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Bursitis and tendonitis are inflammatory conditions of the bursae (fluid-filled sacs) and tendons that can be caused by repetitive overuse, trauma, or systemic diseases. Common symptoms include pain, swelling, warmth, and reduced range of motion near the affected area. Treatment involves rest, ice/heat, braces or splints, medications, and injections to reduce inflammation and promote healing.
Bursitis and tendonitis are inflammatory conditions of the bursae (fluid-filled sacs) and tendons that can be caused by repetitive overuse, trauma, or systemic diseases. Common symptoms include pain, swelling, warmth, and reduced range of motion near the affected area. Treatment involves rest, ice/heat, braces or splints, medications, and injections to reduce inflammation and promote healing.
Bursitis and tendonitis are inflammatory conditions of the bursae (fluid-filled sacs) and tendons that can be caused by repetitive overuse, trauma, or systemic diseases. Common symptoms include pain, swelling, warmth, and reduced range of motion near the affected area. Treatment involves rest, ice/heat, braces or splints, medications, and injections to reduce inflammation and promote healing.
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.