Entesopathies

Z. Rozkydal

I.Ortopedická klinika MU v Brně

Entezopathy

Patological changes of insertionsof tendons, ligaments and joint capsules into the bone

Dystrophia, microrupturesof Sharpey´s filaments from boneinflammation, periostitisossifications, metaplasia

Acute and chronic overloading

Microtraumatisation

Repetitive movements and activities

Cause

Epicondylitis radialis humeriTennis elbow

Pain with activity of extensorsTendernessPainfull supinationPainful resisted dorsiflexion of the wristand of the third fingerChair test

Tennis elow- the cause

EntesopathyBursitisOssifications of insertion of extensorsPainfull annular ligamentPainful synovial plicaOsteochondrosis dissecansPressure od radial nerveReferred pain from cervical spine and shoulder

Tennis elbow

Conservative treatment:Rest, NSAIDStretching, slingCorticoids locallyfysiotherapyOrthesis or immobilisation

Operative treatmentOp. sec. HohmanOp. sec. Boyd- Mc Leod

Golf elbow -Epicondylitis ulnaris humeri

Entesopathy of insertions of flexorson ulnar epicondylePain, tendernesResisted movements

Treatment:Conservative

OperativeDistalisation of flexor´s insertion

Bursitis of olecranon

Swelling and fluidTenderness

Treatment:Aspiration, NSAIDBandage, immobilisation Corticoids locally

Risk of pyogenic inflammation

M. de Quervain

Stenosing tenosynovitis oflong abductor and short extensorof the thunb

Tenderness over styloid processFinkelstein test

TreatmentRest, orthesis, plaster NSAID, corticoidsSurgery

M. de Quervain

Dissection of the tendonsheat

Bursitis and entesopathies in hip region

Greater trochanter Ischial tubercleBursa ileopectineaGracilis syndrom (natažené tříslo)Spina iliaca ant. sup.Spina iliaca ant inf.

Prepatelar bursitis

Bursitis of pes anserinus

Bursitis in the knee region

Therapy: Rest, aspiration, corticoidsNSAID, surgery

Baker´s cyst

Bursa gastrocnemio- semimembranaceaIs connected with joint spaceSwelling, soft mass in popliteal regionLimited movementsPressure onto large veins inpopliteal region.

Secondary to pathology in the knee

Therapy:Conservative – aspiration, local corticoids, NSAIDSurgery

Jumper´s knee- distal pole of the patella

m. Osgood- Schlatter

Entesopathy in ligaments insertion

Entesopathy at Gerdy´s tubercle

Entesopathies in knee region

Bursitis and entesopathies in the foot

AchillodyniaCalcaneal spurHaglund´s exostosisOsteophytes – dorsalOs tibiale externum

Achillodynia

Painful Achillis tendonand it´s insertion

DegenerationHaemorhage, rupturesPeritenonitis

The risk of rupture

Achillodynia

Conservative treatment:

Rest, taping, NSAIDPhysiotherapyOrthesisNo corticoids !

Surgery:PeritenonectomyExcision of necrotic tissue

Entesopathy at the spine

Painfull insertions of ligaments and tendons:Transverse or spinal processScapula, pelvis

Painful shoulder

Tenosynovitis of tendon of long head of bicepsRupture of tendon of long head of bicepsSubacromial bursitisSupraspinatus tendinitis Rotator cuff ruptureImpimgement syndrom Frozen shoulder syndromOsteoarthritis of glenohumeral jointDisorders of acromioclavicular jointInflammationsTumorsReferred pain from cervical spine

Tenosynovitis of long head of biceps

TendernessResisted flexion and supination of the elbow

Therapy:Corticosteroids locallyRest, slingNSAID

Rupture of long head of biceps

Tenderness

Distalisation of muscle belly

Diminished strength

Rupture of long head of biceps

Therapy:

Rest, slingNSAIDSurgery – up to 40 yearsConservative- over 40 years

Surgery:key hole fixation to the humerusSuture to the short head of biceps

Subacromialis bursitis

InflammationWhite fluidSevere, burning painRestricted movementsTendernessCalcifications

Conservative treatment:Rest, slingLavage with 2 needlesCorticosteroids locallyNSAIDPhysiotherapy

Surgery:Removal of bursa

Subacromial bursitis

Supraspinatus tendinitis

Tenderness over greater tuberosityLimited movements

Therapy:Rest, NSAIDCorticosteroidsPhysiotherapy

Rotator cuff

Rotator cuff:m. supraspinatusm. infraspinatusm. teres minorm. subscapularis

Function:First 30 ° of abductionPressure of the humeral headinto glenoid cavityDepressor of the humeralhead

Anatomy of the shoulder

Anatomy of the shoulder

Rupture of rotator cuff

Partial rupture:

Severe painPainful arcPainful abductionKeeps the arm in positionof adjusted abduction

Ultrasonography

Management: conservative

Rupture of rotator cuff

Complete rupture:No active abductionLifting of the shoulder

Managemet:suture: ASK, openattachment to greater tuberosity

Impingement syndrom

Greater tuberosity impingesto distal surface of acromion andcoracoacromial ligament

Narrowing of subacromial space

Impingement syndrom

The cause:

Spure of acromionChange of contoursof acromionDistal osteophytes of acromio- clavicular jointProminence of gr. tuberosity

Impingement syndrom

Stages:1. Swelling, hemorhage of supraspinatus

2. Fibrosis, tendinitis, bursitis degenerative changes of cuff

3. Rupture od rotator cuff and long biceps tendon

Impingement syndrom

Symptoms:Painful arcImpingement signImpingement testJobe test

X-ray:Narrowed subacromial spaceY view- outlet viewArthrographyUltrasonography

Impingement syndrom

Therapy:1. stage: conservativeRest, NSAID,Physiotherapy,Local corticosteroids

2. stage: the same+ bursectomy, arthroscopy

3. stage: ASK or surgerySubacromial decompressionNeer- acromioplastyASK

Frozen shoulder- capsulitis adhesiva

Progressive limitation of movementsPainNo motivation for movement

Shrinkage of capsuleAdhesions in distal recesusTightening of soft tissueMuscle spasmLow capacity of joint space

The cause

All conditions limitingjoint movements:Impingement syndromArthrosis of AC jointPosttraumatic conditionsInflammationsThoralic outlet syndromTumors of the lungsDisorders of pleuraCardiac disorders

Frozen shoulder

Management:Long lasting periodHeatPassive movementsPositioning Active movementsPhysioterapyNSAIDLocal corticosteroidsASK- decompressionRedressement forceRemoval of adhesions

Glenohumeralis osteoarthritis- omarthrosis

Disorders of acromioclavicular joint

SynovitisO.A. SprainSubluxationDislocations

Disorders of sternoclavicular joint

SynovitisO.A. SprainSubluxationDislocationsChronic subluxation

Referred pain to the shoulder

Cervical spineThoracic outlet syndromCardiac diseasesLung and pleura disordersHerpes zoster neuralgia