Tendon Problems Flashcards by Martha Innes

What is tendinopathy?

Damage to tendons

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What is tendonitis?

Inflammation of tendons

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What is tenosynovitis?

Disease of synovium surrounding tendons

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What is enthesopathy?

Disorder of the attachment of a tendon to bone

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What is the function of tendons?

To link muscle to bone to enable joint function

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What is the predominant cell of tendons?

Fibroblast

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What is the function of fibroblasts?

Production and maintenance of collagen and other proteins

This allows flexibility and tensile strength of tendons

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What is the organisation of tendons?

Tendons are made up of fascicles, separated by endotendon which is covered in epitenon
Hundreds of fibrils are contains within fascicles
Sub-fibrils make up fibrils
Microfibrils make up sub-fibrils

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What are the sources of blood supply to tendons?

Perimysium
Periosteal insertion of the tendon
Paratenon

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What are intrinsic factors that contribute to tendinopathy?

Age
Obesity
Pre-disposing diseases (e.g. RA)
Anatomical factors (e.g. malalignment, leg length discrepancy)

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What are extrinsic factors the contribute to tendinopathy?

Trauma/injury
Repetitive injury
Drugs (steroids, antibiotics)
Sports related factors

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What is tendinosis?

Histologic degeneration of collagen and extracellular matrix

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Which type of areas does tendinosis usually affect?

Areas of poor blood supply

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What is the general conservative treatment for tendinosis?

Rest
Physio
Analgesia
Anti-inflammatories

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When can steroid injections be used in tendinosis, and when should they not be used?

Use in rotator cuff and tennis elbow

Do not use in Achilles tendon or extensor knee mechanism

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What are the surgical treatment options for tendinosis?

Debridement
Decompression
Synivectomy
Tendon transfer

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What are the upper limb tendon problems?

Rotatoe cuff
Biceps brachii rupture
Tennis elbow
GOlfer'selbow
De Quervain's tenosynovitis
Rheumatoid extensor tendon rupture
Extensor pollicis longus  rupture
Trigger finger

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What are the muscles of the rotator cuff?

Subscapularis
Supraspinatous
Infraspinatus
Teres minor

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Who are usually affected by rotator cuff pathology?

Athletes (throwing events)
Manual workers (painters)

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What are the symptoms and sings of rotator cuff pathology?

Achy pain down arm
Difficulty sleeping on affected side, reaching overhead and on lifting
Painful arc
May be weakness
Positive impingement tests

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What are the impingement tests for which rotator cuff muscles?

Subscapularis - can patient place hand behind back at with palm touching the back and resist the examiner placing force on the hand
Supraspinatous - can patient hold both arms out at 45˚ from midline with thumbs down and resist examiner pushing down arm
Infraspinatous - can patient extend their arms at 45˚ from midline with elbows bent and kept at their sides, and resist the examiner pushing their arm back towards the midline
Teres minor - can patient hold arm up with fingers pointing t the ceiling with elbow bent at 90˚

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What investigations are done for rotator cuff pathology?

USS (gold standard)
MRI
Arthroscopy

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What is the management for rotator cuff pathology?

Physio
Steroid injection
Surgical - subacromial decompression

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How does rotator cuff tendinopathy develop?

Over time cuff tendons degenerate

Can be provoked by excessive effort of the shoulder

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Where is the biceps brachii usually affected by tendinopathy?

Long head of biceps where it passes through the bicipital groove anteriorly on the proximal humerous

What tendon conditions can affect the biceps brachii?

Tendonitis Tendonosis Tendon rupture Tenosynovitis

What are causes of biceps brachii tendinopathy?

Overuse, instability, inpaingement, trauma Occupations where heavy lifting or overhead work is typical Athletes involved in throwing events, swimmers, gymnasts

What are the symptoms and signs of biceps brachii tendinopathy?

Anterior shoulder pain radiating to elbow Aggravated by shoulder flexion, forearm pronation and elbow flexion Clicking or snapping with shoulder movements and subluxation Extensive bruising

What investigation is done for biceps brachii tendinopathy?

USS

What is lateral epicondylitis also known as?

Tennis elbow

What is an example of a cause of lateral epicondylitis?

Repetitive strain injury

What are the symptoms and signs of lateral epicondylitis?

Pain and tenderness over the lateral epicondyle at the attachment of the forearm muscle Pain worse when stretching the muscles e.g. opening a jar Mill's test positive (pain produced by resisted wrist extension with palm pronated)

How is lateral epicondylitis diagnosed?

Clinical diagnosis USS or MRI if uncertain NCS if nerve symptoms

What is medial epicondylitis also known as?

Golfer's elbow

What is medial epicondylitis?

Inflammation of the flexor forearm muscles | Self-limiting

What is the cause of medial epicondylitis?

Repetitive stress at the muscle junction (e.g. golf)

What are the symptoms and signs of medial epicondylitis?

Medial elbow pain at the origin of the wrist flexors Pain aggravated by wrist flexion and pronation Pain worse upon grasping May have an associated ulnar neuropathy and muscle weakness

What is the investigation for medial epicondylitis?

MRI or USS if diagnosis unclear | NCS if nerve symptoms

What is De Quervain's tenosynovitis?

Tenosynovitis of the first extensor of the compartment, affecting the abductor pollicis longus and extensor pollicis brevis tendons

Who usually present withDe Quervain's tenosynovitis?

Women between 30 and 50 Pregnancy RA

What are the symptoms and signs of De Quervain's tenosynovitis?

Pain over radial styloid process at the wrist Repetitive strain injury Finklestein's test (patient makes a fist over thumb and the hand is ulnar deviated to produce pain)

What are the investigations for De Quervain's tenosynovitis?

USS | X-ray to rule out CMC joint OA which can mimic DQ

What are causes of extensor tendon rupture?

Colles fracture | Rheumatoid arthritis

What are the symptoms of extensor tendon rupture?

Wrist extension weakness Dropped finger Substantial loss of function

What can prevent extensor tendon rupture from getting worse?

Synovectomy

What is the management for extensor tendon rupture?

Tendon transfer

What is trigger finger?

Stenosing tenosynovitis leads to fibrocartilagenous metaplasia which causes a nodule on the flexor digitorum superficially tendon The nodule catches on the A1 pulley, causing triggering

What is the management for trigger finger?

Observe Steroid injection Surgical release

What are the lower limb tendon problems?

``` Knee extensor mechanism Calcaneal tendon (Achilles) Tibialis posterior tendon dysfunction ```

What is the knee extensor mechanism made up of?

Quadricpes muscle Quadriceps tendon Patella Patella tendon

What problems can occur with the knee extensor mechanism?

Rupture Tendonitis Traction apophysitis

What are causes of knee extensor mechanism rupture?

Middle aged adults playing running or jumping sports Blunt or penetrating trauma Steroid or anabolic use Diabetes

What are symptoms of knee extensor mechanism rupture?

Difficulty or inability to straight leg raise | Palpable gap

What investigations can be done for knee extensor mechanism rupture?

X-ray - effusion or displaced patella | USS or MRI - may show tear

What is the management for knee extensor mechanism rupture?

Surgical repair | Immobilisation and physio for small partial tears of the quadriceps

Where does traction apophysitis affect?

At the insertion of the patellar tendon into the tibial tuberosity Can also happen at patella and achilles tendons

Who does traction apophysitis affect?

adolescent active boys

What are causes of Achilles tendon injury?

Sudden force, such as forceful push off the foot

Who are usually affected by Achilles tendon injury?

Middle aged Rheumatoid arthrtiis Patients on steroids Tendonitis

What are symptoms and signs of Achilles tendon injury?

``` Feels like being kicked or shot Bruising Palpable gap Unable to tiptoe stand Simmond's test positive (if lying with feet hanging off bed and you squeeze calf does the foot plantar flex) ```

What are the investigations for Achilles tendon rupture?

Clinical diagnosis | USS or MRI of diagnosis is uncertain, re-rupture of tendon or large gap is suspected

What is the management for Achilles tendon rupture?

Plaster | Repair

What causes tibias posterior tendon injury?

Tenosynovitis causes progressive elongation and eventually rupture

What are the symptoms of tibias posterior tendon injury?

Progressive flat foot and valves hindfoot