Tendonitis and Bursitis Thomas Mullin, MD, CAQSM

Neither I, Thomas Mullin, MD, nor any family member(s) have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation. Disclosure

1. What are tendons and bursas and why can they cause pain? 2. What are the commonly affected areas for tendonitis and bursitis? 3. How can I get the pain to go away and get back to my normal activities? Objectives

Tendons connect muscle to bone Ligaments connect bone to bone A tendon is a tough band of tissue that connects muscle to bone They are capable of withstanding tension They transmit the force produced by muscles to the bone and cause movement at joints. What is a Tendon?

Bursae are flattened sacs that contain fluid Protective layer between bones and muscles or between bones and tendons/skin. Reduce friction and aid in smooth motion Humans have approximately 160 bursae What is a Bursa?

Suffix “itis” means inflammation Usually occurs from overuse Little if any inflammation in the tendons when evaluated microscopically Tears Disorganization Change in the cell type Better term is Tendinopathy which indicates an abnormality in the tendon For this talk we will continue to refer to the problem as tendonitis What is Tendonitis?

Tendonitis

Inflammation or irritation of the bursa May be the result of Overuse Injury Infection Other conditions Gout, arthritis What is Bursitis?

Bursitis

Tendonitis and Bursitis

Shoulder Rotator Cuff Tendonitis and Bursitis Biceps Tendonitis Elbow Tennis Elbow Golfer’s Elbow Olecranon bursitis Wrist DeQuervain’s syndrome Commonly Affected Areas Upper Body

Hip Trochanteric bursitis Gluteal Tendonitis Knee Patellar tendonitis Ankle Achilles tendonitis Foot Plantar fasciitis Commonly Affected Areas Lower Body

Shoulder

Pain in the shoulder and upper arm Usually worse with activity Pain is often worse with overhead motions Risks Repetitive overhead shoulder activity Rotator cuff weakness Overhead athletes Older patients can develop rotator cuff tears from chronic impingement Calcium can be deposited into the rotator cuff that can cause pain Shoulder Rotator Cuff Tendonitis and Bursitis

Shoulder

Calcific Tendonitis

Shoulder

Pain in the front of the shoulder Worse with reaching outwards and with lifting objects (grocery bags) Caused by overuse of the biceps Risks Repetitive use of the upper extremities with overhead motion Painting, throwing, swimming, racquet sorts Shoulder Biceps Tendonitis

Elbow

Tennis Elbow

Elbow Tennis Elbow

Tennis Elbow is also called “Lateral Epicondylitis” Pain at the outside part of the elbow Worse with wrist and elbow motion Occurs in dominant arm 75% of the time Risks Risks : age 40 – 60 years old Poor technique or equipment in tennis 90% of tennis elbow precipitated by activities that require repetitive wrist extension Elbow Tennis Elbow

Elbow Golfer’s Elbow

Elbow Golfer’s Elbow

Also known as “Medial Epicondylitis” Pain at the inside aspect of the elbow Dominant hand most often affected Usually due to repetitive flexion and pronation at the wrist and elbow Racquet sports, swimming, golfing, carpenters, plumbers, and butchers may be at risk Elbow Golfer’s Elbow

Elbow Golfer’s Elbow

Pain and swelling over the back of the elbow Injury or infection irritates the cells of the bursa and causes them to produce an abnormal amount of fluid Can be from injury or repetitive use seen in sports Wrestling, volleyball, football Other activities requiring repetitive use (carpentry) Infection Infections cause ~ 20% of olecranon bursitis Elbow Olecranon Bursitis

Elbow Olecranon Bursitis

Elbow Olecranon Bursitis

Wrist DeQuervain’s Tenosynovitis

Irritation of the tendons that move the thumb and wrist Commonly seen in year olds More common in females Most common tendonitis of the dorsal wrist Pain along the wrist around the thumb, worse with moving the wrist or thumb Risks – activities requiring forceful grasp with excessive ulnar deviation Repetitive use of the thumb Golf, bowling, racquets sports Wrist DeQuervain’s Tenosynovitis

Wrist DeQuervain’s Tenosynovitis

Lower Body

Hip

Greater Trochanteric Pain Syndrome

Called Greater Trochanteric Pain Syndrome Pain can be from bursitis or it can be from tendonitis of the muscles that attach to the hip Pain at the outside hip, worse with walking, standing, rising after sitting, lying on affected side, squatting, climbing stairs Risks 30 – 60 years old More common in females Common in runners and those with hip arthritis, knee problems, leg length differences, hip replacements, weakness of the hip stabilizers, flat feet Hip Trochanteric Bursitis and Gluteal Tendonitis

Hip Greater Trochanteric Pain Syndrome

Knee

Also known as Patellar Tendonitis Pain in the front of the knee that is worse with activities like running and jumping Common 40-50% among high level volleyball players and 35-40% among elite basketball players Occurs from overuse Common in activities with excessive jumping or running (volleyball, basketball, soccer, track and field) Risks Excessive jumping sports, increasing training volume and intensity, poor flexibility of quads and hamstrings Knee Jumper’s Knee

Knee Prepatellar Bursitis

Knee

Most common knee bursitis Swelling, pain and inflammation at the front of the knee Usually from repeated kneeling or trauma to the knee Carpet layers, carpenters, wrestlers Can be caused by an infection Remove the fluid and send to the lab for analysis Knee Prepatellar Bursitis

Ankle

Achilles Tendonitis

Ankle Achilles Tendonitis

Overuse injury of the Achilles tendon that causes pain in the back of the calf and heel. Heel pain that initially gets better with activity but over time pain returns with continued use Morning stiffness is common Risks: In running and jumping sports lifetime incidence is 50% Recent increase in activity level, duration or intensity Inflexibility and tight heel cords Leg malalignment from the hip or the knee Flat feet Worn shoes – change shoes every 250 – 500 miles, pain with running and sprinting Recent use of antibiotics Ankle Achilles Tendonitis

Foot Plantar Fasciitis

Foot Plantar Fasciitis

Foot Plantar Fasciitis

Pain at the bottom of the heel Worse with first few steps out of bed in the AM Pain worsens after prolonged sitting, lessens with activity and worsens at the end of the day Can be bilateral 2 million cases in the US, accounts for 80% of patients with plantar heel pain Peak age is 40 – 60 years old Risks – Gait abnormalities, limited flexibility, poor footwear, obesity, prolonged standing Spurs – 50% of patients with Plantar fasciitis have heel spurs, 19% of patients without plantar fasciitis have heel spurs Heel spurs can occur with plantar fasciitis but they are not the cause Foot Plantar Fasciitis

Foot Plantar Fasciitis

Treatment Options

Rest Ice 20 – 30 minutes, 3 – 4 times per day Activity modification Adequate warm up and cool down routine Stretching Over the counter medications Acetaminophen, ibuprofen, naproxen New or supportive shoes for lower extremity conditions Treatment Common Sense Approach

Treatment Options

Physical therapy and Occupational therapy Stretching Strengthening Addressing biomechanical causes for the pain Modalities Iontophoresis Kinesiotaping/McConnell Taping Ultrasound Treatment Options Physical Therapy

Treatment Options Stretching

Treatment Options Eccentric Strengthening

Treatment Options Kinesiotaping and McConnell Taping

Treatment Options Taping

Treatment Options Ionotophoresis

Treatment Options Ionotophoresis

Bracing and immobilization Prescription strength NSAIDS Short term 1 – 2 weeks Naproxen, Meloxicam, Oral or Topical Diclofenac Treatment Options

Topical nitroglycerin patch Improves blood flow Good success when combined with physical therapy Headache is a common side effect Treatment Options Topical Nitroglycerin

Treatment Options

Injections “Cortisone Injections” More commonly used for the shoulder, hip and wrist Never for the Achilles tendon Use to improve pain so physical therapy is tolerated PRP, autologous blood, stem cells Ongoing research, some looks promising, stay tuned Insurance does not currently cover this procedure Cost ~$500 - $7,000 Treatment Options

Injection for Calcific Tendonitis

Treatment Options

Tenex Ultrasound guided percutaneous needle tenotomy Option if symptoms don’t resolve after 4 months Minimally invasive procedure done under local anesthetic (numbing) Remove the diseased tissue and stimulate a response for the body to heal and repair the damaged tendon Can usually resume all activities about 6 weeks after the procedure Treatment Options

Tenex Shoulder Calcific Tendonitis Elbow Tennis Elbow Golfer’s Elbow Knee Jumper’s Knee/Patellar Tendonitis Ankle Achilles Tendonitis Foot Plantar Fasciitis Treatment Options Tenex

Treatment Options

Treatment Options

Tendonitis and bursitis are common Usually the pain resolves within 6 months If it persists the chance of it resolving without intervention is low Physical therapy can help Oral medications can be helpful for short term pain relief Cortisone injections have varying levels of success depending on the problem Topical nitroglycerin and Tenex can be helpful if symptoms do not resolve in 4 – 6 months Summary

Questions?