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Bursitis, Tendonitis, Fibromyalgia, and RSD

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Presentation on theme: "Bursitis, Tendonitis, Fibromyalgia, and RSD"— Presentation transcript:

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

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

3 Objectives List common types of bursitis and tendonitis found at the:
Shoulder Elbow Wrist 5. List indications / contraindications for injection therapy of bursitis and tendonitis Hip Knee Ankle

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

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

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

7 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 Intro

8 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 Intro

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

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

11 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 Intro

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

13 Tendons Most overuse syndromes are NOT inflammatory
Biopsy: no inflammatory cells High glutamate concentrations NSAIDs / steroids: no advantage TendonITIS a misnomer Intro

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

15 Bursitis / 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 Intro

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

17 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 Phase

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

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

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

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

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

23 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 Labs

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

25 Management Shoulder: immobilize few days
Risk of adhesive capsulitis Lateral epicondylitis: forearm brace Olecranon bursitis: compression dressing Rx

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

27 Local Injection

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

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

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

31 Local Injection 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 Rx

32 Indications Diagnosis Obtain fluid for analysis
Eliminate referred pain Therapy Give pain relief Deliver therapeutic agents Inject

33 Contraindication: Absolute
Bacteremia Infectious arthritis Periarticular cellulitis Adjacent osteomyelitis Significant bleeding disorder Hypersensitivity to steroid Osteochondral fracture Inject

34 Contraindication: Relative
Violation of skin integrity Chronic local infection Anticoagulant use Poorly controlled diabetes Internal joint derangement Hemarthrosis Preexisting tendon injury Partial tendon rupture Inject

35 Preparations Local anesthetic Hydrocortisone / corticosteroid
Rapid anti-inflammatory effect Categorized by solubility and relative potency High solubility  short duration Absorbed, dispersed more rapidly Inject

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

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

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

39 Technique 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 fistula Agitate syringe prior to injection: steroid can precipitate or layer Inject

40 Complications: Acute Reaction to anesthetic: rare
Treat as in standard textbooks Accidental IV injection Vagal reaction: have patient flat Nerve injury: pain, paresthesias Post injection flare: starts in hours, gone in days (~2%) Inject

41 Complications: Delayed
Localized subcutaneous or cutaneous atrophy at injection site Small depression in skin with depigmentation, transparency, and occasional telangiectasia Evident in 6 weeks to 3 months Usually resolve within 6 months Can be permanent Inject

42 Complications: Delayed
Tendon rupture: low risk (<1%) Dose-related Related to direct tendon injection? Limit injections to no more than once every 3 to 4 months Avoid major stress-bearing tendons: Achilles, patellar Inject

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

44 Some specific entities…

45 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 Shoulder

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

47 Bicipital Tendonitis Lipman 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 body Shoulder

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

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

50 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis
Jobe’s sign, AKA “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 Shoulder

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

52 Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis
If 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 supraspinatus If uses hip to propel arm from 0° to beyond 30°, suspect supraspinatus Shoulder

53 Calcific Tendonitis Supraspinatus Tendonitis 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 Shoulder

54 Calcific Tendonitis / Supraspinatus Tendonitis / 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 Shoulder

55 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 Shoulder

56 Elbow and Wrist

57 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 Elbow

58 Lateral Epicondylitis
History 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 Elbow

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

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

61 Olecranon Bursitis “Student's” or “barfly elbow” Elbow
Most frequent site of septic bursitis Aseptic: motion at elbow joint complete and painless Septic: all motion usually painful Elbow

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

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

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

65 Carpal Tunnel Syndrome
Median nerve compression in fibro-osseous tunnel of wrist Pain 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 finger Wrist

66 Carpal Tunnel Syndrome
Patient 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 wrist 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 distribution Wrist

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

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

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

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

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

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

74 Hip and Groin

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

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

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

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

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

80 Legs and Feet

81 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 Knee

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

83 Baker’s Cyst Pseudothrombophlebitis syndrome Knee
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 Knee

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

85 Anserine Bursitis Cavalryman'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 tendon Knee

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

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

88 Ankle and Foot Ankle

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

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

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

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

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

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

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

96 Fibromyalgia F M

97 Fibromyalgia Pain in muscles, joints, ligaments and tendons F M
“Tender points“ Knees, elbows, hips, neck 5% of population, including kids Main symptom: sensitivity to pain F M

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

99 Fibromyalgia Jaw pain F M Dry eyes Difficulty focusing Dizziness
Balance problems Chest pain Rapid or irregular heartbeat F M

100 Fibromyalgia Shortness of breath F M Difficulty swallowing Heartburn
Gas Cramping abdominal pain Alternating diarrhea & constipation Frequent urination F M

101 Fibromyalgia Pain in bladder area F M Urgency Pelvic pain
Painful menstrual periods Painful sexual intercourse Depression Anxiety F M

102 Compare to Somatization
Fibromyalgia Vomiting Abdominal pain Nausea Bloating Diarrhea Leg / arm pain Back pain F M

103 Compare to Somatization
Fibromyalgia Joint pain Dysuria Headaches Breathlessness Palpitations Chest pain Dizziness F M

104 Compare to Somatization
Fibromyalgia Amnesia Dysphagia Vision changes Weak muscles Sexual apathy Dyspareunia Impotence F M

105 Compare to Somatization
Fibromyalgia Dysmenorrhea Irregular menstruation Excessive menstrual flow F M

106 Fibromyalgia Treatment ? F M

107 Reflex Sympathetic Dystrophy
Causalgia Shoulder-hand syndrome Sudeck's atrophy Post-traumatic pain syndrome Complex regional pain syndrome type I and type II Sympathetically maintained pain R S D

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

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


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