PERIARTICULAR

DISORDERS OF THE
EXTREMITIES

INTRODUCTION
Periarticular disorders have been increasing
in incidence in the last 20 to 30 years
Reasons include greater participation by
more people of a wide age group in
recreational sports

BURSITIS
Inflammation of a bursa
Results from excessive frictional forces from
overuse, trauma, systemic disease (e.g.,
rheumatoid arthritis, gout), or infection

BURSITIS
Subacromial bursitis (subdeltoid bursitis)
the most common form of bursitis
caused by repetitive overhead motion and often
accompanies rotator cuff tendinitis

Trochanteric bursitis
involves the bursa around the insertion of the
gluteus medius onto the greater trochanter of the
femur
pain over the lateral aspect of the hip and upper
thigh

BURSITIS
Olecranon bursitis
occurs over the posterior elbow
when the area is acutely inflamed, infection or
gout should be excluded

Achilles bursitis
located above the insertion of the tendon to the
calcaneus
results from overuse and wearing tight shoes

BURSITIS
Retrocalcaneal bursitis
located between the calcaneus and posterior
surface of the Achilles tendon
pain is experienced at the back of the heel, and
swelling appears on the medial and/or lateral
side of the tendon
occurs in association with spondyloarthropathies,
rheumatoid arthritis, gout, or trauma

BURSITIS
Ischial bursitis
weaver's bottom
affects the bursa separating the gluteus medius from
the ischial tuberosity
develops from prolonged sitting and pivoting on hard
surfaces

Iliopsoas bursitis
between the iliopsoas muscle and hip joint and is
lateral to the femoral vessels
Pain is experienced over this area and is made worse
by hip extension and flexion

BURSITIS
Anserine bursitis
inflammation of the sartorius bursa located over
the medial side of the tibia just below the knee
and under the conjoint tendon
manifested by pain on climbing stairs

Prepatellar bursitis
housemaid's knee
situated between the patella and overlying skin
caused by kneeling on hard surfaces

BURSITIS
TREATMENT
prevention of the aggravating situation
rest of the involved part
administration of a nonsteroidal antiinflammatory drug (NSAID)
local glucocorticoid injection.

ROTATOR CUFF TENDINITIS

and
IMPINGEMENT SYNDROME

Major cause of a painful shoulder

Caused by inflammation of the tendon(s)
Supraspinatus tendon is the most often
affected

because of its repeated impingement

(impingement syndrome) between the humeral
head and the undersurface of the anterior third of
the acromion and coracoacromial ligament
above

ROTATOR CUFF TENDINITIS

Tendon of the infraspinatus and that of the
long head of the biceps are less commonly
involved
Begins with edema and hemorrhage of the
rotator cuff
Later evolves to fibrotic thickening
Eventually to rotator cuff degeneration with
tendon tears and bone spurs

ROTATOR CUFF TENDINITIS

Symptoms usually begin after injury or
overuse
Occurs especially with activities involving
elevation of the arm with some degree of
forward flexion
Impingement syndrome occurs in persons
participating in baseball, tennis, swimming, or
occupations that require repeated elevation of
the arm

ROTATOR CUFF TENDINITIS

Persons above age 40 are particularly
susceptible
Patients usually complain of a dull aching in
the shoulder, which may interfere with sleep
Severe pain is experienced when the arm is
actively abducted into an overhead position
arc between 60 and 120 is especially
painful
Tenderness is present over the lateral aspect
of the humeral head just below the acromion

Treatment

NSAIDs
Local glucocorticoid injection
Physical therapy
In patients refractory to conservative
treatment, surgical decompression of the
subacromial space may be necessary

Calcific Tendinitis
Characterized by deposition of calcium salts,
primarily hydroxyapatite, within a tendon
Exact mechanism of calcification is not
known
Supraspinatus tendon is most often affected
frequently impinged on and has a reduced blood
supply when the arm is abducted

Usually develops after age 40

Bicipital Tendinitis and

Rupture
Produced by friction on the tendon of the
long head of the biceps as it passes through
the bicipital groove
Anterior shoulder pain that radiates down the
biceps into the forearm
Abduction and external rotation of the arm
are painful and limited
Bicipital groove is very tender to palpation

Bicipital Tendinitis and

Rupture
Pain may be elicited along the course of the
tendon by resisting supination of the forearm
with the elbow at 90 (Yergason's supination
sign)
Acute rupture of the tendon may occur with
vigorous exercise of the arm and is often
painful

Yergasons sign

De Quervain's Tenosynovitis
inflammation involves the abductor pollicis
longus and the extensor pollicis brevis as
these tendons pass through a fibrous sheath
at the radial styloid process
Usual cause is repetitive twisting of the wrist
May occur in pregnancy, and it also occurs in
mothers who hold their babies with the
thumb outstretched

De Quervain's Tenosynovitis

De Quervain's Tenosynovitis
Pain on grasping with their thumb, such as with
pinching
Swelling and tenderness are often present over
the radial styloid process
Finkelstein sign is positive
elicited by having the patient place the thumb in the
palm and close the fingers over it
wrist is then ulnarly deviated, resulting in pain over the
involved tendon sheath in the area of the radial styloid

Finkelstein's test for

DeQuervain's tenosynovitis

Treatment
initially of splinting the wrist
NSAID
When severe or refractory to conservative
treatment, glucocorticoid injections can be
very effective.

Patellar Tendinitis
(Jumper's Knee)
Involves the patellar tendon at its attachment
to the lower pole of the patella
Experience pain when
jumping during basketball or volleyball,
going up stairs
doing deep knee squats

Tenderness is noted on examination over the

lower pole of the patella

ADHESIVE CAPSULITIS
Frozen shoulder
Characterized by pain and restricted
movement of the shoulder, usually in the
absence of intrinsic shoulder disease
Night pain is often present in the affected
shoulder
May follow bursitis or tendinitis of the
shoulder

ADHESIVE CAPSULITIS
Prolonged immobility of
the arm contributes to
the development
Capsule of the
shoulder is thickened,
and a mild chronic
inflammatory infiltrate
and fibrosis may be
present

ADHESIVE CAPSULITIS
Occurs more commonly in women after
age 50
Pain and stiffness usually develop gradually
over several months to a year but progress
rapidly in some patients
Pain may interfere with sleep
Shoulder is tender to palpation, and both
active and passive movement are restricted

ADHESIVE CAPSULITIS
Radiographs of the shoulder show
osteopenia
Diagnosis is confirmed by arthrography,
only a limited amount of contrast material,
usually <15 mL, can be injected under pressure
into the shoulder joint
Slow but forceful injection of contrast material
into the joint may lyse adhesions and stretch the
capsule, resulting in improvement of shoulder
motion

ADHESIVE CAPSULITIS
In most patients, the condition improves
spontaneously 13 years after onset
Although pain usually improves, most
patients are left with some limitation of
shoulder motion
Early mobilization of the arm following an
injury to the shoulder may prevent the
development of this disease

ADHESIVE CAPSULITIS
Manipulation under anesthesia may be
helpful in some patients
Once the disease is established, therapy
may have little effect on its natural course
Local injections of glucocorticoids, NSAIDs,
and physical therapy may provide temporary
relief of symptoms

Lateral Epicondylitis
(Tennis Elbow)
A painful condition involving the soft tissue
over the lateral aspect of the elbow
Pain originates at or near the site of
attachment of the common extensors to the
lateral epicondyle
May radiate into the forearm and dorsum of
the wrist

Lateral Epicondylitis
(Tennis Elbow)
Postulated to be caused by small tears of the
extensor aponeurosis resulting from
repeated resisted contractions of the
extensor muscles
Pain usually appears after work or
recreational activities involving repeated
motions of wrist extension and supination
against resistance

Lateral Epicondylitis
(Tennis Elbow)
The injury in tennis usually occurs when
hitting a backhand with the elbow flexed
Most patients with this disorder injure
themselves in activities other than tennis,
such as pulling weeds, carrying suitcases or
briefcases, or using a screwdriver
Shaking hands and opening doors can
reproduce the pain

Lateral Epicondylitis
(Tennis Elbow)

Treatment
Rest along with administration of an NSAID
Ultrasound, icing, and friction massage may
also help relieve pain
When pain is severe, the elbow is placed in a
sling or splinted at 90 of flexion
When the pain is acute and well localized,
injection of a glucocorticoid using a smallgauge needle may be effective

Treatment
Following injection, the patient should be
advised to rest the arm for at least 1 month
and avoid activities that would aggravate the
elbow
Once symptoms have subsided, the patient
should begin rehabilitation to strengthen and
increase flexibility of the extensor muscles
before resuming physical activity involving
the arm

Treatment
Forearm band placed 2.55.0 cm (12 in.)
below the elbow may help to reduce tension
on the extensor muscles at their attachment
to the lateral epicondyle
Patient is advised to restrict activities
requiring forcible extension and supination of
the wrist

MEDIAL EPICONDYLITIS
Golfers elbow
An overuse syndrome resulting in pain over
the medial side of the elbow with radiation
into the forearm
Secondary to repetitive resisted motions of
wrist flexion and pronation
Lead to microtears and granulation tissue at the
origin of the pronator teres and forearm flexors,
particularly the flexor carpi radialis

MEDIAL EPICONDYLITIS

MEDIAL EPICONDYLITIS
Usually seen in patients >35 years and is
much less common than lateral epicondylitis
Most often in work-related repetitive activities
but also occurs with recreational activities
such as swinging a golf club (golfer's elbow)
or throwing a baseball

MEDIAL EPICONDYLITIS
P.E. - tenderness just distal to the medial
epicondyle over the origin of the forearm
flexors
Pain can be reproduced by resisting wrist
flexion and pronation with the elbow
extended
Radiographs are usually normal

MEDIAL EPICONDYLITIS
Differential Diagnosis:
tears of the pronator teres
acute medial collateral ligament tear
medial collateral ligament instability

Ulnar neuritis has been found in 2550% of

patients with medial epicondylitis
associated with tenderness over the ulnar nerve
at the elbow as well as hypesthesia and
paresthesia on the ulnar side of the hand.

Treatment
Initial treatment of medial epicondylitis is
conservative:

Rest
NSAIDs
friction massage
Ultrasound
Icing

Some patients may require splinting

Treatment
Rest arm for at least 1 month
Physical therapy started once the pain has
subsided
Chronic debilitating medial epicondylitis that
remains unresponsive after at least a year of
treatment
surgical release of the flexor muscle at its origin
may be necessary and is often successful

PLANTAR FASCIITIS
Common cause of foot pain in adults
Peak incidence occurring in people between
the ages of 4060 years
May also be seen more frequently in a
younger population consisting of runners,
aerobic exercise dancers, and ballet dancers

PLANTAR FASCIITIS
Pain originates at or near the site of the
plantar fascia attachment to the medial
tuberosity of the calcaneus
The plantar fascia is a thick fibrous band that
extends distally, dividing into five slips that
insert into each metatarsal head
function is to tighten and elevate the
longitudinal arch as well as to invert the hind
foot during the push-off phase of gait

PLANTAR FASCIITIS

PLANTAR FASCIITIS
Result of repetitive microtrauma to the tissue
Pathology of involved fascia reveals
degeneration of fibrous tissue with or without
fibroblast proliferation and chronic
inflammation

PLANTAR FASCIITIS
Factors that increase the risk of developing
plantar fasciitis include:

Obesity
pes planus (excessive pronation of the foot)
pes cavus (high-arched foot)
limited dorsiflexion of the ankle
prolonged standing, walking on hard surfaces,
faulty shoes

In runners, factors include excessive running

and a change to a harder running surface

PLANTAR FASCIITIS
Onset of inferior heel pain of plantar fasciitis is
typically gradual, but in some individuals it can
be abrupt
Severe pain with the first steps on arising in
the morning or following inactivity during the
day (gel phenomenon)
Pain usually lessens with weight-bearing
activity during the day, only to worsen with
continued activity

PLANTAR FASCIITIS
Pain is made worse on walking barefoot or
up stairs
Physical examination
maximal tenderness is elicited on palpation over
the inferior heel corresponding to the site of
attachment of the plantar fascia

PLANTAR FASCIITIS
Plain radiographs may show heel spurs
Calcaneal stress fracture may be detected
on plain radiographs
Bone scan is more sensitive
demonstrates increased uptake at the
attachment of the plantar fascia to the calcaneus

PLANTAR FASCIITIS
Ultrasonography in plantar fasciitis can
demonstrate thickening of the fascia and
diffuse hypoechogenicity
indicating edema at the attachment of the plantar
fascia to the calcaneus

MRI is a sensitive method for detecting

plantar fasciitis
but it is usually not required for establishing the
diagnosis

PLANTAR FASCIITIS
Differential diagnosis of inferior heel pain
includes:

Calcaneal stress fractures

Spondyloarthritides
Rheumatoid arthritis
Gout
Neoplastic or infiltrative bone processes
Nerve compression/entrapment syndromes

PLANTAR FASCIITIS
Resolution of symptoms occurs within 12
months in more than 80% of patients with
plantar fasciitis
Treatment should begin immediately with the
diagnosis of plantar fasciitis
Initial treatment consists of ice, heat,
massage, and stretching
Stretching of the plantar fascia and calf muscles
are commonly employed and can be beneficial

PLANTAR FASCIITIS
Orthotics provide medial arch support and
can be effective in relieving symptoms
Foot strapping or taping are commonly
performed
some patients may benefit by wearing a night
splint designed to keep the ankle in a neutral
position

PLANTAR FASCIITIS
Short course of NSAIDs can be given to alleviate
symptoms in patients where the benefits outweigh
the risks
Local glucocorticoid injections have also been
shown to be efficacious
but this may carry an increased risk for plantar fascia
rupture

Plantar fasciotomy is reserved for those patients

who have failed to improve after at least 612
months of conservative treatment

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