apophysitis at the insertion of the tibialis anterior into the os calis
Scenario of an Achilles/calcaneal tendon rupture?
Common injury that occurs after a sudden force, such as a forceful push off the foot while running/jumping, etc
Occurrence of Achilles tendon rupture?
More common in patients with RA, tendonitis and steroid use
Clinical examination findings of Achilles tendon rupture?
Bruising
Palpable gap
Patient cannot tip-toe stand
+ve Simmond’s test (patient lies prone with feet hanging off the edge of the bed; on squeezing the corresponding calf, the foot should normally plantarflex - if not, Achilles tendon rupture is likely)
Ix for Achilles tendon rupture?
USS and MRI
Management of Achilles tendon rupture?
Conservative (plaster cast)
Surgical repair (rehab and early ROM are better following surgical repair and it may decrease re-rupture rate)
Pathophysiology of rupture of the tibialis posterior tendon?
Tenosynovitis causes progressive elongation of the tendon and eventual rupture
Signs of tibialis posterior tendon rupture?
Secondary flat foot
Valgus hindfoot (“too many toes” sign)
Management of tibialis posterior tendon rupture?
- NSAIDs
- Orthotics
- Injection
- Debridement
- May be helped by a tendon transfer
