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Bursitis, Tendonitis, Fibromyalgia, and RSD Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA

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Presentation on theme: "Bursitis, Tendonitis, Fibromyalgia, and RSD Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA"— Presentation transcript:

1 Bursitis, Tendonitis, Fibromyalgia, and RSD Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA

2 Objectives 1.Explain how bursitis and tendonitis are similar 2.Explain how bursitis and tendonitis differ from from another 3.List phases in development and healing of bursitis and tendonitis

3 Objectives 4.List common types of bursitis and tendonitis found at the: uShoulder uElbow uWrist 5. List indications / contraindications for injection therapy of bursitis and tendonitis uHip uKnee uAnkle

4 Objectives 6.Describe typical findings in a patient with fibromyalgia 7.Describe typical findings in a patient with reflex sympathetic dystrophy

5 Sports Society more athleticSociety more athletic Physical activity  health benefitsPhysical activity  health benefits Overuse syndromes increaseOveruse syndromes increase 25% to 50% of participants will experience tendonitis or bursitis25% to 50% of participants will experience tendonitis or bursitis

6 Workplace Musculoskeletal disorders from… …repetitive motions …localized contact stress …awkward positions …vibrations …forceful exertions Ergonomic design  incidenceErgonomic design  incidence

7 Bursae Closed, round, flat sacsClosed, round, flat sacs Lined by synoviumLined by synovium May or may not communicate with synovial cavityMay or may not communicate with synovial cavity Occur at areas of friction between skin and underlying ligaments / boneOccur at areas of friction between skin and underlying ligaments / bone

8 Bursae Permit lubricated movement over areas of potential impingementPermit lubricated movement over areas 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 from frequent irritationNew bursae may form anywhere from frequent irritation

9 Bursitis Inflamed by… …chronic friction …trauma …crystal deposition …infection …systemic disease: rheumatoid arthritis, psoriatic arthritis, gout ankylosing spondylitis

10 Bursitis Inflammation causes bursal synovial cells to thickenInflammation causes bursal synovial cells to thicken Excess fluid accumulates inside and around affected bursaeExcess fluid accumulates inside and around affected bursae

11 Tendons Tendon sheaths composed of same synovial cells as bursaeTendon sheaths composed of same synovial cells as bursae Inflamed in similar mannerInflamed in similar manner Tendonitis: inflammation of tendon onlyTendonitis: inflammation of tendon only Tenosynovitis: inflammation of tendon plus its sheathTenosynovitis: inflammation of tendon plus its sheath

12 Tendons Inflammatory changes involving sheath well documentedInflammatory changes involving sheath well documented Inflammatory lesions of tendon alone not well documentedInflammatory lesions of tendon alone not well documented Distinction uncertain: terms tendonitis and tenosynovitis used interchangeablyDistinction uncertain: terms tendonitis and tenosynovitis used interchangeably

13 Tendons Most overuse syndromes are NOT inflammatoryMost overuse syndromes are NOT inflammatory Biopsy: no inflammatory cellsBiopsy: no inflammatory cells High glutamate concentrationsHigh glutamate concentrations NSAIDs / steroids: no advantageNSAIDs / steroids: no advantage TendonITIS a misnomerTendonITIS a misnomer

14 Bursitis / Tendonitis Most common causes: mechanical overload and repetitive microtraumaMost common causes: mechanical overload and repetitive microtrauma Most injuries multifactorialMost injuries multifactorial

15 Bursitis / Tendonitis Intrinsic factors: malalignment, poor muscle flexibility, muscle weakness or imbalanceIntrinsic factors: malalignment, poor muscle flexibility, muscle weakness or imbalance Extrinsic factors: design of equipment or workplace and excessive duration, frequency, or intensity of activityExtrinsic factors: design of equipment or workplace and excessive duration, frequency, or intensity of activity

16 Immediate Phase Release of chemotactic and vasoactive chemical mediatorsRelease of chemotactic and vasoactive chemical mediators Vasodilation and cellular edemaVasodilation and cellular edema  PMNs perpetuate process  PMNs perpetuate process Lasts 48 hours to 2 weeksLasts 48 hours to 2 weeks Repetitive insults prolong inflammatory stageRepetitive insults prolong inflammatory stage

17 Healing Phase Classic inflammatory signs: pain, warmth, erythema, swellingClassic inflammatory signs: pain, warmth, erythema, swelling Healing goes through proliferative and maturationHealing goes through proliferative and maturation 6 to 12 weeks: organization and collagen cross-linking mature to preinjury strength6 to 12 weeks: organization and collagen cross-linking mature to preinjury strength

18 History Changes in sports activity, work activities, or workplaceChanges in sports activity, work activities, or workplace Cause not always foundCause not always found Pregnancy, quinolone therapy, connective tissue disorders, systemic illnessPregnancy, quinolone therapy, connective tissue disorders, systemic illness

19 History Most common complaint: PAINMost common complaint: PAIN Acute or chronicAcute or chronic Frequently more severe after periods of restFrequently more severe after periods of rest May resolve quickly after initial movement only to become throbbing pain after exerciseMay resolve quickly after initial movement only to become throbbing pain after exercise

20 Articular vs. Periarticular In joint capsule Joint pain / warmth / swellingJoint pain / warmth / swelling Worse with active & passive movementWorse with active & passive movement All parts of joint involvedAll parts of joint involved Periarticular Pain not uniform across jointPain not uniform across joint Pain only certain movementsPain only certain movements Pain character & radiation varyPain character & radiation vary

21 Physical Exam Careful palpationCareful palpation Range of motionRange of motion Heat, warmth, rednessHeat, warmth, redness

22 Lab Studies Screening tests: CBC, CRP, ESRScreening tests: CBC, CRP, ESR Chronic rheumatic disease: mild anemiaChronic rheumatic disease: mild anemia Rheumatoid factor, antinuclear antibody, antistreptolysin O titers, and Lyme serologies for follow-upRheumatoid factor, antinuclear antibody, antistreptolysin O titers, and Lyme serologies for follow-up Serum uric acid: not helpfulSerum uric acid: not helpful

23 Synovial Fluid Especially crystalline, suppurative etiologyEspecially crystalline, suppurative etiology Appearance, cell count and diff, crystal analysis, Gram’s stainAppearance, cell count and diff, crystal analysis, Gram’s stain Positive Gram’s: diagnosticPositive Gram’s: diagnostic Negative Gram’s: cannot rule outNegative Gram’s: cannot rule out

24 Management RestRest Pain relief: meds, heat, coldPain relief: meds, heat, cold No advantage to NSAIDsNo advantage to NSAIDs Exceptions: olecranon bursitis and prepatellar bursitis have a moderate risk of being infected (Staphylococcus aureus)Exceptions: olecranon bursitis and prepatellar bursitis have a moderate risk of being infected (Staphylococcus aureus)

25 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 dressingOlecranon bursitis: compression dressing

26 Management De Quervain’s: splint wrist and thumb in 20 o dorsiflexionDe Quervain’s: splint wrist and thumb in 20 o dorsiflexion Achilles tendonitis: heel lift or splint in slight plantar flexionAchilles tendonitis: heel lift or splint in slight plantar flexion

27 Local Injection

28 Lidocaine or steroid injection can overcome refractory painLidocaine or steroid injection can overcome refractory pain Steroids universally given, often with great successSteroids universally given, often with great success No good prospective data to support or refute therapeutic benefitNo good prospective data to support or refute therapeutic benefit

29 Local Injection Short course of oral steroid may produce statistically similar resultsShort course of oral steroid may produce statistically similar results Primary goal of steroid injection: relieve pain so patient can participate in physical rehabPrimary goal of steroid injection: relieve pain so patient can participate in physical rehab

30 Local Injection Adjunct to other modalities: pain control, PT, exercise, OT, relative rest, immobilizationAdjunct to other modalities: pain control, PT, exercise, OT, relative rest, immobilization Additional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, electrical nerve stimulationAdditional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, electrical nerve stimulation

31 Local Injection Analgesics + exercise: better results than exercise aloneAnalgesics + exercise: better results than exercise alone Eliminate provoking factorsEliminate provoking factors Avoid repeat steroid injection unless good prior responseAvoid repeat steroid injection unless good prior response Wait at least 6 weeks between injections in same siteWait at least 6 weeks between injections in same site

32 Indications Diagnosis Obtain fluid for analysisObtain fluid for analysis Eliminate referred painEliminate referred painTherapy Give pain reliefGive pain relief Deliver therapeutic agentsDeliver therapeutic agents

33 Contraindication: Absolute BacteremiaBacteremia Infectious arthritisInfectious arthritis Periarticular cellulitisPeriarticular cellulitis Adjacent osteomyelitisAdjacent osteomyelitis Significant bleeding disorderSignificant bleeding disorder Hypersensitivity to steroidHypersensitivity to steroid Osteochondral fractureOsteochondral fracture

34 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

35 Preparations Local anestheticLocal anesthetic Hydrocortisone / corticosteroidHydrocortisone / corticosteroid Rapid anti-inflammatory effectRapid anti-inflammatory effect Categorized by solubility and relative potencyCategorized by solubility and relative potency High solubility  short durationHigh solubility  short duration Absorbed, dispersed more rapidlyAbsorbed, dispersed more rapidly

36 Preparations Triamcinolone hexacetonide: least soluble, longest durationTriamcinolone hexacetonide: least soluble, longest duration Potential for subcutaneous atrophyPotential for subcutaneous atrophy Intra-articular injections onlyIntra-articular injections only Methylprednisolone acetate (Depo- Medrol®): reasonable first choice for most ED indicationsMethylprednisolone acetate (Depo- Medrol®): reasonable first choice for most ED indications

37 Dosage Large bursa: subacromial, olecranon, trochanteric: 40 – 60 mg methylprednisoloneLarge bursa: subacromial, olecranon, trochanteric: 40 – 60 mg methylprednisolone Medium or wrist, knee, heel ganglion: 10 – 20 mgMedium or wrist, knee, heel ganglion: 10 – 20 mg Tendon sheath: de Quervain, flexor tenosynovitis: 5 – 15 mgTendon sheath: de Quervain, flexor tenosynovitis: 5 – 15 mg

38 Site Preparation Use careful aseptic techniqueUse careful aseptic technique Mark landmarks with skin pencil, tincture of iodine, or thimerosal (Merthiolate®) (sterile Q-tip)Mark landmarks with skin pencil, tincture of iodine, or thimerosal (Merthiolate®) (sterile Q-tip) Clean point of entry: povidone- iodine (Betadine®) and alcoholClean point of entry: povidone- iodine (Betadine®) and alcohol Do not need sterile drapesDo not need sterile drapes

39 Technique Make skin wheal: 1% lidocaine or 0.25% bupivacaine OR…Make skin wheal: 1% lidocaine or 0.25% bupivacaine OR… …use topical vapocoolant: e.g., Fluori-Methane® Use Z-tract technique: limits risk of soft tissue fistulaUse Z-tract technique: limits risk of soft tissue fistula Agitate syringe prior to injection: steroid can precipitate or layerAgitate syringe prior to injection: steroid can precipitate or layer

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

41 Complications: Delayed Localized subcutaneous or cutaneous atrophy at injection siteLocalized subcutaneous or cutaneous atrophy at injection site Small depression in skin with depigmentation, transparency, and occasional telangiectasiaSmall depression in skin with depigmentation, transparency, and occasional 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

42 Complications: Delayed 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 once every 3 to 4 monthsLimit injections to no more than once every 3 to 4 months Avoid major stress-bearing tendons: Achilles, patellarAvoid major stress-bearing tendons: Achilles, patellar

43 Complications: Delayed Systemic absorption slower than with oral steroidsSystemic absorption slower than with oral steroids Can suppress hypopituitary- adrenal axis for 2 to 7 daysCan suppress hypopituitary- adrenal axis for 2 to 7 days Can exacerbate hyperglycemia in diabetesCan exacerbate hyperglycemia in diabetes Abnormal uterine bleeding reportedAbnormal uterine bleeding reported

44 Some specific entities…

45 Bicipital Tendonitis Risk: repeatedly flex elbow against resistance: weightlifter, swimmerRisk: repeatedly flex elbow against resistance: weightlifter, swimmer Tendon goes through bicipital (intertubercular) grooveTendon goes through bicipital (intertubercular) groove Pain with elbow at 90° flexion, arm internally / externally rotatedPain with elbow at 90° flexion, arm internally / externally rotated

46 Bicipital Tendonitis Range of motion: normal or restrictedRange of motion: normal or restricted Strength: normalStrength: normal Tenderness: bicipital grooveTenderness: bicipital groove Pain: elevate shoulder, reach hip pocket, pull a back zipperPain: elevate shoulder, reach hip pocket, pull a back zipper

47 Bicipital Tendonitis Lipman test: "rolling" bicipital tendon produces localized tendernessLipman test: "rolling" bicipital tendon produces localized tenderness Yergason test: pain along bicipital groove when patient attempts supination of forearm against resistance, holding elbow flexed at 90° against side of bodyYergason test: pain along bicipital groove when patient attempts supination of forearm against resistance, holding elbow flexed at 90° against side of body

48 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Calcific (calcareous) tendonitis: hydroxyapatite deposits in one or more rotator cuff tendonsCalcific (calcareous) tendonitis: hydroxyapatite deposits in one or more rotator cuff tendons Commonly supraspinatusCommonly supraspinatus Sometimes rupture into adjacent subacromial bursaSometimes rupture into adjacent subacromial bursa Acute deltoid pain, tendernessAcute deltoid pain, tenderness

49 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Clinically similar: difficult to differentiateClinically similar: difficult to differentiate Rotator cuff: teres minor, supraspinatus, infraspinatus, subscapularisRotator cuff: teres minor, supraspinatus, infraspinatus, subscapularis Insert as conjoined tendon into greater tuberosity of humerusInsert as conjoined tendon into greater tuberosity of humerus

50 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Jobe’s sign, AKA “empty can test” Abduct arm to 90 o in the scapular plane, then internally rotate arms to thumbs pointed downwardAbduct arm to 90 o in the scapular plane, then internally rotate arms to thumbs pointed downward Place downward force on arms: weakness or pain if supraspinatusPlace downward force on arms: weakness or pain if supraspinatus

51 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Other tests: Neer, HawkinsOther tests: Neer, Hawkins Passively abduct arm to 90°, then passively lower arm to 0° and ask patient to actively abduct arm to 30°Passively abduct arm to 90°, then passively lower arm to 0° and ask patient to actively abduct arm to 30°

52 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis If can abduct to 30° but no further, suspect deltoidIf can abduct to 30° but no further, suspect deltoid If cannot get to 30°, but if placed at 30° can actively abduct arm further, suspect supraspinatusIf cannot get to 30°, but if placed at 30° can actively abduct arm further, suspect supraspinatus If uses hip to propel arm from 0° to beyond 30°, suspect supraspinatusIf uses hip to propel arm from 0° to beyond 30°, suspect supraspinatus

53 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Subacromial bursa: superior and lateral to supraspinatus tendonSubacromial bursa: superior and lateral to supraspinatus tendon Tendon and bursa in space between acromion process and head of humerusTendon and bursa in space between acromion process and head of humerus Prone to impingementProne to impingement

54 Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis Patient holds arm protectively against chest wallPatient holds arm protectively against chest wall May be incapacitatingMay be incapacitating All ROM disturbed, but internal rotation markedly limitedAll ROM disturbed, but internal rotation markedly limited Diffuse perihumeral tendernessDiffuse perihumeral tenderness X-ray: hazy shadowX-ray: hazy shadow

55 Rotator Cuff Tear Drop arm test: arm passively abducted at 90 o, patient asked to maintain  dropped arm represents large rotator cuff tearDrop arm test: arm passively abducted at 90 o, patient asked to maintain  dropped arm represents large rotator cuff tear Shrug sign: attempt to abduct arm results in shrug onlyShrug sign: attempt to abduct arm results in shrug only

56 Elbow and Wrist

57 Lateral Epicondylitis Pain at insertion of extensor carpi radialis and extensor digitorum musclesPain at insertion of extensor carpi radialis and extensor digitorum muscles Radiohumeral bursitis: tender over radiohumeral grooveRadiohumeral bursitis: tender over radiohumeral groove Tennis elbow: tender over lateral epicondyleTennis elbow: tender over lateral epicondyle

58 Lateral Epicondylitis History repetitive overhead motion: golfing, gardening, using toolsHistory repetitive overhead motion: golfing, gardening, using tools Worse when middle finger extended against resistance with wrist and the elbow in extensionWorse when middle finger extended against resistance with wrist and the elbow in extension Worse when wrist extended against resistanceWorse when wrist extended against resistance

59 Medial Epicondylitis “Golfer's elbow” or “pitcher’s elbow” similar“Golfer's elbow” or “pitcher’s elbow” similar Much less commonMuch less common Worse when wrist flexed against resistanceWorse when wrist flexed against resistance Tender medial epicondyleTender medial epicondyle

60 Cubital Tunnel Syndrome Ulnar nerve passes through cubital tunnel just behind ulnar elbowUlnar nerve passes through cubital tunnel just behind ulnar elbow Numbness and pain small and ring fingersNumbness and pain small and ring fingers Initial treatment: rest, splintInitial treatment: rest, splint

61 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 complete and painlessAseptic: motion at elbow joint complete and painless Septic: all motion usually painfulSeptic: all motion usually painful

62 Olecranon Bursitis Aseptic olecranon bursitis Cosmetically bothersome, usually resolves spontaneouslyCosmetically bothersome, usually resolves spontaneously If bothersome, aspiration and steroid injection speed resolutionIf bothersome, aspiration and steroid injection speed resolution Oral NSAID after steroid injection does not affect outcomeOral NSAID after steroid injection does not affect outcome

63 Septic Olecranon Bursitis Most common septic bursitis: olecranon and prepatellarMost common septic bursitis: olecranon and prepatellar 2 o to acute trauma / skin breakage2 o to acute trauma / skin breakage Impossible to differentiate acute gouty olecranon bursitis from septic bursitis without laboratory analysisImpossible to differentiate acute gouty olecranon bursitis from septic bursitis without laboratory analysis

64 Ganglion Cysts Swelling on dorsal wristSwelling on dorsal wrist ~60% of wrist and hand soft tissue tumors~60% of wrist and hand soft tissue tumors Etiology obscureEtiology obscure Lined with mesothelium or synoviumLined with mesothelium or synovium Arise from tendon sheaths or near joint capsuleArise from tendon sheaths or near joint capsule

65 Carpal Tunnel Syndrome Median nerve compression in fibro-osseous tunnel of wristMedian nerve compression in fibro-osseous tunnel of wrist Pain at wrist that sometimes radiates upward into forearmPain at wrist that sometimes radiates upward into forearm Associated with tingling and paresthesias of palmar side of index and middle fingers and radial half of the ring fingerAssociated with tingling and paresthesias of palmar side of index and middle fingers and radial half of the ring finger

66 Carpal Tunnel Syndrome Patient wakes during night with burning or aching pain, numbness, and tinglingPatient wakes during night with burning or aching pain, numbness, and tingling Positive Tinel sign: reproduce tingling and paresthesias by tapping over median nerve at volar crease of wristPositive Tinel sign: reproduce tingling and paresthesias by tapping over median nerve at volar crease of wrist

67 Carpal Tunnel Syndrome Positive Phalen test: flexed wrists held against each other for several minutes in effort to provoke symptoms in median nerve distributionPositive Phalen test: flexed wrists held against each other for several minutes in effort to provoke symptoms in median nerve distribution

68 Carpal Tunnel Syndrome May be idiopathicMay be idiopathic Known causes: rheumatoid arthritis pregnancy, diabetes, hypothyroidism, acromegalyKnown causes: rheumatoid arthritis pregnancy, diabetes, hypothyroidism, acromegaly

69 Carpal Tunnel Syndrome Insert needle just radial or ulnar to palmaris longus and proximal to distal wrist creaseInsert needle just radial or ulnar to palmaris longus and proximal to distal wrist crease Ulnar preferred: avoids nerveUlnar preferred: avoids nerve Direct needle at 60° to skin surface, point toward tip of middle fingerDirect needle at 60° to skin surface, point toward tip of middle finger

70 de Quervain’s Disease Chronic teno-synovitis due to narrowed tendon sheaths around abductor policis longus and extensor pollicis brevis musclesChronic teno-synovitis due to narrowed tendon sheaths around abductor policis longus and extensor pollicis brevis muscles

71 de Quervain’s Disease 1 st dorsal compartment1 st dorsal compartment Radial border of anatomic snuffboxRadial border of anatomic snuffbox 1 st compartment may cross over 2 nd compartment (ECRL/B) proximal to extensor retinaculum1 st compartment may cross over 2 nd compartment (ECRL/B) proximal to extensor retinaculum Steroid injections relieve most symptomsSteroid injections relieve most symptoms

72 Trigger Finger Digital flexor tenosynovitisDigital flexor tenosynovitis Stenosed tendon sheathStenosed tendon sheath Palmar surface over MC headPalmar surface over MC head Intermittent tendon “catch”Intermittent tendon “catch” “Locks” on awakening“Locks” on awakening Most frequent: ring and middleMost frequent: ring and middle

73 Trigger Finger Tendon sheath walls lined with synovial cellsTendon sheath walls lined with synovial cells Tendon unable to glide within sheathTendon unable to glide within sheath Initial treatment: splint, moist heat, NSAIDInitial treatment: splint, moist heat, NSAID Steroid for recalcitrant casesSteroid for recalcitrant cases

74 Hip and Groin

75 Trochanteric Bursitis Second leading cause of lateral hip pain after osteoarthritisSecond leading cause of lateral hip pain after osteoarthritis Discrete tenderness to deep palpationDiscrete tenderness to deep palpation Principal bursa between gluteus maximus and posterolateral prominence of greater trochanterPrincipal bursa between gluteus maximus and posterolateral prominence of greater trochanter

76 Trochanteric Bursitis Pain usually chronicPain usually chronic Pathology in hip abductorsPathology in hip abductors May radiate down thigh, lateral or posteriorMay radiate down thigh, lateral or posterior Worse with lying on side, stepping from curb, descending stepsWorse with lying on side, stepping from curb, descending steps

77 Trochanteric Bursitis Patrick fabere sign (flexion, abduction, external rotation, and extension) may be negativePatrick fabere sign (flexion, abduction, external rotation, and extension) may be negative Passive ROM relatively painlessPassive ROM relatively painless Active abduction when lying on opposite side  painActive abduction when lying on opposite side  pain Sharp external rotation  painSharp external rotation  pain

78 Ischiogluteal Bursitis Weaver's bottom / tailor’s seat: pain center of buttock radiating down back of legWeaver's bottom / tailor’s seat: pain center of buttock radiating down back of leg Often mistaken for back strain, herniated diskOften mistaken for back strain, herniated disk Pain worse with sitting on hard surface, bending forward, standing on tiptoePain worse with sitting on hard surface, bending forward, standing on tiptoe

79 Ischiogluteal Bursitis Tenderness over ischial tuberosityTenderness over ischial tuberosity Ischiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / posterior femoral cutaneous nervesIschiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / posterior femoral cutaneous nerves

80 Legs and Feet

81 Prepatellar Bursitis Housemaid’s knee / nun’s knee: swelling with effusion of superficial bursa over lower pole of patellaHousemaid’s knee / nun’s knee: swelling with effusion of superficial bursa over lower pole of patella Passive motion fully preservedPassive motion fully preserved Pain mild except during extreme knee flexion or direct pressurePain mild except during extreme knee flexion or direct pressure

82 Prepatellar Bursitis Pressure from repetitive kneeling on a firm surface: rug cutter's kneePressure from repetitive kneeling on a firm surface: rug cutter's knee Rarely direct traumaRarely direct trauma Second most common site for septic bursitisSecond most common site for septic bursitis

83 Baker’s Cyst Pseudothrombophlebitis syndromePseudothrombophlebitis syndrome Herniated fluid-filled sacs of articular synovial membrane that extend into popliteal fossaHerniated fluid-filled sacs of articular synovial membrane that extend into popliteal fossa Causes: trauma, rheumatoid arthritis, gout, osteoarthritisCauses: trauma, rheumatoid arthritis, gout, osteoarthritis Pain worse with active knee flexionPain worse with active knee flexion

84 Baker’s Cyst Can mimic deep venous thrombosisCan mimic deep venous thrombosis Ultrasound eseentialUltrasound eseential Many resolve over weeksMany resolve over weeks May require surgeryMay require surgery Steroid injections not performed: risk of neurovascular injurySteroid injections not performed: risk of neurovascular injury

85 Anserine Bursitis Cavalryman's disease / pes bursitis / goosefoot bursitis: obese women with large thighs, athletes who runCavalryman's disease / pes bursitis / goosefoot bursitis: obese women with large thighs, athletes who run Anteromedial knee, inferior to joint line at insertion of sartorius, semitendinous, and gracilis tendonAnteromedial knee, inferior to joint line at insertion of sartorius, semitendinous, and gracilis tendon

86 Anserine Bursitis Abrupt knee pain, local tenderness 4 to 5 cm below medial aspect of tibial plateauAbrupt knee pain, local tenderness 4 to 5 cm below medial aspect of tibial plateau Knee flexion exacerbatesKnee flexion exacerbates

87 Iliotibial Band Syndrome Lateral knee painLateral knee pain Cyclists, dancers, distance runners, football playersCyclists, dancers, distance runners, football players Pain worse climbing stairsPain worse climbing stairs Tenderness when patient supine, knee flexed to 90 oTenderness when patient supine, knee flexed to 90 o

88 Ankle and Foot

89 Peroneal Tendonitis Peroneal tendons cross behind lateral malleolusPeroneal tendons cross behind lateral malleolus Running, jumping, sprainRunning, jumping, sprain Holding foot up and out against downward pressure causes painHolding foot up and out against downward pressure causes pain

90 Peroneal Tendon Rupture Torn retinaculumTorn retinaculum Have patient dorsiflex and plantar flex with foot in inversionHave patient dorsiflex and plantar flex with foot in inversion Feel for “snapping” behind lateral malleolusFeel for “snapping” behind lateral malleolus

91 Retrocalcaneal Bursitis Ankle overuse: excessive walking, running, or jumpingAnkle overuse: excessive walking, running, or jumping Heel pain: especially with walking, running, palpationHeel pain: especially with walking, running, palpation Haglund disease: bony ridge on posterosuperior calcaneusHaglund disease: bony ridge on posterosuperior calcaneus Treatment: open heels (clogs), bare feet, sandals, or heel liftTreatment: open heels (clogs), bare feet, sandals, or heel lift

92 Plantar Fasciitis Policeman's heel / soldier's heel: associated with heel spursPoliceman's heel / soldier's heel: associated with heel spurs Degenerated plantar fascial band at origin on medial calcaneousDegenerated plantar fascial band at origin on medial calcaneous Heel pain worse in morning and after long periods of restHeel pain worse in morning and after long periods of rest May be relieved with activityMay be relieved with activity

93 Plantar Fasciitis Microtears in fascia from overuse?Microtears in fascia from overuse? Eliminate precipitators, rest, strength and stretching exercises, arch supports, and night splintsEliminate precipitators, rest, strength and stretching exercises, arch supports, and night splints Sometimes need steroid injectionSometimes need steroid injection Risk of plantar fascia rupture and fat pad atrophyRisk of plantar fascia rupture and fat pad atrophy

94 Tarsal Tunnel Syndrome Between medial malleolus and flexor retinaculumBetween medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tinglingVague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periodsWorse with activity, especially standing, walking for long periods Tender along course of nerveTender along course of nerve

95 Tarsal Tunnel Syndrome Between medial malleolus and flexor retinaculumBetween medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tinglingVague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periodsWorse with activity, especially standing, walking for long periods Tender along course of nerveTender along course of nerve

96 Fibromyalgia

97 Pain in muscles, joints, ligaments and tendonsPain in muscles, joints, ligaments and 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

98 Fibromyalgia Pain: chronic, deep or burning, migratory, intermittentPain: chronic, deep or burning, migratory, intermittent Fatigue, poor sleepFatigue, poor sleep Numbness or tinglingNumbness or tingling “Poor blood flow”“Poor blood flow” Sensitivity to odors, bright lights, loud noises, medicinesSensitivity to odors, bright lights, loud noises, medicines

99 Fibromyalgia Jaw painJaw pain Dry eyesDry eyes Difficulty focusingDifficulty focusing DizzinessDizziness Balance problemsBalance problems Chest painChest pain Rapid or irregular heartbeatRapid or irregular heartbeat

100 Fibromyalgia Shortness of breathShortness of breath Difficulty swallowingDifficulty swallowing HeartburnHeartburn GasGas Cramping abdominal painCramping abdominal pain Alternating diarrhea & constipationAlternating diarrhea & constipation Frequent urinationFrequent urination

101 Fibromyalgia Pain in bladder areaPain in bladder area UrgencyUrgency Pelvic painPelvic pain Painful menstrual periodsPainful menstrual periods Painful sexual intercoursePainful sexual intercourse DepressionDepression AnxietyAnxiety

102 Compare to SomatizationSomatizationFibromyalgiaVomiting Abdominal pain Nausea Bloating Diarrhea Leg / arm pain Back pain

103 Compare to SomatizationSomatizationFibromyalgia Joint pain Dysuria Headaches Breathlessness Palpitations Chest pain Dizziness

104 Compare to SomatizationSomatizationFibromyalgiaAmnesia Dysphagia Vision changes Weak muscles Sexual apathy Dyspareunia Impotence

105 Compare to SomatizationSomatizationFibromyalgiaDysmenorrhea Irregular menstruation Excessive menstrual flow

106 Fibromyalgia TreatmentTreatment

107 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 type I and type IIComplex regional pain syndrome type I and type II Sympathetically maintained painSympathetically maintained pain

108 Reflex Sympathetic Dystrophy Distal extremity pain, tendernessDistal extremity pain, tenderness Bone demineralization, trophic skin changes, vasomotor instabilityBone demineralization, trophic skin changes, vasomotor instability Precipitating event in 2/3: injury, stroke, MI, local trauma, fracturePrecipitating event in 2/3: injury, stroke, MI, local trauma, fracture Associated with emotional liability, depression, anxietyAssociated with emotional liability, depression, anxiety

109 Reflex Sympathetic Dystrophy Treatments: medication, physical therapy, sympathetic nerve blocks, psychological supportTreatments: medication, physical therapy, sympathetic nerve blocks, psychological support Possible sympathectomy or dorsal column stimulatorPossible sympathectomy or dorsal column stimulator Pain Clinic with coordinated plan may be helpfulPain Clinic with coordinated plan may be helpful


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