Tendon Problems Flashcards
what is tendinopathy
disease of a tendon
define tendonitis
inflammation of a tendon
what is tendonosis
chronic tendon injury with damage to a tendon extracellular matrix
define tenosynovitis
inflammation of the tendon sheath
what is enthesopathy
inflammation of the tendon origin or the insertion into the bone
what is the purpose of a tendon
transmit load from muscle to bone
what is the composition of tendons
water
collagen (type 1 85% of dry weight)
proteogylcans
what cells produce collagen and proteoglycans
fibroblasts
what is the blood supply to tendons like
poor- watershed areas (has weakest blood supply) are linked to tendon pathology and rupture
what is the order of components of tendons
microfibrils subfibrils fibrils fascicles tendon unit
what is the endotendon
surrounds and separates fascicles, contains nerves and small blood vessels
what is the epitenon
outer connective tissue layer, covers endotendon, lies within loose areolar tissue (paratenon) or within the tendon sheath
what is the blood supply to tendons
comes from:
- perimyseum
- periosteal insertion of the tendon
- paratenon
what are the intrinsic causes of tendinopathy
age, gender, obesity, pre disposing diseases (RA)m anatomical factors (mal-alignment)
what are the extrinsic causes of tendinopathy
trauma/ injury, repetitive injury, drugs (steroids, antibiotics (fluroquinolones)), sports related factors
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)
where do you not do steroid injections- why
achilles tendon or extensor knee mechanisms
risk of rupture
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
what can cause a rotator cuff pathology
intrinsic- degeneration, tendon vascularity
extrinsic compression
inflammation of the subacromial bursa
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
what is the management for rotator cuff pathology
conservative- physio, inject, rest
surgery- subacromial decompression, rotator cuff repair
what is the gold standard for imaging the rotator cuff
US
what causes biceps tendonopathy
can be tendonosis, tendonitis, rupture or tenosynovitis- overuse, instability, impingement or trauma
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
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
