Bursitis, Tendonitis, Fibromyalgia, and RSDJoe Lex, MD, FAAEMTemple University School of MedicinePhiladelphia, PAjoe@joelex.net

ObjectivesExplain how bursitis and tendonitis are similarExplain how bursitis and tendonitis differ from from anotherList phases in development and healing of bursitis and tendonitis

ObjectivesList common types of bursitis and tendonitis found at the:ShoulderElbowWrist5. List indications / contraindications for injection therapy of bursitis and tendonitisHipKneeAnkle

ObjectivesDescribe typical findings in a patient with fibromyalgiaDescribe typical findings in a patient with reflex sympathetic dystrophy

SportsSociety more athleticPhysical activity health benefitsOveruse syndromes increase25% to 50% of participants will experience tendonitis or bursitis

WorkplaceMusculoskeletal disorders fromrepetitive motionslocalized contact stressawkward positionsvibrationsforceful exertionsErgonomic design incidence

BursaeClosed, round, flat sacsLined by synoviumMay or may not communicate with synovial cavityOccur at areas of friction between skin and underlying ligaments / bone

BursaePermit lubricated movement over areas of potential impingementMany are nameless~78 on each side of bodyNew bursae may form anywhere from frequent irritation

BursitisInflamed bychronic frictiontraumacrystal depositioninfectionsystemic disease: rheumatoid arthritis, psoriatic arthritis, gout ankylosing spondylitis

BursitisInflammation causes bursal synovial cells to thickenExcess fluid accumulates inside and around affected bursae

TendonsTendon sheaths composed of same synovial cells as bursae Inflamed in similar mannerTendonitis: inflammation of tendon onlyTenosynovitis: inflammation of tendon plus its sheath

TendonsInflammatory changes involving sheath well documented Inflammatory lesions of tendon alone not well documentedDistinction uncertain: terms tendonitis and tenosynovitis used interchangeably

TendonsMost overuse syndromes are NOT inflammatoryBiopsy: no inflammatory cellsHigh glutamate concentrationsNSAIDs / steroids: no advantageTendonITIS a misnomer

Bursitis / TendonitisMost common causes: mechanical overload and repetitive microtrauma Most injuries multifactorial

Bursitis / TendonitisIntrinsic factors: malalignment, poor muscle flexibility, muscle weakness or imbalance Extrinsic factors: design of equipment or workplace and excessive duration, frequency, or intensity of activity

Immediate PhaseRelease of chemotactic and vasoactive chemical mediatorsVasodilation and cellular edemaPMNs perpetuate processLasts 48 hours to 2 weeksRepetitive insults prolong inflammatory stage

Healing PhaseClassic inflammatory signs: pain, warmth, erythema, swelling Healing goes through proliferative and maturation6 to 12 weeks: organization and collagen cross-linking mature to preinjury strength

HistoryChanges in sports activity, work activities, or workplaceCause not always foundPregnancy, quinolone therapy, connective tissue disorders, systemic illness

HistoryMost common complaint: PAINAcute or chronicFrequently more severe after periods of restMay resolve quickly after initial movement only to become throbbing pain after exercise

Articular vs. PeriarticularIn joint capsuleJoint pain / warmth / swellingWorse with active & passive movementAll parts of joint involvedPeriarticular Pain not uniform across jointPain only certain movementsPain character & radiation vary

Physical ExamCareful palpationRange of motionHeat, warmth, redness

Lab StudiesScreening tests: CBC, CRP, ESR Chronic rheumatic disease: mild anemiaRheumatoid factor, antinuclear antibody, antistreptolysin O titers, and Lyme serologies for follow-up Serum uric acid: not helpful

Synovial FluidEspecially crystalline, suppurative etiologyAppearance, cell count and diff, crystal analysis, Grams stainPositive Grams: diagnostic Negative Grams: cannot rule out

ManagementRest Pain relief: meds, heat, coldNo advantage to NSAIDsExceptions: olecranon bursitis and prepatellar bursitis have a moderate risk of being infected (Staphylococcus aureus)

ManagementShoulder: immobilize few daysRisk of adhesive capsulitisLateral epicondylitis: forearm braceOlecranon bursitis: compression dressing

ManagementDe Quervains: splint wrist and thumb in 20o dorsiflexionAchilles tendonitis: heel lift or splint in slight plantar flexion

Local Injection

Local InjectionLidocaine or steroid injection can overcome refractory painSteroids universally given, often with great successNo good prospective data to support or refute therapeutic benefit

Local InjectionShort course of oral steroid may produce statistically similar resultsPrimary goal of steroid injection: relieve pain so patient can participate in physical rehab

Local InjectionAdjunct to other modalities: pain control, PT, exercise, OT, relative rest, immobilizationAdditional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, electrical nerve stimulation

Local InjectionAnalgesics + exercise: better results than exercise aloneEliminate provoking factorsAvoid repeat steroid injection unless good prior responseWait at least 6 weeks between injections in same site

IndicationsDiagnosisObtain fluid for analysisEliminate referred painTherapyGive pain reliefDeliver therapeutic agents

Contraindication: AbsoluteBacteremiaInfectious arthritisPeriarticular cellulitisAdjacent osteomyelitis Significant bleeding disorderHypersensitivity to steroidOsteochondral fracture

Contraindication: RelativeViolation of skin integrityChronic local infectionAnticoagulant usePoorly controlled diabetesInternal joint derangementHemarthrosisPreexisting tendon injuryPartial tendon rupture

PreparationsLocal anestheticHydrocortisone / corticosteroidRapid anti-inflammatory effectCategorized by solubility and relative potencyHigh solubility short durationAbsorbed, dispersed more rapidly

PreparationsTriamcinolone hexacetonide: least soluble, longest durationPotential for subcutaneous atrophyIntra-articular injections onlyMethylprednisolone acetate (Depo-Medrol): reasonable first choice for most ED indications

DosageLarge bursa: subacromial, olecranon, trochanteric: 40 60 mg methylprednisolone Medium or wrist, knee, heel ganglion: 10 20 mgTendon sheath: de Quervain, flexor tenosynovitis: 5 15 mg

Site PreparationUse careful aseptic techniqueMark landmarks with skin pencil, tincture of iodine, or thimerosal (Merthiolate) (sterile Q-tip)Clean point of entry: povidone-iodine (Betadine) and alcoholDo not need sterile drapes

TechniqueMake skin wheal: 1% lidocaine or 0.25% bupivacaine ORuse topical vapocoolant: e.g., Fluori-MethaneUse Z-tract technique: limits risk of soft tissue fistulaAgitate syringe prior to injection: steroid can precipitate or layer

Complications: AcuteReaction to anesthetic: rareTreat as in standard textbooksAccidental IV injectionVagal reaction: have patient flatNerve injury: pain, paresthesiasPost injection flare: starts in hours, gone in days (~2%)

Complications: DelayedLocalized subcutaneous or cutaneous atrophy at injection siteSmall depression in skin with depigmentation, transparency, and occasional telangiectasiaEvident in 6 weeks to 3 monthsUsually resolve within 6 monthsCan be permanent

Complications: DelayedTendon rupture: low risk (

Complications: DelayedSystemic absorption slower than with oral steroidsCan suppress hypopituitary-adrenal axis for 2 to 7 daysCan exacerbate hyperglycemia in diabetesAbnormal uterine bleeding reported

Some specific entities

Bicipital TendonitisRisk: repeatedly flex elbow against resistance: weightlifter, swimmerTendon goes through bicipital (intertubercular) groovePain with elbow at 90 flexion, arm internally / externally rotated

Bicipital TendonitisRange of motion: normal or restrictedStrength: normalTenderness: bicipital groovePain: elevate shoulder, reach hip pocket, pull a back zipper

Bicipital TendonitisLipman test: "rolling" bicipital tendon produces localized tendernessYergason test: pain along bicipital groove when patient attempts supination of forearm against resistance, holding elbow flexed at 90 against side of body

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisCalcific (calcareous) tendonitis: hydroxyapatite deposits in one or more rotator cuff tendonsCommonly supraspinatusSometimes rupture into adjacent subacromial bursaAcute deltoid pain, tenderness

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisClinically similar: difficult to differentiateRotator cuff: teres minor, supraspinatus, infraspinatus, subscapularisInsert as conjoined tendon into greater tuberosity of humerus

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisJobes sign, AKA empty can testAbduct arm to 90o in the scapular plane, then internally rotate arms to thumbs pointed downwardPlace downward force on arms: weakness or pain if supraspinatus

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisOther tests: Neer, HawkinsPassively abduct arm to 90, then passively lower arm to 0 and ask patient to actively abduct arm to 30

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisIf can abduct to 30 but no further, suspect deltoidIf cannot get to 30, but if placed at 30 can actively abduct arm further, suspect supraspinatusIf uses hip to propel arm from 0 to beyond 30, suspect supraspinatus

Calcific Tendonitis Supraspinatus Tendonitis Subacromial BursitisSubacromial bursa: superior and lateral to supraspinatus tendonTendon and bursa in space between acromion process and head of humerusProne to impingement

Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial BursitisPatient holds arm protectively against chest wallMay be incapacitatingAll ROM disturbed, but internal rotation markedly limitedDiffuse perihumeral tendernessX-ray: hazy shadow

Rotator Cuff TearDrop arm test: arm passively abducted at 90o, patient asked to maintain dropped arm represents large rotator cuff tearShrug sign: attempt to abduct arm results in shrug only

Elbow and Wrist

Lateral EpicondylitisPain at insertion of extensor carpi radialis and extensor digitorum musclesRadiohumeral bursitis: tender over radiohumeral grooveTennis elbow: tender over lateral epicondyle

Lateral EpicondylitisHistory repetitive overhead motion: golfing, gardening, using toolsWorse when middle finger extended against resistance with wrist and the elbow in extensionWorse when wrist extended against resistance

Medial EpicondylitisGolfer's elbow or pitchers elbow similarMuch less commonWorse when wrist flexed against resistanceTender medial epicondyle

Cubital Tunnel SyndromeUlnar nerve passes through cubital tunnel just behind ulnar elbowNumbness and pain small and ring fingersInitial treatment: rest, splint

Olecranon BursitisStudent's or barfly elbow Most frequent site of septic bursitisAseptic: motion at elbow joint complete and painlessSeptic: all motion usually painful

Olecranon BursitisAseptic olecranon bursitisCosmetically bothersome, usually resolves spontaneouslyIf bothersome, aspiration and steroid injection speed resolutionOral NSAID after steroid injection does not affect outcome

Septic Olecranon BursitisMost common septic bursitis: olecranon and prepatellar2o to acute trauma / skin breakage Impossible to differentiate acute gouty olecranon bursitis from septic bursitis without laboratory analysis

Ganglion CystsSwelling on dorsal wrist~60% of wrist and hand soft tissue tumorsEtiology obscureLined with mesothelium or synoviumArise from tendon sheaths or near joint capsule

Carpal Tunnel SyndromeMedian nerve compression in fibro-osseous tunnel of wristPain at wrist that sometimes radiates upward into forearmAssociated with tingling and paresthesias of palmar side of index and middle fingers and radial half of the ring finger

Carpal Tunnel SyndromePatient wakes during night with burning or aching pain, numbness, and tinglingPositive Tinel sign: reproduce tingling and paresthesias by tapping over median nerve at volar crease of wrist

Carpal Tunnel SyndromePositive Phalen test: flexed wrists held against each other for several minutes in effort to provoke symptoms in median nerve distribution

Carpal Tunnel SyndromeMay be idiopathicKnown causes: rheumatoid arthritis pregnancy, diabetes, hypothyroidism, acromegaly

Carpal Tunnel SyndromeInsert needle just radial or ulnar to palmaris longus and proximal to distal wrist creaseUlnar preferred: avoids nerveDirect needle at 60 to skin surface, point toward tip of middle finger

de Quervains DiseaseChronic teno-synovitis due to narrowed tendon sheaths around abductor policis longus and extensor pollicis brevis muscles

de Quervains Disease1st dorsal compartment Radial border of anatomic snuffbox1st compartment may cross over 2nd compartment (ECRL/B) proximal to extensor retinaculum Steroid injections relieve most symptoms

Trigger FingerDigital flexor tenosynovitis Stenosed tendon sheathPalmar surface over MC headIntermittent tendon catchLocks on awakeningMost frequent: ring and middle

Trigger FingerTendon sheath walls lined with synovial cellsTendon unable to glide within sheath Initial treatment: splint, moist heat, NSAIDSteroid for recalcitrant cases

Hip and Groin

Trochanteric BursitisSecond leading cause of lateral hip pain after osteoarthritisDiscrete tenderness to deep palpationPrincipal bursa between gluteus maximus and posterolateral prominence of greater trochanter

Trochanteric BursitisPain usually chronicPathology in hip abductorsMay radiate down thigh, lateral or posteriorWorse with lying on side, stepping from curb, descending steps

Trochanteric BursitisPatrick fabere sign (flexion, abduction, external rotation, and extension) may be negativePassive ROM relatively painlessActive abduction when lying on opposite side painSharp external rotation pain

Ischiogluteal BursitisWeaver's bottom / tailors seat: pain center of buttock radiating down back of legOften mistaken for back strain, herniated diskPain worse with sitting on hard surface, bending forward, standing on tiptoe

Ischiogluteal BursitisTenderness over ischial tuberosityIschiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / posterior femoral cutaneous nerves

Legs and Feet

Prepatellar BursitisHousemaids knee / nuns knee: swelling with effusion of superficial bursa over lower pole of patellaPassive motion fully preservedPain mild except during extreme knee flexion or direct pressure

Prepatellar BursitisPressure from repetitive kneeling on a firm surface: rug cutter's kneeRarely direct traumaSecond most common site for septic bursitis

Bakers CystPseudothrombophlebitis syndromeHerniated fluid-filled sacs of articular synovial membrane that extend into popliteal fossaCauses: trauma, rheumatoid arthritis, gout, osteoarthritisPain worse with active knee flexion

Bakers CystCan mimic deep venous thrombosisUltrasound eseentialMany resolve over weeksMay require surgerySteroid injections not performed: risk of neurovascular injury

Anserine BursitisCavalryman's disease / pes bursitis / goosefoot bursitis: obese women with large thighs, athletes who runAnteromedial knee, inferior to joint line at insertion of sartorius, semitendinous, and gracilis tendon

Anserine BursitisAbrupt knee pain, local tenderness 4 to 5 cm below medial aspect of tibial plateauKnee flexion exacerbates

Iliotibial Band SyndromeLateral knee painCyclists, dancers, distance runners, football playersPain worse climbing stairsTenderness when patient supine, knee flexed to 90o

Ankle and Foot

Peroneal TendonitisPeroneal tendons cross behind lateral malleolusRunning, jumping, sprainHolding foot up and out against downward pressure causes pain

Peroneal Tendon RuptureTorn retinaculumHave patient dorsiflex and plantar flex with foot in inversionFeel for snapping behind lateral malleolus

Retrocalcaneal BursitisAnkle overuse: excessive walking, running, or jumpingHeel pain: especially with walking, running, palpationHaglund disease: bony ridge on posterosuperior calcaneusTreatment: open heels (clogs), bare feet, sandals, or heel lift

Plantar FasciitisPoliceman's heel / soldier's heel: associated with heel spursDegenerated plantar fascial band at origin on medial calcaneousHeel pain worse in morning and after long periods of restMay be relieved with activity

Plantar FasciitisMicrotears in fascia from overuse?Eliminate precipitators, rest, strength and stretching exercises, arch supports, and night splintsSometimes need steroid injectionRisk of plantar fascia rupture and fat pad atrophy

Tarsal Tunnel SyndromeBetween medial malleolus and flexor retinaculumVague pain in sole of foot: burning or tinglingWorse with activity, especially standing, walking for long periodsTender along course of nerve

Tarsal Tunnel SyndromeBetween medial malleolus and flexor retinaculumVague pain in sole of foot: burning or tinglingWorse with activity, especially standing, walking for long periodsTender along course of nerve

Fibromyalgia

FibromyalgiaPain in muscles, joints, ligaments and tendonsTender pointsKnees, elbows, hips, neck5% of population, including kidsMain symptom: sensitivity to pain

FibromyalgiaPain: chronic, deep or burning, migratory, intermittentFatigue, poor sleepNumbness or tinglingPoor blood flowSensitivity to odors, bright lights, loud noises, medicines

FibromyalgiaJaw painDry eyesDifficulty focusingDizzinessBalance problemsChest painRapid or irregular heartbeat

FibromyalgiaShortness of breathDifficulty swallowingHeartburnGasCramping abdominal painAlternating diarrhea & constipation Frequent urination

FibromyalgiaPain in bladder areaUrgencyPelvic painPainful menstrual periodsPainful sexual intercourseDepressionAnxiety

Compare to Somatization

SomatizationFibromyalgiaVomitingAbdominal painNauseaBloatingDiarrheaLeg / arm painBack pain

Compare to Somatization

SomatizationFibromyalgiaJoint painDysuriaHeadachesBreathlessnessPalpitationsChest painDizziness

Compare to Somatization

SomatizationFibromyalgiaAmnesiaDysphagiaVision changesWeak musclesSexual apathyDyspareuniaImpotence

Compare to Somatization

SomatizationFibromyalgiaDysmenorrhea Irregular menstruationExcessive menstrual flow

FibromyalgiaTreatment

Reflex Sympathetic DystrophyCausalgiaShoulder-hand syndromeSudeck's atrophyPost-traumatic pain syndromeComplex regional pain syndrome type I and type IISympathetically maintained pain

Reflex Sympathetic DystrophyDistal extremity pain, tendernessBone demineralization, trophic skin changes, vasomotor instabilityPrecipitating event in 2/3: injury, stroke, MI, local trauma, fractureAssociated with emotional liability, depression, anxiety

Reflex Sympathetic DystrophyTreatments: medication, physical therapy, sympathetic nerve blocks, psychological supportPossible sympathectomy or dorsal column stimulatorPain Clinic with coordinated plan may be helpful