Bursitis, Tendonitis, Fibromyalgia, and RSD

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Bursitis, Tendonitis, Fibromyalgia, and RSD

• Joe Lex, MD, FAAEM
• Temple University School of Medicine
• Philadelphia, PA
• joe_at_joelex.net

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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

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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

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Objectives

• Describe typical findings in a patient with
  fibromyalgia
• Describe typical findings in a patient with
  reflex sympathetic dystrophy

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Sports

• Society more athletic
• Physical activity ? health benefits
• Overuse syndromes increase
• 25 to 50 of participants will experience
  tendonitis or bursitis

Intro
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Workplace

• Musculoskeletal disorders from
• repetitive motions
• localized contact stress
• awkward positions
• vibrations
• forceful exertions
• Ergonomic design ? incidence

Intro
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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
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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
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Bursitis

• Inflamed by
• chronic friction
• trauma
• crystal deposition
• infection

• systemic disease rheumatoid arthritis,
  psoriatic arthritis, gout ankylosing spondylitis

Intro
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Bursitis

• Inflammation causes bursal synovial cells to
  thicken
• Excess fluid accumulates inside and around
  affected bursae

Intro
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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
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Tendons

• Inflammatory changes involving sheath well
  documented
• Inflammatory lesions of tendon alone not well
  documented
• Distinction uncertain terms tendonitis and
  tenosynovitis used interchangeably

Intro
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Tendons

• Most overuse syndromes are NOT inflammatory
• Biopsy no inflammatory cells
• High glutamate concentrations
• NSAIDs / steroids no advantage
• TendonITIS a misnomer

Intro
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Bursitis / Tendonitis

• Most common causes mechanical overload and
  repetitive microtrauma
• Most injuries multifactorial

Intro
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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
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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
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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
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History

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

History
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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
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Articular vs. Periarticular

• In joint capsule
• Joint pain / warmth / swelling
• Worse with active passive movement
• All parts of joint involved

• Periarticular
• Pain not uniform across joint
• Pain only certain movements
• Pain character radiation vary

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Physical Exam

• Careful palpation
• Range of motion
• Heat, warmth, redness

Exam
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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
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Synovial Fluid

• Especially crystalline, suppurative etiology
• Appearance, cell count and diff, crystal
  analysis, Grams stain
• Positive Grams diagnostic
• Negative Grams cannot rule out

Labs
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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
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Management

• Shoulder immobilize few days
• Risk of adhesive capsulitis
• Lateral epicondylitis forearm brace
• Olecranon bursitis compression dressing

Rx
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Management

• De Quervains splint wrist and thumb in 20o
  dorsiflexion
• Achilles tendonitis heel lift or splint in
  slight plantar flexion

Rx
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Local Injection
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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
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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
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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
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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
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Indications

• Diagnosis
• Obtain fluid for analysis
• Eliminate referred pain
• Therapy
• Give pain relief
• Deliver therapeutic agents

Inject
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Contraindication Absolute

• Bacteremia
• Infectious arthritis
• Periarticular cellulitis
• Adjacent osteomyelitis
• Significant bleeding disorder
• Hypersensitivity to steroid
• Osteochondral fracture

Inject
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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
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Preparations

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

Inject
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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
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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
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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
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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
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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
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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
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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
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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
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Some specific entities
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Shoulder Region
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Shoulder Region
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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
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Bicipital Tendonitis

• Range of motion normal or restricted
• Strength normal
• Tenderness bicipital groove
• Pain elevate shoulder, reach hip pocket, pull a
  back zipper

Shoulder
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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
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Yergason Test
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Injection for bicipital tendonitis
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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
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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
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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
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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
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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
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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
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Lateral Approach Subacromial Bursitis
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Posterior Approach Subacromial Bursitis
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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
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Calcific Tendonitis / Supraspinatus Tendonitis /
Subacromial Bursitis
Shoulder
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Rotator Cuff Tear
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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
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Elbow and Wrist
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Elbow and Wrist
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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
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Lateral Epicondylitis
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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
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Injection for Lateral Epicondylitis
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Radial Tunnel Syndrome
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Medial Epicondylitis

• Golfer's elbow or pitchers elbow similar
• Much less common
• Worse when wrist flexed against resistance
• Tender medial epicondyle

Elbow
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Medial Epicondylitis
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Injection for Medial Epicondylitis
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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
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Cubital Tunnel Syndrome
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Cubital Tunnel Syndrome
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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
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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
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Olecranon Bursitis
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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
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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
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Ganglion Cysts
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Ganglion Cysts
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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
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Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome
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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
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Carpal Tunnel Syndrome
Wrist
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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
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Carpal Tunnel Syndrome
Wrist
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Carpal Tunnel Syndrome

• May be idiopathic
• Known causes rheumatoid arthritis pregnancy,
  diabetes, hypothyroidism, acromegaly

Wrist
102
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
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Carpal Tunnel Syndrome
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de Quervains Disease

• Chronic teno-synovitis due to narrowed tendon
  sheaths around abductor policis longus and
  extensor pollicis brevis muscles

Wrist
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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
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de Quervains Disease
Finkelsteins Test
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de Quervains Disease
Wrist
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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
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Trigger Finger
Finger
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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
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Hip and Groin
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Hip and Groin
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Hip and Groin
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Hip and Groin
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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
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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
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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
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Trochanteric Bursitis
Hip
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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
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Ischiogluteal Bursitis

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

Hip
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Some Other Back Pains
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Legs and Feet
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Knee
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Bursae of the Knee
Knee
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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
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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
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Prepatellar Bursitis
Knee
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Prepatellar Bursitis
Knee
129
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
130
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
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Bakers Cyst
Knee
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Bakers Cyst
Knee
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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
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Anserine Bursitis

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

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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
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Iliotibial Band Syndrome
Knee
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Iliotibial Band Syndrome
Knee
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Ankle and Foot
Ankle
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Ankle
Ankle
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Peroneal Tendonitis

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

Ankle
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Ankle
Ankle
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Peroneal Tendon Rupture

• Torn retinaculum
• Have patient dorsiflex and plantar flex with foot
  in inversion
• Feel for snapping behind lateral malleolus

Ankle
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Foot
Foot
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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
145
Retrocalcaneal Bursitis
Foot
146
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
147
Plantar Fasciitis
Foot
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Plantar Fasciitis
Foot
149
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
150
Tarsal Tunnel Syndrome
Foot
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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
152
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
153
Achilles Tendonitis
Foot
154
Fibromyalgia
F M
155
Fibromyalgia
F M
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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
159
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
160
Fibromyalgia

• Jaw pain
• Dry eyes
• Difficulty focusing
• Dizziness
• Balance problems
• Chest pain
• Rapid or irregular heartbeat

F M
161
Fibromyalgia

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

F M
162
Fibromyalgia

• Pain in bladder area
• Urgency
• Pelvic pain
• Painful menstrual periods
• Painful sexual intercourse
• Depression
• Anxiety

F M
163
Compare to Somatization
F M
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Compare to Somatization
F M
165
Compare to Somatization
F M
166
Compare to Somatization
F M
167
Fibromyalgia

• Treatment

?
F M
168
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
169
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
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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
171
Harry Lawrence Pharmacist in Charlotte, NC
Nelson Eran Deran Mead, retired in Oregon
Joe Lex, Philadelphia
Valley Forge General Hospital Phoenixville, PA
1968