103 Tendonopathy and Bursitis

Question 1

Tendons - connect bone to ?

Answer 1

muscle

Question 2

Major precipitating causes of most tendinopathies - 2

Answer 2

mechanical overload
repetitive microtrauma

Question 3

What intrinsic factors can result in high or frequency mechanical loads on tendons?

Answer 3

age
gender
blood type o
adiposity
tobacco use
malalignment
joint laxity
m weakness
imbalance

Question 4

What extrinsic factors can result in high or frequency mechanical loads on tendons?

Answer 4

ergonomics
abnormal movements
excessive duration of activity
incr frequency/intensity of activity
envrionmental conditions

Question 5

What abx cause incr risk of tendon rupture?

Answer 5

Fluoroquinolones

Question 6

DDX tendinopathy

Answer 6

tendon rupture
ligamentous injury
inflammatory arthritis
fractures
tumors
tenosynovitis
osteochondrosis
bursitis
septic arthritis
OA
FB
rhabdo
OM
nerve entrapment syndromes
tendon sheath infections

Question 7

Acute healing of tendons: Stage I: hemorrhagic phase

Answer 7

Blood accumulates and clots at site

Question 8

Acute healing of tendons: Stage II: inflammatory phase

Answer 8

neutrophils and macrophages initiate phagocytosis, removing existing necrotic material

Question 9

Acute healing of tendons: Stage III: proliferative phase

Answer 9

extrinsic cells (tendon sheath, fascia, periosteum) and intrinsic cells migrate and proliferate at injured tendon

collagen type III synthesized

Question 10

Acute healing of tendons: Stage IV: formative stage

Answer 10

type III collagen stronger to handle tension forces

Question 11

Acute healing of tendons: Stage V: remodeling phase

Answer 11

normalization of ratio between type I and III collagen followed by reintroduction of physiologic load into tendon

• up to 12 weeks for tendon to regain former strength

Question 12

General tendinopathy -characteristic hx features

Answer 12

recent repetitive motions

hx fq use, statin, infectious disease, systemic illness, hx of RA/infections

Question 13

Dismcomfort of tendons typically __ after rest

Answer 13

more

Question 15

What structures might cause impingement of the shoulder?

Answer 15

Bursa, sits muscles, glenohumeral ligaments,

Greater to varsity impinges the tendons of usually the supraspinatus the anterior third of the acromiun

Question 16

What is the pain of a rotator cuff tear described like?

Answer 16

Dull ache over the anterolateral part of the shoulder, extending from the shoulder to the middle upper arm, often after an activity involving flexion and abduction of the arm

Question 17

Second stage of impingement syndrome leading to rotator cure:

Answer 17

Mechanical trauma continues, fibrosis, and thickening of the tendon and subacromial bursa can continue

Pain is constant at worse night

Question 18

Third stage of impingement causing

Answer 18

Second stage, but also history of prolong shoulder problems

Question 19

What test is best for assessing supraspinatus tenderness?

Answer 19

empty can/jobe test
sn 62%, sp 54%

Question 20

Tests for rotator cuff tendinitis: Neer test

Answer 20

pain at end arc
sn 75-86%

sp 48-49%

Question 21

Tests for rotator cuff tendinitis: Hawkins-Kennedy

Answer 21

sn 75-82%

sp 44-48%

Question 22

Tests for complete rotator cuff tear: drop arm test

Answer 22

sn 74% but actually only 10% full thicknes
sp 98%

Question 23

Tests for complete rotator cuff tear: shrug test - what is this?

Answer 23

[t with acute macrotrauma to rotator cuf asked to abduct arm to 90 deg and appears o shrug with that side (as inability of cuff to hold abduction cause torn)

Question 24

Bicipital tendinopathy: what is this?

Answer 24

tendon in long head of bicep is between supra and subscap tendons in anterior shoulder

pain radiating anterior shoulder to elbow, discomfort at night, reach into pocke, door handle

Question 25

Bicipital tendinopathy: Yergason test

Answer 25

pt flex elbow to 90 deg with arm against body, then provider R ind forearm in supination sn low at 37 but sp 83%, +LR 2.2

Question 26

Bicipital tendinopathy: Speed's test

Answer 26

elbow extended and forearm supinated, shoulder adducted at 60 deg pt R forward flexion of shoulder - pain positive at groove sn 61-83% sp 33-71%

Question 27

Calcific tendinopathy: what is this?

Answer 27

acute or chronic pain assoc with deposition of ca crystals in or around tendons mc in rotator cuff

Question 28

Underlying causes?

Answer 28

tissue hypoxia and degen from overuse ca deposition overtime then when resorption occurs, causes pain

Question 29

Calcific tendinopathy: risks (comorbidites?)

Answer 29

females dm thyroid disorder nephrolithiasis

Question 30

Calcific tendinopathy: dx

Answer 30

pain at site with xr showing calcification - ultrasound actually better and can tx with percutaneous needle lavage

Question 31

Lateral epicondylitis: what tendons does this involve/their insertion?

Answer 31

common extensor tendon - ext carpi radialis brevis onto latera epicondyle

Question 32

Cozen's test for lateral epicondylitis:

Answer 32

grasp forearm with one hand and R pt wrist extension on affected side with other hand + means reproduction of pain at lateral epicondyle

Question 33

Maudsley's test/active extension of middle finger: for lateral epicondylitis:

Answer 33

pain over lateral epicondyle poor sp and sn

Question 34

DDX lateral epicondylitis

Answer 34

fractures PIN entrapment (mo of radial n), plica lesions, synovitis, chondromalacia, adolescent osteochondral defects

Question 35

Medial epicondylitis: where is this?

Answer 35

insertion at flexor carpi radialis on medial epicondyle

Question 36

de Quervain's tenosynovitis: what is this?

Answer 36

synovial lining of abductor pollicis longus and extensor pollicis brevis tendons - likely thickening of the extensor retinaculum covering first dorsal compartment of the wrist

Question 37

de Quervain's tenosynovitis: type of pain/presentation

Answer 37

often gradual onset over radial styloid process radiation pain forearm or distally down thumb pain generally constant grasping, abd of thumb, ulnar deviation

Question 38

de Quervain's tenosynovitis: physical examination

Answer 38

crepitus over abductor pollicis longus and epb swelling over radial styloid finkelstein's test pathognomonic

Question 39

Finkelstein's test what is this?

Answer 39

most pathognomonic physical sign - thumb in neutral position, patient deviates wrist toward ulna pain near radial styloid either of these are +

Question 40

Eichoff's test - what is this?

Answer 40

patient thumb in fist, then deviating wrist toward ulna

Question 41

DDX of de Quervain's tenosynovitis:

Answer 41

scaphoid fracture OA of CMC joint TB disseminated gonococcal infections

Question 42

Patellar tendinopathy: symptoms?

Answer 42

pain at inferior pole of patella typically jumping sport

Question 43

Patellar tendinopathy: exam

Answer 43

quads musculature relaxed with knee flexed at 30 deg, tenderness may be localized to deep surface of proximal attachment of patellar tendon at inferior pole

Question 44

DDX for patellar tendinopathy

Answer 44

patellofemoral syndrome arises from imablance of forces of patella tracking during flexion and extension

Question 45

Achilles tendionopathy: result of systemic disease RF

Answer 45

dm renal disease ankylosing spond reactive arthritis gout pseudogout FQ and statins moderate etoh (not heavy though interestingly)

Question 46

Achilles tendon rupture - common sx

Answer 46

“pop” followed by acute weakness and an inability to continue with activity. Patients may report feeling as though they were “struck” in the posterior ankle.

Question 47

PE of tendon rupture:

Answer 47

defect palpated in tendon possible hematoma may feel boggy decreased PF (Normal 20-30 deg) thomspon test - evaluate for a complete rupture - no PF means + test

Question 48

+ diagnosis of Achilles rupture:

Answer 48

2 ore more: palpable defect 2cm to 6cm proximal to its insertion + thomspon test increased passive ankle DF decreased PF strength

Question 49

100% npv if which 3 factors are absent:

Answer 49

palpable defect 2cm to 6cm proximal to its insertion + thomspon test increased passive ankle DF

Question 50

Acute or chronic tendinopathy: what might be seen on POCUS?

Answer 50

loss of fibrillar echotexture focal tendon thickening diffuse thicekning focal hypoechoic areas extended hypoecho irregular and ill defined borders microruptures intratendinous calcification peritendinous inflamm edema

Question 51

Management of a general tendinopathy

Answer 51

1. cause 2. eliminate cause 3. NSAID 4. protect 5. relative rest 6. optimal load/ergonomics 7. application of ICE 8. education and modify 9. enhance diet 10. refer if needed

Question 52

What 2 tendons should CS injection particularly be avoided in?

Answer 52

achilles patellar

Question 53

What tendinopathies apparently do well with NTG patch?

Answer 53

medial lat epicondylitis - but also may incr risk of nonop tx failure noninsertional achilles rotator cuff tendinopathy

Question 54

Platelet rich plasma injections - literature on this for tendinopathies?

Answer 54

variable!

Question 55

Calcific tendinopathy tx

Answer 55

mainly conservative and consists of analgesia and brief immobilization (e.g., a shoulder sling for rotator cuff calcific tendinopathy) because prolonged immobilization may result in decreased range of motion. Both extracorporeal shock wave therapy (akin to that which is used for nephrolithiasis) and ultrasound-guided needle lavage and aspiration (Fig. 103.9) are effective treatments for this condition

Question 56

de Quervain's tx

Answer 56

immob with thumb spica splint antiinflamm meds prompt referral CS good

Question 57

Management of an achilles rupture

Answer 57

posterior lower leg splint in 20 deg of PF if not feasible consider walkingboot with 2 inch heel lift NWB until seen by specialist

Question 58

What is a bursa?

Answer 58

closed sac lined by synovial membrane which helps to lubricate tow areas of tissue/friction

Question 59

Bursitis causes

Answer 59

trauma systemic inflamm - gout, pseudogout, RA, psoriatic arthritis infection - staph idiopathi

Question 60

Septic bursitis common symptoms

Answer 60

pain tender erythema warmth spetic is almost always proceeded by some kind of trauma

Question 61

RF for septic arthritis

Answer 61

dm etoh abuse chronic skin cond like atopic dermatitis RA/gout ie prior noninfectious

Question 62

What movement issues would indicate more of a septic arthritis picture than septic bursitis?

Answer 62

significant decr rom generalized joint swelling joint pain? warmth? effusion?

Question 63

Subacromial bursitis

Answer 63

similar to supraspinatus tendinopathy

Question 64

Trochanteric bursa - where is deep and superficial?

Answer 64

deep bursa is between greater trochanter and tensor fasciae latae super: between greater trochanter and skin

Question 65

Trochanteric bursitis: symptoms? signs?

Answer 65

mc middle aged woman, lying on hip and walking may make worse, complication of RA palpation direct on site and hip adduction while pain of deep trochanteric bursitis may be reporudced with abd, normal hip ROM

Question 66

Iliopsoas bursitis: manigests as what?

Answer 66

anterior hip pain radiating down medial thigh to knee, exacerbated by hip extension

Question 67

Pes Anserine bursitis

Answer 67

sartorius, gracilis and semitendinosis all come here - medial knee pain 2-3cm distal to join line

Question 68

DDX of atraumatic nonseptic bursitis

Answer 68

ra pseudogout ank spond hypertrophic pulmonary osteoarthropathy oxalosis gout scleroderma sle whipple disease idopathic hypereosinophilic syndrome

Question 69

Bursitis - consider diagnostic testing with?

Answer 69

aspiration 18-20g needle septic = purulent send wbc an d diff, gram stain, crystals, appropriate cultures and sn, glucose level

Question 70

labs for bursitis

Answer 70

cbc crp glucose

Question 71

Bursa wbc > ? suggests infection

Answer 71

5000

Question 72

Septic arthritis - oral abx for 14d - what options?

Answer 72

dcloxacillin 500mg PO qid septra 1-2 tabs po twice daily clinda 300mg po qid if pen allergic

Question 73

IV options for septic bursitis

Answer 73

vancomycin 20-35mg/kg actual bw, then 15-20mg/kg actual bw q8-12h

Question 74

Nonseptic bursitis tx

Answer 74

nsaid compression occas

Question 75

1. What is the etiology of most tendinopathies? a. Direct blow to the tendon b. Recent or previous complete tendon rupture c. High-grade inflammation of the tendon d. Mechanical overload and repetitive microtrauma

Answer 75

d

Question 76

4. What is the most important predisposing factor in septic bursitis? a. Chronic obstructive pulmonary disease b. Diabetes mellitus c. Human immunodeficiency virus (HIV) d. Trauma

Answer 76

d

Question 77

5. What is the causative organism in the majority of cases of septic bursitis? a. Beta-hemolyticstreptococci b. Pseudomonas aeruginosa c. Staphylococcusaureus d. Prototheca wickerhamii

Answer 77

c

Question 78

2. Which of the following interventions should routinely be used when treating patients with tendinopathies? a. Activitymodification b. NSAIDs c. Intratendinous corticosteroid injection d. Immobilization of the affected tendon/joint

Answer 78

a

Question 79

3. A 38-year-old male presents after feeling a “pop,” followed by pain to the back of his leg while playing basketball. You note a defect to his Achilles tendon, decreased resting plantar flexion of the ankle, and a positive Thompson test on examination. What should be the next step in the patient’s management? a. Provide crutches and advise the patient to remain non- weightbearing until follow-up. b. Splint the affected leg in an equinus position and refer for prompt follow-up. c. Obtain emergent magnetic resonance imaging (MRI). d. Perform a steroid injection to the affected tendon.

Answer 79

b

Question 80

6. A 42-year-old female without significant past medical history pres- ents with 4 days of edema, mild warmth, and mild erythema in the area of the right olecranon bursa. She is afebrile and has minimal tenderness to palpation of the bursa. Aspiration of the bursa reveals a white blood cell count of 1500/μL.3 What is the most appropriate next step in the patient’s management? a. Admit for intravenous (IV) antibiotics. b. Apply a compression dressing and give ibuprofen. c. Discharge the patient to home with oral antibiotics. d. Obtain magnetic resonance imaging (MRI) for further evalua- tion.

Answer 80

Answer: B. The clinical presentation and results of the fluid analysis highly suggest a nonseptic bursitis. Cases of nonseptic bursitis can be managed with a compressive dressing, nonsteroidal antiinflammatory drugs (NSAIDs), avoidance of local trauma, and close follow-up.