Tendon Problems Flashcards
What are some features of tendon problems?
Most conditions are self-limiting, can be hard to treat, common (30% of MSK consults)
What is a tendinopathy and tendonitis?
Tendinopathy = disease of tendon Tendonitis = inflammation of the tendon within the collagen
What are tendonosis and tenosynovitis?
Tendonosis = inflammation of tendon (more chronic, changes at cellular level) Tenosynovitis = inflammation of tendon sheath
What is the definition of enthesopathy?
Disease of the origin of the tendon where it attaches to the bone
What is the function of tendons, and what is the predominant cell within them?
Linnks muscle to bone
Predominant cell is fibroblast = produces and maintains collagen
What are the main types of collagen?
Type 1 = harder structures (bone, tendons)
Type 2 = softer structures (articular cartilage)
Type 3 = fibrocartilage (used in healing)
What are the two main structures that supply blood to the tendons?
Paratenon and synovial sheath
What are some intrinsic causes of tendinopathy?
Age, gender, obesity, predisposing diseases (e.g RA), anatomical factors (malalignment, LLD)
What are some extrinsic causes of tendinopathy?
Trauma/injury, repetitive injury, drugs (steroids, antibiotics), sports related injury
What causes tendonosis?
Histological degeneration of collagen and extracellular matrix = likely due to matrix metalloproteinases (MMPs) which increase with age and repetitive injury
Where does tedonosis usually occur?
At areas of poor blood supply = can be present and not painful
What are the conservative management options for tendon problems?
Rest and physio (eccentric strengthening)
Analgesia = anti-inflammatories
Injections = not for lower limb, good for rotator cuff
Splinting = Achilles tendon
What are some surgical options for tendon problems?
Debridement = removal of diseased tissue
Decompression
Synovectomy = helps to prevent further rupture
Tendon transfer = tib. posterior, EPL
What are some controversial tendon problem treatments?
Ultrasound, platelet rich plasma (PRP), surgery
Steroid injection = toxic to tenocytes, physio just as effective in tennis elbow and shoulder impingement
Who tends to suffer from rotator cuff pathology?
Athletes = throwing events
Manual workers = painters
What are some signs and symptoms of rotator cuff pathology?
Achy pain down arm, difficulty sleeping on affected side, reaching overhead and on lifting, painful arc +/- weakness, positive impingement test
How is rotator cuff pathology managed?
Physio, injections, subacromial decompression
Where can biceps tendinopathy occur and what may cause it?
May be proximal or distal
Causes = overuse, instability, impingement, trauma
What are some symptoms of biceps tendinopathy?
Pain on anterior shoulder radiating to elbow = aggravated by shoulder flexion, forearm pronation and elbow flexion
What may occur if there is subluxation of the biceps tendon?
Snapping with shoulder movements
What imaging can be done for biceps tendinopathy and how is it treated?
Can be diagnosed using USS
Treatment is conservative or surgical (for distal attachment pathology)
What are some features of lateral epicondylitis (tennis elbow)?
10-20% bilateral, pain and tenderness over lateral epicondyle (origin of extensor tendons of wrist), diagnosed by tests that exacerbate pain, injections may help
What are some features of medial epicondylitis (golfer’s elbow)?
Medial elbow pain (origin of wrist flexors), caused by repetitive stress, self-limiting, avoid injections (due to ulnar nerve), surgical release is last resort
Who gets DeQuervain’s tenosynovitis?
More common in women aged 30-50, associated with rheumatoid arthritis
How does DeQuervain’s tenosynovitis present?
Pain over radial styloid process, occurs in first extensor compartment (APL and EPB), positive Finklestein’s test
What investigations can be done for DeQuervain’s tenosynovitis?
USS
X-ray = to exclude osteoarthritis of the CMC
How is DeQuervain’s tenosynovitis treated?
Splinatge, rest, physio, injections, analgesia, surgical decompression
What causes extensor tendon rupture in rheumatoid arthritis?
Autoimmune attack on synovium causes tendon degeneration and subsequent rupture = causes weakness in wrist or dropped finger
How is extensor tendon rupture treated?
Can’t repair diseased tendon = tendon transfer
Synovectomy can prevent rupture
What are some features of extensor pollicis brevis rupture?
Associated with RA and Colles fracture, causes substantial loss of function, requires tendon transfer (EIP)
What is the pathogenesis of trigger finger?
Stenosing tenosynovitis cause fibrocartilaginous metaplasia, creating a nodule on the FDS tendon = nodule catches on A1 pulley causing triggering
How is trigger finger treated?
Can occur at any age = observe, may give injection
Surgical release = can only release A1 pulley as cutting too many pulleys causes bowstringing
What pathologies may affect the extensor mechanism of the knee?
Tendonitis, rupture, traction apophysitis
Where does traction apophysitis affect?
At tibial tubercle = Osgood-Schlatter’s disease
Insertion at patellar tendon into tibial tuberosity
Can also happen at patella and Achilles
How does traction apophysitis present?
Leaves prominent bony lump, often occurs in adolescent active boys
Who gets a ruptured calcaneal (Achilles) tendon?
Middle aged people, caused by sudden acceleration/deceleration (running/squash)
Associated with RA, steroids and tendonitis
How does Achilles tendon rupture present?
Feels like being shot, palpable gap, unable to tiptoe stand, Simmond’s test positive
How can Achilles tendon rupture be imaged, and how is it treated?
May be imaged using USS or MRI
Treatment = plaster if early presentation, surgery if late presentation
What causes tibialis posterior rupture?
Tenosynovitis causes progressive elongation, which leads to eventual rupture, cause is unclear
What may a rupture tibialis posterior cause?
Leads to progressive flat foot and valgus hindfoot
How is a ruptures tibialis posterior treated?
NSAIDs, orthotics/cast, injection, debridement, may be helped by tendon transfer
