Tendon Problems Flashcards
what can cause a rotator cuff pathology
extrinsic compression
intrinsic degeneration
inflammation of subacromial bursa
what are the clinical findings in a rotator cuff pathology?
achy pain down the arm
difficulty sleeping on affected side, reaching overhead etc
painful arc +/- weakness
tenderness over shoulder around glenohumeral joint and AC joint
positive impingement tests (Hawkins-Kennedy, Jobes and scarf tests)
how is rotator cuff pathology managed?
conservative - physio, injections
surgical - subacromial decompression
what is the gold standard imaging for rotator cuff pathology?
US
MRI and arthroscopy also used
what causes biceps tendinopathy?
tendinosis leads to inflammation overuse instability impingement trauma
what are the possible types of biceps tendinopathy?
tendonitis
tendonosis
rupture
tenosynovitis
what are the symptoms of biceps tendinopathy?
pain in the anterior shoulder radiating to the elbow
- aggravated by shoulder flexion, forearm pronation and elbow flexion
- snapping sensation with shoulder movements if subluxation
which head of the biceps is most commonly affected by tendinopathy?
long head where it passes through the bicipital groove on the anterior proximal humerus - where most inflammation/friction occurs
how is biceps tendinopathy diagnosed?
clinical exam
US
how is biceps tendinopathy managed?
conservative or surgical
what is the clinical sign of biceps rupture?
popeye sign
bulge at opposite end of muscle
how biceps rupture managed?
mainstay = conservative with rest and physio
surgical repair if conservative doesn’t work but carries high risk
what is lateral epicondylitis?
“tennis elbow”
eccentric overload at common extensor tendon origin due to overuse causing tendinosis and inflammation at ECRB origin
what is the pathophysiology of tennis elbow?
peritendinous inflammation > angiofibroblastic hyperplasia > breakdown/fibrosis
what are the clinical features of tennis elbow?
commonly in dominant arm
pain and tenderness over lateral epicondyle (worse when stretching muscles)
pain with resisted extension of middle finger
how is tennis elbow managed?
self limiting - rest, physio, steroid injections
surgical release and debridement of ERCB origin
how is tennis elbow diagnosed?
mainly clinical - mills sign positive
US and MRI can be needed
what is medial epicondylitis?
“golfers elbow”
inflammation of the flexor forearm muscles
repetitive stress leads to peritendinous inflammation > angiofibroblastic hyperplasia > breakdown/fibrosis
at origin of wrist flexors at medial epicondyle
what are the features of golfers elbow?
medial elbow pain - tender point over origin of the flexors
- aggravated by wrist flexion and pronation and using muscles (opening a jar)
can have associated ulnar neuropathy/weakness
how is golfers elbow managed?
conservative - rest, physio, modification of activities
avoid injections - ulnar nerve
debridement surgery can be used in refractory cases
what is De Quervains Tenosynovitis and what causes it?
pathology of first extensor compartment (APL and EPB) of the tendon sheath
caused unknown but more common in females - possible pregnancy related
what are the features of De Quervains tenosynovitis?
pain whilst using thumb
tender over compartment
pain on resisted active thumb extension
positive finklesteins test
how is De Quervains diagnosed?
US
X ray
how is De Quervains managed?
splint rest physio anagesics injections surgical decompression
what can cause an extensor tendon rupture?
RA
autoimmune attack on synovium > tendon degeneration > rupture
what are the features of RA extensor tendon rupture and how is it treated?
weak wrist extension or dropped finger
tendon transfer
(can be prevented by synovectomy)
what is the most common hand tendon rupture?
EPL rupture
occurs a few weeks after an undisplaced distal radius fracture
what happens in an EPL rupture?
watershed area of tendon as it passes around Lister’s tubercle
fracture haematoma hinders perfusion
causes loss of function of thumb extension, but not always too bad
how is EPL rupture managed?
may need tendon transfer
how does trigger finger occur?
stenosing tenosynovitis > fibrocartilaginous metaplasia > nodule on FDS tendon > nodule catches on A1 pulley > clicking and locking during flexion/extension of finger
what are the features of trigger finger?
pain and tenderness over tendon sheath at level of MCPs
can have fixed flexion contracture (esp. in diabetics)
how is trigger finger managed?
observe
inject (cures most)
surgical release of A1 pulley
- not in RA as can exacerbate ulnar drift so use synovectomy instead
rule for quads, patellar and achilless tendons tendonitis?
don’t inject!
how does a quads or patella tendon rupture present?
palpable gap
cant do straight leg raise
may be high or low patella on X ray
how is quads or patella tendon rupture managed?
surgical repair through open approach
what is Osgood schlatters disease?
traction apophysitis at the tibial tubercle
(inflammation of the bony prominence at the growth plate due to chronic traction of the tendon at its insertion at the growth plate)
what are the features of traction apophysitis?
leaves prominent bony lump
growing pains
usually in active adolescent boys
how does an achilles tendon rupture usually present?
middle aged
sudden acceleration/deceleration
feels like being kicked or shot
what are the risk factors for achilles tendon rupture?
RA
steroids
tendonitis
what are the clinical findings in achilles tendon rupture?
palpable gap
unable to plantarflex
+ve Simmonds test
how is achilles tendon rupture diagnosed?
clinical examination usually enough but may need US or MRI if complex
how is an achilles tendon rupture managed?
serial plater casts
surgical repair
how does tibialis posterior rupture occur and what can it lead to?
tenosynovitis > progressive elongation > rupture > progressive flat foot and valgus hindfoot
how is tibialis posterior rupture managed?
NSAIDs orthotics/casts injections debridement may be helped by tendon transfer
what is the function of tendons and how are they made up?
link muscle to bone to enable joint function
microfibrils > subfibrils > fibrils > fascicles > tendon unit
tendon unit surrounded by endotendon which contains nerves and small blood vessels
endotendon surrounded by epitenon - connective tissue, within the tendon sheath
what are tendons composed of?
water
type 1 collagen
proteoglycans
what cells are present in tendons?
fibroblasts - produce collagen and proteoglycan
what is the blood supply to tendons?
poor supply
watershed areas linked to tendon pathology and rupture
what are the 5 types of tendon disease?
tendinopathy = disease of a tendon tendonitis = inflammation of a tendon tendonosis = chronic tendon injury with damage to a tendon ECM tenosynovitis = inflammation of the tendon sheath enthesopathy = inflammation of the tendon origin or insertion into bone
