powerpoint bursitis tendonitis english

Bursitis, Tendonitis, Fibromyalgia, and RSD

Joe Lex, MD, FAAEMJoe Lex, MD, FAAEMTemple University School of MedicineTemple University School of Medicine

Philadelphia, PAPhiladelphia, PA

[email protected]@joelex.net

mailto:[email protected]

Objectives

1.1. Explain how bursitis and Explain how bursitis and tendonitis are similartendonitis are similar

2.2. Explain how bursitis and Explain how bursitis and tendonitis differ from from anothertendonitis differ from from another

3.3. List phases in development and List phases in development and healing of bursitis and tendonitishealing of bursitis and tendonitis

Objectives

4.4. List common types of bursitis and List common types of bursitis and tendonitis found at the:tendonitis found at the: ShoulderShoulder ElbowElbow WristWrist

5. List indications / contraindications 5. List indications / contraindications for injection therapy of bursitis for injection therapy of bursitis and tendonitisand tendonitis

HipKneeAnkle

Objectives

6.6. Describe typical findings in a Describe typical findings in a patient with fibromyalgiapatient with fibromyalgia

7.7. Describe typical findings in a Describe typical findings in a patient with reflex sympathetic patient with reflex sympathetic dystrophydystrophy

Sports

• Society more athleticSociety more athletic

• Physical activity Physical activity health benefits health benefits

• Overuse syndromes increaseOveruse syndromes increase

• 25% to 50% of participants will 25% to 50% of participants will experience tendonitis or bursitisexperience tendonitis or bursitis

Workplace

Musculoskeletal disorders from…Musculoskeletal disorders from…

……repetitive motionsrepetitive motions

……localized contact stresslocalized contact stress

……awkward positionsawkward positions

……vibrationsvibrations

……forceful exertionsforceful exertions

• Ergonomic design Ergonomic design incidence incidence

Bursae

• Closed, round, flat sacsClosed, round, flat sacs

• Lined by synoviumLined by synovium

• May or may not communicate with May or may not communicate with synovial cavitysynovial cavity

• Occur at areas of friction between Occur at areas of friction between skin and underlying ligaments / skin and underlying ligaments / bone bone

Bursae

• Permit lubricated movement over Permit lubricated movement over areas of potential impingementareas of potential impingement

• Many are namelessMany are nameless

• ~78 on each side of body~78 on each side of body

• New bursae may form anywhere New bursae may form anywhere from frequent irritationfrom frequent irritation

Bursitis

Inflamed by…Inflamed by………chronic frictionchronic friction

……traumatrauma

……crystal crystal depositiondeposition

……infectioninfection

……systemic systemic disease: disease: rheumatoid rheumatoid arthritis, arthritis, psoriatic psoriatic arthritis, gout arthritis, gout ankylosing ankylosing spondylitisspondylitis

Bursitis

• Inflammation causes bursal Inflammation causes bursal synovial cells to thickensynovial cells to thicken

• Excess fluid accumulates inside Excess fluid accumulates inside and around affected bursaeand around affected bursae

Tendons

• Tendon sheaths composed of Tendon sheaths composed of same synovial cells as bursae same synovial cells as bursae

• Inflamed in similar mannerInflamed in similar manner

• Tendonitis: inflammation of tendon Tendonitis: inflammation of tendon onlyonly

• Tenosynovitis: inflammation of Tenosynovitis: inflammation of tendon plus its sheathtendon plus its sheath

Tendons

• Inflammatory changes involving Inflammatory changes involving sheath well documented sheath well documented

• Inflammatory lesions of tendon Inflammatory lesions of tendon alone not well documentedalone not well documented

• Distinction uncertain: terms Distinction uncertain: terms tendonitis and tenosynovitis used tendonitis and tenosynovitis used interchangeablyinterchangeably

Tendons

• Most overuse syndromes are NOT Most overuse syndromes are NOT inflammatoryinflammatory

• Biopsy: no inflammatory cellsBiopsy: no inflammatory cells

• High glutamate concentrationsHigh glutamate concentrations

• NSAIDs / steroids: no advantageNSAIDs / steroids: no advantage

• TendonITIS a misnomerTendonITIS a misnomer

Bursitis / Tendonitis

• Most common causes: mechanical Most common causes: mechanical overload and repetitive overload and repetitive microtrauma microtrauma

• Most injuries multifactorialMost injuries multifactorial

Bursitis / Tendonitis

• Intrinsic factors: malalignment, Intrinsic factors: malalignment, poor muscle flexibility, muscle poor muscle flexibility, muscle weakness or imbalance weakness or imbalance

• Extrinsic factors: design of Extrinsic factors: design of equipment or workplace and equipment or workplace and excessive duration, frequency, or excessive duration, frequency, or intensity of activityintensity of activity

Immediate Phase

• Release of chemotactic and Release of chemotactic and vasoactive chemical mediatorsvasoactive chemical mediators

• Vasodilation and cellular edemaVasodilation and cellular edemaPMNs perpetuate processPMNs perpetuate process

• Lasts 48 hours to 2 weeksLasts 48 hours to 2 weeks

• Repetitive insults prolong Repetitive insults prolong inflammatory stageinflammatory stage

Healing Phase

• Classic inflammatory signs: pain, Classic inflammatory signs: pain, warmth, erythema, swelling warmth, erythema, swelling

• Healing goes through proliferative Healing goes through proliferative and maturationand maturation

• 6 to 12 weeks: organization and 6 to 12 weeks: organization and collagen cross-linking mature to collagen cross-linking mature to preinjury strengthpreinjury strength

History

• Changes in sports activity, work Changes in sports activity, work activities, or workplaceactivities, or workplace

• Cause not always foundCause not always found

• Pregnancy, quinolone therapy, Pregnancy, quinolone therapy, connective tissue disorders, connective tissue disorders, systemic illnesssystemic illness

History

• Most common complaint: Most common complaint: PAINPAIN

• Acute or chronicAcute or chronic

• Frequently more severe after Frequently more severe after periods of restperiods of rest

• May resolve quickly after initial May resolve quickly after initial movement only to become movement only to become throbbing pain after exercisethrobbing pain after exercise

Articular vs. Periarticular

In joint capsuleIn joint capsule

• Joint pain / warmth / Joint pain / warmth / swellingswelling

• Worse with active & Worse with active & passive movementpassive movement

• All parts of joint All parts of joint involvedinvolved

Periarticular Periarticular

• Pain not uniform Pain not uniform across jointacross joint

• Pain only certain Pain only certain movementsmovements

• Pain character & Pain character & radiation varyradiation vary

Physical Exam

• Careful palpationCareful palpation

• Range of motionRange of motion

• Heat, warmth, rednessHeat, warmth, redness

Lab Studies

• Screening tests: CBC, CRP, ESR Screening tests: CBC, CRP, ESR

• Chronic rheumatic disease: mild Chronic rheumatic disease: mild anemiaanemia

• Rheumatoid factor, antinuclear Rheumatoid factor, antinuclear antibody, antistreptolysin O titers, antibody, antistreptolysin O titers, and Lyme serologies for follow-up and Lyme serologies for follow-up

• Serum uric acid: not helpfulSerum uric acid: not helpful

Synovial Fluid

• Especially crystalline, suppurative Especially crystalline, suppurative etiologyetiology

• Appearance, cell count and diff, Appearance, cell count and diff, crystal analysis, Gram’s staincrystal analysis, Gram’s stain• Positive Gram’s: diagnostic Positive Gram’s: diagnostic

• Negative Gram’s: cannot rule outNegative Gram’s: cannot rule out

Management

• Rest Rest

• Pain relief: meds, heat, coldPain relief: meds, heat, cold

• No advantage to NSAIDsNo advantage to NSAIDs

• Exceptions: olecranon bursitis and Exceptions: olecranon bursitis and prepatellar bursitis have a prepatellar bursitis have a moderate risk of being infected moderate risk of being infected ((Staphylococcus aureusStaphylococcus aureus))

Management

• Shoulder: immobilize few daysShoulder: immobilize few days• Risk of adhesive capsulitisRisk of adhesive capsulitis

• Lateral epicondylitis: forearm braceLateral epicondylitis: forearm brace

• Olecranon bursitis: compression Olecranon bursitis: compression dressingdressing

Management

• De Quervain’s: splint wrist and De Quervain’s: splint wrist and thumb in 20thumb in 20oo dorsiflexion dorsiflexion

• Achilles tendonitis: heel lift or splint Achilles tendonitis: heel lift or splint in slight plantar flexionin slight plantar flexion

Local Injection

Local Injection

• Lidocaine or steroid injection can Lidocaine or steroid injection can overcome refractory painovercome refractory pain

• Steroids universally given, often Steroids universally given, often with great successwith great success

• No good prospective data to No good prospective data to support or refute therapeutic support or refute therapeutic benefitbenefit

Local Injection

• Short course of oral steroid may Short course of oral steroid may produce statistically similar resultsproduce statistically similar results

• Primary goal of steroid injection: Primary goal of steroid injection: relieve pain so patient can relieve pain so patient can participate in physical rehabparticipate in physical rehab

Local Injection

• Adjunct to other modalities: pain Adjunct to other modalities: pain control, PT, exercise, OT, relative control, PT, exercise, OT, relative rest, immobilizationrest, immobilization

• Additional pain control: NSAIDs, Additional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, acupuncture, ultrasound, ice, heat, electrical nerve stimulationelectrical nerve stimulation

Local Injection

• Analgesics + exercise: better Analgesics + exercise: better results than exercise aloneresults than exercise alone

• Eliminate provoking factorsEliminate provoking factors

• Avoid repeat steroid injection Avoid repeat steroid injection unless good prior responseunless good prior response

• Wait at least 6 weeks between Wait at least 6 weeks between injections in same siteinjections in same site

Indications

DiagnosisDiagnosis

• Obtain fluid for analysisObtain fluid for analysis

• Eliminate referred painEliminate referred pain

TherapyTherapy

• Give pain reliefGive pain relief

• Deliver therapeutic agentsDeliver therapeutic agents

Contraindication: Absolute

• BacteremiaBacteremia

• Infectious arthritisInfectious arthritis

• Periarticular cellulitisPeriarticular cellulitis

• Adjacent osteomyelitis Adjacent osteomyelitis

• Significant bleeding disorderSignificant bleeding disorder

• Hypersensitivity to steroidHypersensitivity to steroid

• Osteochondral fractureOsteochondral fracture

Contraindication: Relative

• Violation of skin integrityViolation of skin integrity• Chronic local infectionChronic local infection• Anticoagulant useAnticoagulant use• Poorly controlled diabetesPoorly controlled diabetes• Internal joint derangementInternal joint derangement• HemarthrosisHemarthrosis• Preexisting tendon injuryPreexisting tendon injury• Partial tendon rupturePartial tendon rupture

Preparations

• Local anestheticLocal anesthetic

• Hydrocortisone / corticosteroidHydrocortisone / corticosteroid

• Rapid anti-inflammatory effectRapid anti-inflammatory effect

• Categorized by solubility and Categorized by solubility and relative potencyrelative potency

• High solubility High solubility short duration short duration• Absorbed, dispersed more rapidlyAbsorbed, dispersed more rapidly

Preparations

• Triamcinolone hexacetonide: least Triamcinolone hexacetonide: least soluble, longest durationsoluble, longest duration• Potential for subcutaneous atrophyPotential for subcutaneous atrophy

• Intra-articular injections onlyIntra-articular injections only

• Methylprednisolone acetate (Depo-Methylprednisolone acetate (Depo-Medrol®): reasonable first choice Medrol®): reasonable first choice for most ED indicationsfor most ED indications

Dosage

• Large bursa: subacromial, Large bursa: subacromial, olecranon, trochanteric: 40 – 60 olecranon, trochanteric: 40 – 60 mg methylprednisolone mg methylprednisolone

• Medium or wrist, knee, heel Medium or wrist, knee, heel ganglion: 10 – 20 mgganglion: 10 – 20 mg

• Tendon sheath: de Quervain, Tendon sheath: de Quervain, flexor tenosynovitis: 5 – 15 mgflexor tenosynovitis: 5 – 15 mg

Site Preparation

• Use careful aseptic techniqueUse careful aseptic technique

• Mark landmarks with skin pencil, Mark landmarks with skin pencil, tincture of iodine, or thimerosal tincture of iodine, or thimerosal (Merthiolate®) (sterile Q-tip)(Merthiolate®) (sterile Q-tip)

• Clean point of entry: povidone-Clean point of entry: povidone-iodine (Betadine®) and alcoholiodine (Betadine®) and alcohol

• Do not need sterile drapesDo not need sterile drapes

Technique

• Make skin wheal: 1% lidocaine or Make skin wheal: 1% lidocaine or 0.25% bupivacaine OR…0.25% bupivacaine OR…

……use topical vapocoolant: e.g., use topical vapocoolant: e.g., Fluori-Methane®Fluori-Methane®

• Use Z-tract technique: limits risk of Use Z-tract technique: limits risk of soft tissue fistulasoft tissue fistula

• Agitate syringe prior to injection: Agitate syringe prior to injection: steroid can precipitate or layersteroid can precipitate or layer

Complications: Acute

• Reaction to anesthetic: rareReaction to anesthetic: rare• Treat as in standard textbooksTreat as in standard textbooks

• Accidental IV injectionAccidental IV injection

• Vagal reaction: have patient flatVagal reaction: have patient flat

• Nerve injury: pain, paresthesiasNerve injury: pain, paresthesias

• Post injection flare: starts in hours, Post injection flare: starts in hours, gone in days (~2%)gone in days (~2%)

Complications: Delayed

• Localized subcutaneous or Localized subcutaneous or cutaneous atrophy at injection sitecutaneous atrophy at injection site

• Small depression in skin with Small depression in skin with depigmentation, transparency, and depigmentation, transparency, and occasional telangiectasiaoccasional telangiectasia• Evident in 6 weeks to 3 monthsEvident in 6 weeks to 3 months

• Usually resolve within 6 monthsUsually resolve within 6 months

• Can be permanentCan be permanent


• Tendon rupture: low risk (<1%) Tendon rupture: low risk (<1%)

• Dose-relatedDose-related

• Related to direct tendon injection?Related to direct tendon injection?

• Limit injections to no more than Limit injections to no more than once every 3 to 4 monthsonce every 3 to 4 months

• Avoid major stress-bearing Avoid major stress-bearing tendons: Achilles, patellartendons: Achilles, patellar


• Systemic absorption slower than Systemic absorption slower than with oral steroidswith oral steroids

• Can suppress hypopituitary-Can suppress hypopituitary-adrenal axis for 2 to 7 daysadrenal axis for 2 to 7 days

• Can exacerbate hyperglycemia in Can exacerbate hyperglycemia in diabetesdiabetes

• Abnormal uterine bleeding Abnormal uterine bleeding reportedreported

Some specific

entities…

Bicipital Tendonitis

• Risk: repeatedly flex elbow against Risk: repeatedly flex elbow against resistance: weightlifter, swimmerresistance: weightlifter, swimmer

• Tendon goes through bicipital Tendon goes through bicipital (intertubercular) groove(intertubercular) groove

• Pain with elbow at 90° flexion, arm Pain with elbow at 90° flexion, arm internally / externally rotatedinternally / externally rotated


• Range of motion: normal or Range of motion: normal or restrictedrestricted

• Strength: normalStrength: normal

• Tenderness: bicipital grooveTenderness: bicipital groove

• Pain: elevate shoulder, reach hip Pain: elevate shoulder, reach hip pocket, pull a back zipperpocket, pull a back zipper


• Lipman test: "rolling" bicipital Lipman test: "rolling" bicipital tendon produces localized tendon produces localized tendernesstenderness

• Yergason test: pain along bicipital Yergason test: pain along bicipital groove when patient attempts groove when patient attempts supination of forearm against supination of forearm against resistance, holding elbow flexed at resistance, holding elbow flexed at 90° against side of body90° against side of body

Calcific Tendonitis Supraspinatus Tendonitis

Subacromial Bursitis

• Calcific (calcareous) tendonitis: Calcific (calcareous) tendonitis: hydroxyapatite deposits in one or hydroxyapatite deposits in one or more rotator cuff tendonsmore rotator cuff tendons• Commonly supraspinatusCommonly supraspinatus

• Sometimes rupture into adjacent Sometimes rupture into adjacent subacromial bursasubacromial bursa

• Acute deltoid pain, tendernessAcute deltoid pain, tenderness



• Clinically similar: difficult to Clinically similar: difficult to differentiatedifferentiate

• Rotator cuff: teres minor, Rotator cuff: teres minor, supraspinatus, infraspinatus, supraspinatus, infraspinatus, subscapularissubscapularis• Insert as conjoined tendon into Insert as conjoined tendon into

greater tuberosity of humerusgreater tuberosity of humerus



Jobe’s sign, AKA “empty can test”Jobe’s sign, AKA “empty can test”

• Abduct arm to 90Abduct arm to 90oo in the scapular in the scapular plane, then internally rotate arms plane, then internally rotate arms to thumbs pointed downwardto thumbs pointed downward

• Place downward force on arms: Place downward force on arms: weakness or pain if supraspinatusweakness or pain if supraspinatus



• Other tests: Neer, HawkinsOther tests: Neer, Hawkins

• Passively abduct arm to 90°, then Passively abduct arm to 90°, then passively lower arm to 0° and ask passively lower arm to 0° and ask patient to actively abduct arm to patient to actively abduct arm to 30°30°



• If can abduct to 30° but no further, If can abduct to 30° but no further, suspect deltoidsuspect deltoid

• If cannot get to 30°, but if placed at If cannot get to 30°, but if placed at 30° can actively abduct arm 30° can actively abduct arm further, suspect supraspinatusfurther, suspect supraspinatus

• If uses hip to propel arm from 0° to If uses hip to propel arm from 0° to beyond 30°, suspect supraspinatusbeyond 30°, suspect supraspinatus

Calcific Tendonitis

Supraspinatus Tendonitis Subacromial Bursitis

• Subacromial bursa: superior and Subacromial bursa: superior and lateral to supraspinatus tendonlateral to supraspinatus tendon

• Tendon and bursa in space Tendon and bursa in space between acromion process and between acromion process and head of humerushead of humerus

• Prone to impingementProne to impingement

Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis

• Patient holds arm protectively Patient holds arm protectively against chest wallagainst chest wall

• May be incapacitatingMay be incapacitating

• All ROM disturbed, but internal All ROM disturbed, but internal rotation markedly limitedrotation markedly limited

• Diffuse perihumeral tendernessDiffuse perihumeral tenderness

• X-ray: hazy shadowX-ray: hazy shadow

Rotator Cuff Tear

• Drop arm test: arm passively Drop arm test: arm passively abducted at 90abducted at 90oo, patient asked to , patient asked to maintain maintain dropped arm dropped arm represents large rotator cuff tearrepresents large rotator cuff tear

• Shrug sign: attempt to abduct arm Shrug sign: attempt to abduct arm results in shrug onlyresults in shrug only

Elbow and WristElbow and Wrist

Lateral Epicondylitis

• Pain at insertion of extensor carpi Pain at insertion of extensor carpi radialis and extensor digitorum radialis and extensor digitorum musclesmuscles

• Radiohumeral bursitis: tender over Radiohumeral bursitis: tender over radiohumeral grooveradiohumeral groove

• Tennis elbow: tender over lateral Tennis elbow: tender over lateral epicondyleepicondyle

Lateral Epicondylitis

• History repetitive overhead motion: History repetitive overhead motion: golfing, gardening, using toolsgolfing, gardening, using tools

• Worse when middle finger Worse when middle finger extended against resistance with extended against resistance with wrist and the elbow in extensionwrist and the elbow in extension

• Worse when wrist extended Worse when wrist extended against resistanceagainst resistance

Medial Epicondylitis

• ““Golfer's elbow” or “pitcher’s Golfer's elbow” or “pitcher’s elbow” similarelbow” similar

• Much less commonMuch less common

• Worse when wrist flexed against Worse when wrist flexed against resistanceresistance

• Tender medial epicondyleTender medial epicondyle

Cubital Tunnel Syndrome

• Ulnar nerve passes through cubital Ulnar nerve passes through cubital tunnel just behind ulnar elbowtunnel just behind ulnar elbow

• Numbness and pain small and ring Numbness and pain small and ring fingersfingers

• Initial treatment: rest, splintInitial treatment: rest, splint

Olecranon Bursitis

• ““Student's” or “barfly elbow” Student's” or “barfly elbow”

• Most frequent site of septic bursitisMost frequent site of septic bursitis

• Aseptic: motion at elbow joint Aseptic: motion at elbow joint complete and painlesscomplete and painless

• Septic: all motion usually painfulSeptic: all motion usually painful

Olecranon Bursitis

Aseptic olecranon bursitisAseptic olecranon bursitis

• Cosmetically bothersome, usually Cosmetically bothersome, usually resolves spontaneouslyresolves spontaneously

• If bothersome, aspiration and If bothersome, aspiration and steroid injection speed resolutionsteroid injection speed resolution

• Oral NSAID after steroid injection Oral NSAID after steroid injection does not affect outcomedoes not affect outcome

Septic Olecranon Bursitis

• Most common septic bursitis: Most common septic bursitis: olecranon and prepatellarolecranon and prepatellar

• 22oo to acute trauma / skin breakage to acute trauma / skin breakage

• Impossible to differentiate acute Impossible to differentiate acute gouty olecranon bursitis from gouty olecranon bursitis from septic bursitis without laboratory septic bursitis without laboratory analysisanalysis

Ganglion Cysts

• Swelling on dorsal wristSwelling on dorsal wrist

• ~60% of wrist and hand soft tissue ~60% of wrist and hand soft tissue tumorstumors

• Etiology obscureEtiology obscure

• Lined with mesothelium or Lined with mesothelium or synoviumsynovium

• Arise from tendon sheaths or near Arise from tendon sheaths or near joint capsulejoint capsule

Carpal Tunnel Syndrome

• Median nerve compression in Median nerve compression in fibro-osseous tunnel of wristfibro-osseous tunnel of wrist

• Pain at wrist that sometimes Pain at wrist that sometimes radiates upward into forearmradiates upward into forearm

• Associated with tingling and Associated with tingling and paresthesias of palmar side of paresthesias of palmar side of index and middle fingers and radial index and middle fingers and radial half of the ring fingerhalf of the ring finger


• Patient wakes during night with Patient wakes during night with burning or aching pain, numbness, burning or aching pain, numbness, and tinglingand tingling

• Positive Tinel sign: reproduce Positive Tinel sign: reproduce tingling and paresthesias by tingling and paresthesias by tapping over median nerve at volar tapping over median nerve at volar crease of wristcrease of wrist


• Positive Phalen test: flexed wrists Positive Phalen test: flexed wrists held against each other for several held against each other for several minutes in effort to provoke minutes in effort to provoke symptoms in median nerve symptoms in median nerve distributiondistribution


• May be idiopathicMay be idiopathic

• Known causes: rheumatoid Known causes: rheumatoid arthritis pregnancy, diabetes, arthritis pregnancy, diabetes, hypothyroidism, acromegalyhypothyroidism, acromegaly


• Insert needle just radial or ulnar to Insert needle just radial or ulnar to palmaris longus and proximal to palmaris longus and proximal to distal wrist creasedistal wrist crease

• Ulnar preferred: avoids nerveUlnar preferred: avoids nerve

• Direct needle at 60° to skin Direct needle at 60° to skin surface, point toward tip of middle surface, point toward tip of middle fingerfinger

de Quervain’s Disease

• Chronic teno-synovitis due to Chronic teno-synovitis due to narrowed tendon sheaths around narrowed tendon sheaths around abductor policis longus and abductor policis longus and extensor pollicis brevis musclesextensor pollicis brevis muscles

de Quervain’s Disease

• 11stst dorsal compartment dorsal compartment

• Radial border of anatomic snuffboxRadial border of anatomic snuffbox

• 11stst compartment may cross over compartment may cross over 22ndnd compartment (ECRL/B) compartment (ECRL/B) proximal to extensor retinaculum proximal to extensor retinaculum

• Steroid injections relieve most Steroid injections relieve most symptomssymptoms

Trigger Finger

• Digital flexor tenosynovitis Digital flexor tenosynovitis

• Stenosed tendon sheathStenosed tendon sheath• Palmar surface over MC headPalmar surface over MC head

• Intermittent tendon “catch”Intermittent tendon “catch”

• ““Locks” on awakeningLocks” on awakening

• Most frequent: ring and middleMost frequent: ring and middle

Trigger Finger

• Tendon sheath walls lined with Tendon sheath walls lined with synovial cellssynovial cells

• Tendon unable to glide within Tendon unable to glide within sheath sheath

• Initial treatment: splint, moist heat, Initial treatment: splint, moist heat, NSAIDNSAID

• Steroid for recalcitrant casesSteroid for recalcitrant cases

Hip and GroinHip and Groin

Trochanteric Bursitis

• Second leading cause of lateral hip Second leading cause of lateral hip pain after osteoarthritispain after osteoarthritis

• Discrete tenderness to deep Discrete tenderness to deep palpationpalpation

• Principal bursa between gluteus Principal bursa between gluteus maximus and posterolateral maximus and posterolateral prominence of greater trochanterprominence of greater trochanter


• Pain usually chronicPain usually chronic

• Pathology in hip abductorsPathology in hip abductors

• May radiate down thigh, lateral or May radiate down thigh, lateral or posteriorposterior

• Worse with lying on side, stepping Worse with lying on side, stepping from curb, descending stepsfrom curb, descending steps


• Patrick fabere sign (Patrick fabere sign (fflexion, lexion, ababduction, duction, eexternal xternal rrotation, and otation, and eextension) may be negativextension) may be negative

• Passive ROM relatively painlessPassive ROM relatively painless

• Active abduction when lying on Active abduction when lying on opposite side opposite side pain pain

• Sharp external rotation Sharp external rotation pain pain

Ischiogluteal Bursitis

• Weaver's bottom / tailor’s seat: Weaver's bottom / tailor’s seat: pain center of buttock radiating pain center of buttock radiating down back of legdown back of leg

• Often mistaken for back strain, Often mistaken for back strain, herniated diskherniated disk

• Pain worse with sitting on hard Pain worse with sitting on hard surface, bending forward, standing surface, bending forward, standing on tiptoeon tiptoe

Ischiogluteal Bursitis

• Tenderness over ischial tuberosityTenderness over ischial tuberosity

• Ischiogluteal bursa adjacent to Ischiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / ischial tuberosity, overlies sciatic / posterior femoral cutaneous posterior femoral cutaneous nervesnerves

Legs and FeetLegs and Feet

Prepatellar Bursitis

• Housemaid’s knee / nun’s knee: Housemaid’s knee / nun’s knee: swelling with effusion of superficial swelling with effusion of superficial bursa over lower pole of patellabursa over lower pole of patella

• Passive motion fully preservedPassive motion fully preserved

• Pain mild except during extreme Pain mild except during extreme knee flexion or direct pressureknee flexion or direct pressure

Prepatellar Bursitis

• Pressure from repetitive kneeling Pressure from repetitive kneeling on a firm surface: rug cutter's kneeon a firm surface: rug cutter's knee

• Rarely direct traumaRarely direct trauma

• Second most common site for Second most common site for septic bursitisseptic bursitis

Baker’s Cyst

• Pseudothrombophlebitis syndromePseudothrombophlebitis syndrome

• Herniated fluid-filled sacs of Herniated fluid-filled sacs of articular synovial membrane that articular synovial membrane that extend into popliteal fossaextend into popliteal fossa

• Causes: trauma, rheumatoid Causes: trauma, rheumatoid arthritis, gout, osteoarthritisarthritis, gout, osteoarthritis

• Pain worse with active knee flexionPain worse with active knee flexion

Baker’s Cyst

• Can mimic deep venous Can mimic deep venous thrombosisthrombosis

• Ultrasound eseentialUltrasound eseential

• Many resolve over weeksMany resolve over weeks

• May require surgeryMay require surgery

• Steroid injections not performed: Steroid injections not performed: risk of neurovascular injuryrisk of neurovascular injury

Anserine Bursitis

• Cavalryman's disease / pes Cavalryman's disease / pes bursitis / goosefoot bursitis: obese bursitis / goosefoot bursitis: obese women with large thighs, athletes women with large thighs, athletes who runwho run

• Anteromedial knee, inferior to joint Anteromedial knee, inferior to joint line at insertion of sartorius, line at insertion of sartorius, semitendinous, and gracilis tendonsemitendinous, and gracilis tendon

Anserine Bursitis

• Abrupt knee pain, local tenderness Abrupt knee pain, local tenderness 4 to 5 cm below medial aspect of 4 to 5 cm below medial aspect of tibial plateautibial plateau

• Knee flexion exacerbatesKnee flexion exacerbates

Iliotibial Band Syndrome

• Lateral knee painLateral knee pain

• Cyclists, dancers, distance Cyclists, dancers, distance runners, football playersrunners, football players

• Pain worse climbing stairsPain worse climbing stairs

• Tenderness when patient supine, Tenderness when patient supine, knee flexed to 90knee flexed to 90oo

Ankle and Foot

Peroneal Tendonitis

• Peroneal tendons cross behind Peroneal tendons cross behind lateral malleoluslateral malleolus

• Running, jumping, sprainRunning, jumping, sprain

• Holding foot up and out against Holding foot up and out against downward pressure causes paindownward pressure causes pain

Peroneal Tendon Rupture

• Torn retinaculumTorn retinaculum

• Have patient dorsiflex and plantar Have patient dorsiflex and plantar flex with foot in inversionflex with foot in inversion

• Feel for “snapping” behind lateral Feel for “snapping” behind lateral malleolusmalleolus

Retrocalcaneal Bursitis

• Ankle overuse: excessive walking, Ankle overuse: excessive walking, running, or jumpingrunning, or jumping

• Heel pain: especially with walking, Heel pain: especially with walking, running, palpationrunning, palpation

• Haglund disease: bony ridge on Haglund disease: bony ridge on posterosuperior calcaneusposterosuperior calcaneus

• Treatment: open heels (clogs), Treatment: open heels (clogs), bare feet, sandals, or heel liftbare feet, sandals, or heel lift

Plantar Fasciitis

• Policeman's heel / soldier's heel: Policeman's heel / soldier's heel: associated with heel spursassociated with heel spurs

• Degenerated plantar fascial band Degenerated plantar fascial band at origin on medial calcaneousat origin on medial calcaneous

• Heel pain worse in morning and Heel pain worse in morning and after long periods of restafter long periods of rest

• May be relieved with activityMay be relieved with activity

Plantar Fasciitis

• Microtears in fascia from overuse?Microtears in fascia from overuse?

• Eliminate precipitators, rest, Eliminate precipitators, rest, strength and stretching exercises, strength and stretching exercises, arch supports, and night splintsarch supports, and night splints

• Sometimes need steroid injectionSometimes need steroid injection

• Risk of plantar fascia rupture and Risk of plantar fascia rupture and fat pad atrophyfat pad atrophy

Tarsal Tunnel Syndrome

• Between medial malleolus and Between medial malleolus and flexor retinaculumflexor retinaculum

• Vague pain in sole of foot: burning Vague pain in sole of foot: burning or tinglingor tingling

• Worse with activity, especially Worse with activity, especially standing, walking for long periodsstanding, walking for long periods

• Tender along course of nerveTender along course of nerve

FibromyalgiaFibromyalgia

Fibromyalgia

• Pain in muscles, joints, ligaments Pain in muscles, joints, ligaments and tendonsand tendons

• ““Tender points“Tender points“• Knees, elbows, hips, neckKnees, elbows, hips, neck

• 5% of population, including kids5% of population, including kids

• Main symptom: sensitivity to painMain symptom: sensitivity to pain

Fibromyalgia

• Pain: chronic, deep or burning, Pain: chronic, deep or burning, migratory, intermittentmigratory, intermittent

• Fatigue, poor sleepFatigue, poor sleep

• Numbness or tinglingNumbness or tingling

• ““Poor blood flow”Poor blood flow”

• Sensitivity to odors, bright lights, Sensitivity to odors, bright lights, loud noises, medicinesloud noises, medicines

Fibromyalgia

• Jaw painJaw pain

• Dry eyesDry eyes

• Difficulty focusingDifficulty focusing

• DizzinessDizziness

• Balance problemsBalance problems

• Chest painChest pain

• Rapid or irregular heartbeatRapid or irregular heartbeat

Fibromyalgia

• Shortness of breathShortness of breath

• Difficulty swallowingDifficulty swallowing

• HeartburnHeartburn

• GasGas

• Cramping abdominal painCramping abdominal pain

• Alternating diarrhea & constipation Alternating diarrhea & constipation

• Frequent urinationFrequent urination

Fibromyalgia

• Pain in bladder areaPain in bladder area

• UrgencyUrgency

• Pelvic painPelvic pain

• Painful menstrual periodsPainful menstrual periods

• Painful sexual intercoursePainful sexual intercourse

• DepressionDepression

• AnxietyAnxiety

Compare to Somatization

SomatizationSomatization FibromyalgiaFibromyalgia

VomitingVomiting Abdominal painAbdominal pain NauseaNausea BloatingBloating DiarrheaDiarrhea Leg / arm painLeg / arm pain Back painBack pain



Joint painJoint pain DysuriaDysuria HeadachesHeadaches BreathlessnessBreathlessness PalpitationsPalpitations Chest painChest pain DizzinessDizziness



AmnesiaAmnesia DysphagiaDysphagia Vision changesVision changes Weak musclesWeak muscles Sexual apathySexual apathy DyspareuniaDyspareunia ImpotenceImpotence



Dysmenorrhea Dysmenorrhea Irregular Irregular menstruationmenstruation

Excessive Excessive menstrual flowmenstrual flow

Fibromyalgia

• TreatmentTreatment

Reflex Sympathetic Dystrophy

• CausalgiaCausalgia

• Shoulder-hand syndromeShoulder-hand syndrome

• Sudeck's atrophySudeck's atrophy

• Post-traumatic pain syndromePost-traumatic pain syndrome

• Complex regional pain syndrome Complex regional pain syndrome type I and type IItype I and type II

• Sympathetically maintained pain Sympathetically maintained pain


• Distal extremity pain, tendernessDistal extremity pain, tenderness

• Bone demineralization, trophic skin Bone demineralization, trophic skin changes, vasomotor instabilitychanges, vasomotor instability

• Precipitating event in 2/3: injury, Precipitating event in 2/3: injury, stroke, MI, local trauma, fracturestroke, MI, local trauma, fracture

• Associated with emotional liability, Associated with emotional liability, depression, anxietydepression, anxiety


• Treatments: medication, physical Treatments: medication, physical therapy, sympathetic nerve blocks, therapy, sympathetic nerve blocks, psychological supportpsychological support• Possible sympathectomy or dorsal Possible sympathectomy or dorsal

column stimulatorcolumn stimulator

• Pain Clinic with coordinated plan Pain Clinic with coordinated plan may be helpfulmay be helpful

powerpoint bursitis tendonitis english

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