1. Tendinitis and Tenosynovitis Upper and lower limbs
Physio and Occupational therapy
by ICM Robertson
11/8/2018
ICM Robertson

2. Definitions Tendinitis - inflammation in a tendon
Tendinosis - degeneration of a tendon
Tenosynovitis - inflammatory process in tendon sheath
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ICM Robertson

3. Histology Degenerative Tendon Normal 11/8/2018 ICM Robertson
Notice the difference between the normal tendon under the microscope and the degenerate tendon. The areas of pink on the tendon right represent defects in the uniform structure of the tendon. These areas weaken the tendon.
Degenerative Tendon
Normal
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ICM Robertson

4. Tenosynovitis: Bacterial
Tenosynovitis is inflammation of the tendons synovium. It is mainly seen in tendons with a synovial sheath such as the flexor tendons. In bacterial infection the tendons are infected by an organism such as Staphylococcus aureus. Remember the tendon sheaths communicate, so infection of one finger easily spreads to the others via their common synovial sheath.
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ICM Robertson

5. Bacterial Tenosynovitis Finger flexors
Pain on extension
Local tenderness
Pyrexia
An early sign of bacterial synovitis is pain on extension of the involved finger/s. Swelling in the hand is a very late sign.
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ICM Robertson

6. Bacterial Flexor synovitis Treatment
General anaesthetic
Bloodless field
Drain & debride
Irrigate sheath
Antibiotic
Hand baths
Physiotherapy
Treatment is drainage under a tourniquet and bloodless field. A drainage catheter may be left in the synovial sheath.
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ICM Robertson

7. Tuberculous synovitis
Thickened synovium
Painless
Raised ESR
Positive TB Skin test
Treatment
Anti TB drugs
Early mobilisation
In South African TB is a common cause of Tenosynovitis. Suspect it if the symptoms are more than a few weeks duration.
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ICM Robertson

8. Rheumatoid Arthritis 11/8/2018 ICM Robertson
Rheumatoid arthritis causes synovial inflammation and thickening. Involvement of the synovial sheath causes the tendons to appear thickened and tender. Later rupture may occur. It is common on the extensor tendons of the hand. If diagnosed before rupture excision of the inflamed synovium may prevent this complication.
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ICM Robertson

9. Rheumatoid synovitis Thickened tendon sheaths
Other signs of RA e.g. small joint inflammation
Treatment
Medical (NSAIDS, Steroids etc.)
Synovectomy
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10. De Quervain’s Stenosing Synovitis
EPL & Abd Pollicis brevis
This is an overuse injury of the Abductor pollicis longus and the extensor pollicis brevis. It presents as tenderness on their common sheath about 5cm distal to the wrist on the radial border. Finkelsteins test is to forcefully ulnar deviate the wrist. If pain occurs in the area of the tendon pulley it is positive for De Quervain’s
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11. De Quervain’s Stenosing Synovitis
Diagnosis - Finkelstein’s test
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12. De Quervain’s Stenosing Synovitis
Treatment
Splints
Local Steroid
Mobilisation
Treatment is rest, splitting the hand e.g. POP cast or backslab and local steroid injection. If the condition persists surgical excision of the sheath is required.
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ICM Robertson

13. Trigger Finger Causes Rheumatiod Trauma 11/8/2018 ICM Robertson
In trigger finger the finger sticks in flexion and cannot be extended. RA and trauma are common causes. There is a palpable lump in the metacarpal area on the volar side of the hand.
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14. Trigger Finger Treatment Steroid Injection Incise Flexor Sheath
Treatment of trigger finger is to try steroids. If this fails surgical release of the tendon sheath is required.
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15. Rotator Cuff Lesions Supraspinatus Biceps Tendinitis
Calcific tendinitis
Impingement Syndrome
Tear of rotator cuff
Biceps Tendinitis
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16. Anatomy 11/8/2018 ICM Robertson
Note the narrow space between the bony anterior acromion and the humeral head. The Supraspinatus has a poor blood supply and impingement in this area causes it to worsen. The tendon degenerates further because of impingement
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17. Anatomy: Cuff Tear 11/8/2018 ICM Robertson
Note the Supraspinatus coff tears just at this critical point.
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18. Impingement Syndrome Cause Clinical Supraspiatus tendinosis
Abnormal anterior acromion
Clinical
Painful mid arc
tender anterior to acromion
The mid arc of abduction is painful. There is tenderness just inferior to the anterior acromion.
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19. Torn Supraspinatus Tendinosis supraspinatus
leads to rotator cuff rupture
Tendinosis in the Supraspinatus at this point leads to rupture at he spot depicted above.
Drop arm test
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20. Torn Supraspinatus Weakness at mid arc 11/8/2018 ICM Robertson
The mid range of abduction is not only painful there is weakness in this range, The patient may have to support the arm with the other as shown hear.
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21. Impingement Syndrome Rotator cuff arthropathy
X ray
Superior migration humaral head
Osteoarthritis
Late sequelae of a Supraspinatus tear is rotator cuff arhtropathy. This is superior migration of the humeral head on X-ray. This is a late sign and if seen the Supraspinatus is severely ruptured.
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22. Treatment - Impingement syndrome
Conservative
Physiotherapy
Local Steroid
Treatment is initially conservative. A steroid injection will relieve pain and allow physiotherapy. Not more than three steroid injections at 6 week intervals can be safely given.
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23. Treatment - Impingement syndrome
Conservative
Physiotherapy
Physiotherapy - mobilisation of the shoulder and muscle exercises are the mainstay of conservative therapy.
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24. Treatment - Impingement syndrome
Operative
Indications
failed conservative Rx
Operative treatment will be needed if conservative therapy fails after a reasonable trial (say 3 months). Anterior acromionectomy either open or via an arthroscope is done. If the rotator cuff has ruptured it is sutured.
Acromioplasty
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25. Impingement syndrome Postop. Physiotherapy
Postoperative mobilisation of the shoulder is required. Ask the surgeon if the deltoid required detachment as this will delay commencing overhead activities.
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26. Calcific Tendinitis Cause Symptoms Dystrophic Ca++
Tendinosis Supraspinatus
Symptoms
Pain acute in deltoid
Calcific tendonitis is a painful accumulation of calcium in the supraspinatus. The deposits are seen on x-ray. Treatment is by surgical decompression either with a needle or via the arthroscope.
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27. Biceps tendinitis Shoulder pain Tenderness in Biceps groove 11/8/2018
In biceps tendinitis there is tenderness when the biceps is contracted. Tenderness is over the biceps groove and sometimes a snapping can be felt here as the tendon subluxes.
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28. Biceps tendinitis Shoulder pain Tenderness in Biceps groove 11/8/2018
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29. Biceps tendinitis Yergason’s sign
Pain - biceps groove on external rotation
This snapping can ba elicited by Yergasson’s test . The shoulder is externally rotrated and the snap felt over the biceps groove.
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30. Biceps tendinitis Rupture Yergason’s Sign 11/8/2018 ICM Robertson
If rupture of the biceps has taken place, the muscle mass gives the biceps a “Popeye” appearance.
Rupture
Yergason’s Sign
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31. Adhesive Capsulitis 11/8/2018 ICM Robertson
In Frozen shoulder the shoulder becomes painful and motion is lost.
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32. Adhesive Capsulitis Pain esp. at night Limited motion Often diabetic
Ask the patient if he is diabetic. There is a strong association with diabetes mellitus. All shoulder motions are severely limited once the condition is over the initial painful stage.
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33. Adhesive Capsulitis 11/8/2018 ICM Robertson
The condition is self limiting and the cycle lasts up to 2 years. The initial pain becomes stiffness. This limits the pain. Much later the shoulder spontaneously regains motion. Physiotherapy can hasten this cycle.
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34. Frozen shoulder Treatment Physiotherapy mobilise shoulder
MUA resistant cases
If physiotherapy fails the shoulder may, rarely need to be mobilised in theater under general anaesthetic.
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35. Patellar tendinitis Overuse injury - Jumper’s Knee
A cause of anterior knee pain
Patellar tendon - young athlete
Quadriceps tendon - older athlete
About the knee the patellar tendon degenerates in many sporting activities eg long jump. Tenderness is over the inferior pole of the patella in the young athlete. In the older athlete the quadriceps tendon superior to the patella is the more common area for tendonosis.
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ICM Robertson

36. Patellar tendinitis Jumper’s knee Tender at inferior pole patella
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37. Achilles tendinosis Chronic heel pain in the athlete 11/8/2018
Athletes often get acute inflamed achilles tendons. Tendonitis is acute inflammation. In chronic cases tendonosis of physical degenteration of the tendon often leads to chronic thickening of the heel cord. Acute rupture may occur in the occasional athlete eg squash player. He feels a sharp pain in the heel and examination reveals the Acilles thendon is off. Thompsons or Simmonds test is useful where the gastrocnemius is compressed and the spontaneus plantar flection of the non weightbearing observed. If the foot does not plantiiflex the tendon has completeluy ruptured.
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38. Achilles tendinosis Treatment Reduce sporting activity Shoe heel raise
In tendonitis a heel raise and limitation of the causative sporting activity is curative.
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39. Tendinosis Flexor hallucis longus
Pain on standing on toes
Ballet dancers
Ballet dancers are prone to unusual overuse tendon injuries such as flexor hallucis longus tendonitis.
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ICM Robertson

40. Shin Splints Pain in posterior medial border of distal tibia
Running sports
Differential diagnosis - stress
fracture
Treatment - diminish
activity
Shin splints and stress fracture are common overuse sport injuries. A bone scan will be positive in stress fracture.
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ICM Robertson