Sunteți pe pagina 1din 52

Bursitis, Tendonitis

Dr. Amit Patel (BPT, MPT – Ortho)


Associate Professor & Vice Principal,
JG College of Physiotherapy,
Ahmedabad
Bursae
• Closed, round, flat sacs
• Lined by synovium
• May or may not communicate with
synovial cavity
• Occur at areas of friction between
skin and underlying ligaments /
bone
Bursae
• Permit lubricated movement over
areas of potential impingement
• Many are nameless
• ~78 on each side of body
• New bursae may form anywhere
from frequent irritation
Bursitis
Inflamed by… Systemic
…chronic friction disease…
rheumatoid
…trauma
arthritis,
…crystal psoriatic
deposition arthritis, gout
…infection ankylosing
spondylitis
Bursitis
• Inflammation causes bursal
synovial cells to thicken
• Excess fluid accumulates inside
and around affected bursae
Tendons
• Tendon sheaths composed of
same synovial cells as bursae
• Inflamed in similar manner
• Tendonitis: inflammation of tendon
only
• Tenosynovitis: inflammation of
tendon plus its sheath
Tendonitis
• Most common causes: mechanical
overload and repetitive
microtrauma
• Most injuries multifactorial
Tendonitis
• Intrinsic factors: malalignment,
poor muscle flexibility, muscle
weakness or imbalance
• Extrinsic factors: design of
equipment or workplace and
excessive duration, frequency, or
intensity of activity
Healing Phase
• Classic inflammatory signs: pain,
warmth, erythema, swelling
• Healing goes through proliferative
and maturation
• 6 to 12 weeks: organization and
collagen cross-linking mature to
preinjury strength
Physical Examination
• Careful palpation
• Range of motion
• Heat, warmth, redness
Lab Studies
• Chronic rheumatic disease: mild
anemia
• Rheumatoid factor, antinuclear
antibody, for follow-up..
Synovial Fluid
• Especially crystalline, suppurative
etiology
• Appearance, cell count and diff,
crystal analysis, Gram’s stain
• Positive Gram’s: diagnostic
• Negative Gram’s: cannot rule out
Management
• Rest
• Pain relief: Medication, heat, cold
• No advantage to NSAIDs
• Exceptions: olecranon bursitis and
prepatellar bursitis have a
moderate risk of being infected
(Staphylococcus aureus)
Management
• Shoulder: immobilize few days
• Risk of adhesive capsulitis
• Lateral epicondylitis: forearm brace
• Olecranon bursitis: compression
dressing
Management
• De Quervain’s: splint wrist and
thumb in 20o dorsiflexion
• Achilles tendonitis: heel lift or splint
in slight plantar flexion
Local
Injection
Local Injection
• Lidocaine or steroid injection can
overcome refractory pain.
• Adjunct to other modalities: pain
control, Physiotherapy,relative
rest, immobilization
• Additional pain control: NSAIDs,
acupuncture, ultrasound, ice, heat,
electrical nerve stimulation.
• Analgesics + exercise: better
results than exercise alone
• Eliminate provoking factors
• Avoid repeat steroid injection
unless good prior response
• Wait at least 6 weeks between
injections in same site
Contraindication: Absolute
• Bacteremia
• Infectious arthritis
• Periarticular cellulitis
• Adjacent osteomyelitis
• Significant bleeding disorder
• Hypersensitivity to steroid
• Osteochondral fracture
Contraindication: Relative
• Violation of skin integrity
• Chronic local infection
• Anticoagulant use
• Poorly controlled diabetes
• Internal joint derangement
• Hemarthrosis
• Preexisting tendon injury
• Partial tendon rupture
Some
specific
entities…
Bicipital Tendonitis
• Risk: repeatedly flex elbow against
resistance: weightlifter, swimmer
• Tendon goes through bicipital
(intertubercular) groove
• Pain with elbow at 90° flexion, arm
internally / externally rotated
Bicipital Tendonitis
• Range of motion: normal or
restricted
• Strength: normal
• Tenderness: bicipital groove
• Pain: elevate shoulder, reach hip
pocket, pull a back zipper
Bicipital Tendonitis
• Lipman test: "rolling" bicipital
tendon produces localized
tenderness
• Yergason test: pain along bicipital
groove when patient attempts
supination of forearm against
resistance & Shoulder external
rotation, holding elbow flexed at
90° against side of body
Calcific Tendonitis

• Calcific (calcareous) tendonitis:


hydroxyapatite deposits in one or
more rotator cuff tendons
• Commonly supraspinatus
• Sometimes rupture into adjacent
subacromial bursa
• Acute deltoid pain, tenderness
Supraspinatus Tendonitis

• Clinically similar: difficult to


differentiate
• Rotator cuff: teres minor,
supraspinatus, infraspinatus,
subscapularis
• Insert as conjoined tendon into
greater tuberosity of humerus
Supraspinatus Tendonitis

Jobe’s sign, OR “Empty can test”


• Abduct arm to 90o in the scapular
plane, then internally rotate arms
to thumbs pointed downward
• Place downward force on arms:
weakness or pain if supraspinatus
Supraspinatus Tendonitis
• Other tests: Neer, Hawkins
Subacromial Bursitis

• Subacromial bursa: superior and


lateral to supraspinatus tendon
• Tendon and bursa in space
between acromion process and
head of humerus
• Prone to impingement
Subacromial Bursitis

• Patient holds arm protectively


against chest wall
• May be incapacitating
• All ROM disturbed, but internal
rotation markedly limited
• Diffuse perihumeral tenderness
• X-ray: hazy shadow
Rotator Cuff Tear
• Drop arm test: arm passively
abducted at 90o, patient asked to
maintain  dropped arm
represents large rotator cuff tear
• Shrug sign: attempt to abduct arm
results in shrug only
Elbow and Wrist
Lateral Epicondylitis
• Pain at insertion of extensor carpi
radialis and extensor digitorum
muscles
• Radiohumeral bursitis: tender over
radiohumeral groove
• Tennis elbow: tender over lateral
epicondyle
Lateral Epicondylitis
• History of repetitive overhead
motion: golfing, gardening, using
tools
• Worse when middle finger
extended against resistance with
wrist and the elbow in extension
• Worse when wrist extended
against resistance
Medial Epicondylitis
• “Golfer's elbow” or “pitcher’s
elbow” similar
• Much less common
• Worse when wrist flexed against
resistance
• Tender medial epicondyle
Cubital Tunnel Syndrome
• Ulnar nerve passes through cubital
tunnel just behind ulnar elbow
• Numbness and pain in small and
ring fingers
• Initial treatment: rest, splint
Olecranon Bursitis
• “Student's” or “barfly elbow”
• Most frequent site of septic bursitis
• Aseptic: motion at elbow joint
complete and painless
• Septic: all motion usually painful
Olecranon Bursitis
Aseptic olecranon bursitis
• Cosmetically bothersome, usually
resolves spontaneously
• If bothersome, aspiration and
steroid injection leads to speed
resolution
• Oral NSAID after steroid injection
does not affect outcome
Septic Olecranon Bursitis
• Most common septic bursitis:
olecranon and prepatellar
• Secondary to acute trauma / skin
breakage
• Impossible to differentiate acute
gouty Olecranon bursitis from
septic bursitis without laboratory
analysis.
de Quervain’s Disease
• Chronic teno-synovitis due to
narrowed tendon sheaths around
abductor policis longus and
extensor pollicis brevis muscles
de Quervain’s Disease
• 1st dorsal compartment
• Radial border of anatomic snuffbox
• Steroid injections relieve most
symptoms.
Trigger Finger
• Digital flexor tenosynovitis
• Stenosed tendon sheath
• Palmar surface over MC head
• Intermittent tendon “catch”
• “Locks” on awakening
• Most frequent: ring and middle
Trigger Finger
• Tendon sheath walls lined with
synovial cells
• Tendon unable to glide within
sheath
• Initial treatment: splint, moist heat,
NSAID.
Legs and Feet
Prepatellar Bursitis
• Housemaid’s knee / nun’s knee:
swelling with effusion of superficial
bursa over lower pole of patella
• Passive motion fully preserved
• Pain mild except during extreme
knee flexion or direct pressure
Prepatellar Bursitis
• Pressure from repetitive kneeling
on a firm surface: rug cutter's knee
• Rarely direct trauma
• Second most common site for
septic bursitis
Baker’s Cyst
• Pseudothrombophlebitis syndrome
• Herniated fluid-filled sacs of
articular synovial membrane that
extend into popliteal fossa
• Causes: trauma, rheumatoid
arthritis, gout, osteoarthritis
• Pain worse with active knee flexion
Baker’s Cyst
• Can mimic deep venous
thrombosis
• Ultrasound essential
• Many resolve over weeks
• May require surgery
• Steroid injections not performed:
risk of neurovascular injury
Ankle and Foot
Peroneal Tendonitis
• Peroneal tendons cross behind
lateral malleolus
• Running, jumping, sprain
• Holding foot up and out against
downward pressure causes pain
Retrocalcaneal Bursitis
• Ankle overuse: excessive walking,
running, or jumping
• Heel pain: especially with walking,
running, palpation
• Treatment: open heels (clogs),
bare feet, sandals, or heel lift.

S-ar putea să vă placă și