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Title: Bursitis,%20Tendonitis,%20Fibromyalgia,%20and%20RSD


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

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
  • 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
  1. Describe typical findings in a patient with
    fibromyalgia
  2. 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
  • 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

Exam
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, Grams stain
  • Positive Grams diagnostic
  • Negative Grams 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 Quervains 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 (lt1)
  • 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
  • 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
  • Jobes 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 pitchers 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
  • 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
  • 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
  • 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 Quervains Disease
  • Chronic teno-synovitis due to narrowed tendon
    sheaths around abductor policis longus and
    extensor pollicis brevis muscles

Wrist
71
de Quervains Disease
  • 1st dorsal compartment
  • 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
  • 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
  • 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 / tailors 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
  • Housemaids knee / nuns 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
Bakers 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

Knee
84
Bakers Cyst
  • Can mimic deep venous thrombosis
  • 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?
  • 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
  • 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
  • Dry eyes
  • Difficulty focusing
  • Dizziness
  • Balance problems
  • Chest pain
  • Rapid or irregular heartbeat

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

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

F M
102
Compare to Somatization
Somatization Fibromyalgia
Vomiting ? ?
Abdominal pain ? ?
Nausea ? ?
Bloating ? ?
Diarrhea ? ?
Leg / arm pain ? ?
Back pain ? ?
F M
103
Compare to Somatization
Somatization Fibromyalgia
Joint pain ? ?
Dysuria ? ?
Headaches ? ?
Breathlessness ? ?
Palpitations ? ?
Chest pain ? ?
Dizziness ? ?
F M
104
Compare to Somatization
Somatization Fibromyalgia
Amnesia ?
Dysphagia ? ?
Vision changes ? ?
Weak muscles ? ?
Sexual apathy ? ?
Dyspareunia ? ?
Impotence ? ?
F M
105
Compare to Somatization
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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