Tendon Problems Flashcards by Louise Emerson

what is tendinopathy

disease of a tendon

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define tendonitis

inflammation of a tendon

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what is tendonosis

chronic tendon injury with damage to a tendon extracellular matrix

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define tenosynovitis

inflammation of the tendon sheath

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what is enthesopathy

inflammation of the tendon origin or the insertion into the bone

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what is the purpose of a tendon

transmit load from muscle to bone

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what is the composition of tendons

water
collagen (type 1 85% of dry weight)
proteogylcans

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what cells produce collagen and proteoglycans

fibroblasts

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what is the blood supply to tendons like

poor- watershed areas (has weakest blood supply) are linked to tendon pathology and rupture

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what is the order of components of tendons

microfibrils 
subfibrils 
fibrils 
fascicles 
tendon unit

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what is the endotendon

surrounds and separates fascicles, contains nerves and small blood vessels

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what is the epitenon

outer connective tissue layer, covers endotendon, lies within loose areolar tissue (paratenon) or within the tendon sheath

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what is the blood supply to tendons

comes from:

perimyseum
periosteal insertion of the tendon
paratenon

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what are the intrinsic causes of tendinopathy

age, gender, obesity, pre disposing diseases (RA)m anatomical factors (mal-alignment)

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what are the extrinsic causes of tendinopathy

trauma/ injury, repetitive injury, drugs (steroids, antibiotics (fluroquinolones)), sports related factors

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what is the basic principles for management for a tendinopathy

Rest (RICE)
physio
analgesics (anti inflammatories)
steriod injectios (for rotator cuff and tennis/ golfers elbow NOT achilles tendon or extensor knee mechanism)
splinting
(some may require surgery)

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where do you not do steroid injections- why

achilles tendon or extensor knee mechanisms

risk of rupture

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what are the types of surgery that can be used to treat tendinopathies

debridement- removal of diseased tissue

decompression- used in supraspinatus tendonitis and subacromial decompression

synovectomy- helps prevent rupture, extensors of wrist (RA), tibialis posterior

tendon transfer- tibialis posterior, extensor pollicis longus

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what can cause a rotator cuff pathology

intrinsic- degeneration, tendon vascularity

extrinsic compression

inflammation of the subacromial bursa

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what are the possible clinical findings of a rotator cuff pathology

achy pain down arm, difficulty sleeping on affected side/reaching overhead/on lifting, painful arc +/- weakness, positive impingement tests (haekins- kennedy, jpbes, scarf), dull achy pain

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what is the management for rotator cuff pathology

conservative- physio, inject, rest

surgery- subacromial decompression, rotator cuff repair

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what is the gold standard for imaging the rotator cuff

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what causes biceps tendonopathy

can be tendonosis, tendonitis, rupture or tenosynovitis- overuse, instability, impingement or trauma

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what are the signs of biceps tendinopathy

pain in anterior shoulder, radiating to elbow

aggravated by shoulder flexion, forearm pronation and elbow flexion

snapping with shoulder if subluxation

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what head of biceps is more commonly affected by inflammation

long head- as it passes through the bicipital groove

what are the clinical signs of a biceps rupture

popeye sign and extensive bruising

what is the treatment for biceps tendinopathy

conservative with rest and physio | surgical repair if manual job

what causes lateral epicondylitis (tennis elbow)

overuse injury- eccentric overload at common extensor tendon origin Tendinosis and inflammation at ECRB origin (Extensor carpi radialis brevis)

what is the pathophysiology of tennis elbow

Tendinosis and inflammation at ECRB origin | Peritendinous inflammation = angiofibroblastic hyperplasia = breakdown/fibrosis

what are the signs of tennis elbow

pain and tenderness over latral epicondyle , pain with resisted extension of middle finger (felt in elbow), mills test positive

how is tennis elbow treated

self limiting (can be up to 4 years), rest, physio steroid injections, surgical release and debridement of ECRB

where is golfers elbow pain felt

origin of the wrist flexors (medial)

what is the pathophysiology of medial epicondylitis

reptitive stress= Peritendinous inflammation = angiofibroblastic hyperplasia = breakdown/fibrosis

why do you avoid injecting golfers elbow

as risk of hitting ulnar nerve

what is inflamed in golfers elbow

flexor forearm muscles

what movement causes pain in golfers elbow

wrist flexion and pronation

what can some cases of golfer elbow be associated with

ulnar neuropathy

what is the management for golfers elbow

rest, physio, modification of activities, orthotics, or injection of LA and steroid. For refractory cases, surgical release may be required

what is de Quervains tenosynovitis

tendon sheath pathology in first extensor compartment (APL, EPB), cause unknown- can be repetitive strain injury

what are the features of de quervains tenosynovitis

pain whilst using thumb, tendor over compartment (radial styloid), pain on resisted active thumb extension, finklesteins test (thumb in fist, ulnar deviation)

what should you rule out with XR in de queravains tenosynovitis

CMC OA (also do US to investigate)

what is the management for de quervains

splint, rest, physio, analgesics, injections, surgical decompression

how does RA and extensor tendon rupture

autoimmune attack on synovium= tendon degeneration= rupture

what are the features of extensor tendon rupture in the hand

weakness wrist extension or dropped finger

can you repair a diseased tendon

no need tendon transfer

what is the most common hand tendon rupture

extensor pollicis longus

why does an EPL rupture usually occur

a few weeks after (usually) undisplaced distal radium fracture - ischaemia plays a role, watershed area of tendon as it passes around listers tubercle facture haematoma hinders perfusion

what is the effect and treatment for an EPL rupture

loss of function of thumb extension but not always too big an impact may require tendon transfers

what is the pathophysiology of trigger finger

stenosing tenosynovitis = fibrocartilaginous metaplasia = nodule FDS tendon which catches on the A1 pulley causing clicking/ locking during extension and flexion

what are the of trigger finger

pain and tenderness over tendon sheath at level of MCPJ can lead to fixed flexion contracture

who gets trigger finger

can affect any age

what is the treatment for trigger finger

observe, injections- 70% heal, surgical release of A1 pulley

what trigger finger treatment is contraindicated in RA

surgical release of A1 pulley- may exacerbate ulnar drift, synovectomy preferred

what makes up the knee extensor mechanism

quadriceps muscle, quadriceps tendon, the patella, patella tendon

what can knee extensor mechanism tears be associated with

blunt/ penetrating trauma, steroid or antibiotic use, diabetes common in middle age people who play running/ jumping sports

what pathologies can affect the knee extensor mechanism

tendonitis , rupture (partial or complete), traction apophysitis

what are the clinical signs of a knee extensor mechanism

may have effusion, inability to straight leg raise, palpable gap, patellar in wrong place (on xray)

what investigations to see whether it is a complete or partial tear

MRI/ USS

what is osgood schlatters

traction apophysitis of the tibial tubercle, is inflammation of the patellar ligament at its insertion to the tibial tuberosity

what is a general rule for injecting tendons

upper body fine, lower limbs bad

what is the treatment for a extensor mechanisms rupture

surgical repair small tears may be treated with immobilisation and physio

what are the features of osgoods schlatters

It is characterized by a painful, bony and prominent bump just below the knee that is worse with activity and better with rest

who gets osgood schlatters

adolescent active boys

where else can osgood schlatter happen

patella and achilles

what is the treatment for osgood schlatters

rest, physio, analgesia

who tears their achilles tendon

middle aged, after a sudden force (pushing off/ sudden acceleration/ deceleration/ running/ squash) commoner in patients with RA, on steroids, or who have tendonitis

what does tearing your achilles tendon feel like

being kicked or shot

what are the clinical findings of achilles tendon rupture

palpable gap, unable to tiptoe stand, simmonds test +ve, bruising,

how do you investigate an achilles tendon rupture

USS, MRI

what is the treatment for an achilles rupture

plaster (equinus cast with serial casts) / boot vs repair

what is simmonds / thompsons test

squeezing calf causes passing foot plantar flexion in not ruptured

what causes a tibialis posterior to rupture

tenosynovitis- progressive elongation- rupture

what does tibialis posterior elongation and rupture cause

progressive flat foot and valgus hindfoot

what can help treat tibialis posterior rupture

tendon transfer