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Tendon problems Flashcards

1
Q

What is “teninopathy”?

A

Disease of a tendon

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2
Q

What is “tendonitis”?

A

Inflammation of a tendon

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3
Q

What is “tendonosis”?

A

Chronic tendon injury with damage to a tendon at a cellular level

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4
Q

What is “tenosynovitis”?

A

Inflammation of the tendon sheath

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5
Q

What is “enthesopathy”?

A

Inflammation of the tendon origin or the insertion into bone

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6
Q

What is the function of a tendon?

A

To link muscle (motor unit) to the bone to enable joint function (motion)

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7
Q

What shape are tendons usually?

A

Cylindrical in shape with slight widening and flattening at the musculotendinous junction and their bony insertions

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8
Q

What is the predominant cell in tendoons?

A

Fibroblast

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9
Q

What is the function of fibroblasts?

A

Production and manitance of collagen and other proteins which confer the flexibility and tensile strength of tendons

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10
Q

Describe the structure of tendons

A

Tendons have hierarchical structures. The microfibrils make up subfibrils which in turn make up fibrils. Hundreds of these fibrils are contained within the fascicle. The fascicles are separated by endotenon which is covered by epitenon.

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11
Q

Why is the blood supply to tendons important?

A

For healing and maintenance.

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12
Q

Where does the blood supply to the tendons come from? (3)

A

The perimyseum
The periosteal insertion of the tendon
The paratenon

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13
Q

Is tendanosis always painful?

A

No, can be present and not painful.

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14
Q

What is tendanosis histologically?

A

Histologic degeneration of collagen and extracellular matrix

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15
Q

Describe the conservative management of tendon disease:

A

Rest

Analgesics (anti-inflammatories)

Injections (of local anaestheitic and cortisone around the tendon or the insertion) (rotator cuff, tennis elbow, NOT ACHILLES TENDON OR EXTENSOR KNEE MECHANISM due to risk of rupture)

Splinting (or casting) (achilles tendon)

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16
Q

What injections are useful in tendon disease?

A

PRP - platelet rich plasma –> inject into tendon (might settle down tendanopathies) ( controversial)

Steroid injections –> TOXIC TO TENOCYTES (tenocytes produce collagen) –> controversial (too many steroid injections may damage tendon)

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17
Q

Why are steroid injections controversial?

A

Steroid toxic t tenocytes tenocytes produce collagen)

Too many steroid injectiosn may amage tendon

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18
Q

What may have to be done if a tendon ruptures?

A

Tendon transfers.

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19
Q

What are the surgical principles of management of tendanopathies? (4)

A

Depridement (removal of diseased tissue)

Decompression (supraspinatus tendonitis and subacromial decompression)

Synovectomy (helps to prevent rupture) (extensor tendosn of wrist - RA) (tibalis posterior)

Tendon Transfer (Tibialis posterior) (extensor policis longus)

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20
Q

What are the muscles of the rotator cuff? (4)

A

Supraspinatus, infraspinatous, subscapularis and teres minor

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21
Q

Who gets rotator cuff pathology?

A 
Athletes (throwing)
Manual workers (painters)
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22
Q

What are the clinical findings of rotator cuff pathology?

A

Achy pain

Pain in 4 tendons of Rotator Cuff

Shoulder tenderness

Difficulty sleeping on affected side, reaching overheard and on lifting

Painful arc with rottor cuff weakness

Positive impingement tests (such as Hawkins-Kennedy, Jobe’s, Scarf)

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23
Q

What muscle is most commonly affected by a rotator cuff tear?

A

Supraspinatus

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24
Q

What intrinsic factors can cause rotator cuff tears?

A

Degeneration

Tendon vascularity

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25
What extrinsic factors can cause rotator cuff tears?
``` Anatomical features (e.g. the morphology of the acromion) Biomechanical factors (e.g. kinetics and performance) ```
26
How are rotator cuff pathologies managed conservatively?
Rest, physio, steroid and LA injections
27
How are rotator cuff pathologies managed surgically?
Either arthroscopic or open subacromial decompression and rotator cuff repair. If not settling --> sub-acromial decompression
28
What is the gold standard imaging of the rotator cuff?
Ultrasound Scan A dynamic scan can detect impingement too
29
What part of the biceps is most predominantly affected by biceps tendinopathy?
The long head of biceps (where it passes through the bicipital groove, located anteriorly on the proximal humerus).
30
How does biceps tendinopathy present?
Anterior shoulder pain which is aggrevated by shoulder flexion, forearm pronation and elbow flexion. Also --> clicking or snapping sensations with shoulder movement.
31
What are the clinical signs of biceps tendon rupture?
Popeye sign and extensive bruiding. | "Popeye sign" = Biceps "buncing up too much"
32
What three places can a biceps tendinopathy occur in?
Long head of biceps Short head of biceps Proximal end of biceps
33
What causes biceps tendinopathies? | 4
Overuse Instability Impingement Trauma
34
What investigations are used to diagnose biceps tendinopathies?
Clinical exam | Ultrasound scan
35
What is the mainstay of treatment of biceps tendinopathy?
(Conservative) Rst and Physio
36
What high risks are associated with surgical repair of biceps tendinopathy?
Neurovascular complications, especially the distal end
37
What is the other name for lateral epicondyitis?
Tennis elbow
38
Are mos cases of lateral epicondylitis (tennsi elvow) unilateral or bilateral.
Predominantly unilateral but 10-20% bilateral
39
How is lateral epicondylitis characterised symptomatically?
Characterised by pain and tenderness over the lateral epicondyle at the attachment of the forearm muscles. Pain is worse when stretching the muscles (e.g. opening a jar)
40
What is the lateral epicondyle the origin of?
The forearm extensors
41
What is a positive Mill's test?
Pain is reproduced by resisted wrist extension with the palm pronated whilst moving the palm sideways in the direction of the thumb. Pain as a result of contractile ailment of lateral epicondylitis. Positive Mills tests indicates lateral epicondylitis
42
What is a positive Mill's test indicative of?
Lateral epicondylitis
43
Which test sign is positive in lateral epicondylitis?
Mill's test
44
What investigations are used in the diagnosis of lateral epicondylitis (tennis elbow)?
(diagnosis is predimonantly clinical but if uncertainty:) Utrasound Scan (USS) MRI Nerve conduction study (NCS) (if there are nerve symptoms)
45
What are important parts of the management of tennis elbow and golfer's elbow (in the "management ladder"?
Rest + Physio Modify activities Orthotics Injection of LA and steroids Surgical release for refractory cases
46
What is the other name for medial epicondylitis?
"golfer's elbow"
47
What is tennis elbow?
Lateral epicondylitis
48
What is golfer's elbow?
Medial epicondylitis Inflammation of the flexor forearm muscles
49
In medial epicondylitis (golfer's elbow) where is the pain localised?
Patient has medial elbow pain with a tender point being located over origin of the flexors at the medial epicondyle. (The pain is aggravated by wrist flexion and pronation, which is the basis for testing on examination.) It is also worse upon grasping (e.g. opening a jar)
50
What can cause medial epicondylitis?
Repetitive stress at the muscle-tendon junction (e.g. golf)
51
What age range is the peak incidence of medial epicondylitis?
40-50
52
Is medial epiconylitis self-limiting or does it require intervention.
Medial epicondylitis is a self-limiting condition
53
what 2 things may also bee associated with some cases of medial epicondylitis?
Ulnar neuropathy | Muscle weakness
54
If a diagnosis of medial epicondylitis is uncertain, how may it be investigated?
``` Ultrasound Scan (USS) MRI ``` Nerve conduction study (NCS) (if ulnar nerve symptoms are present)
55
What is affected in De Quervain's Tenosynovitis?
The first compartment which contains APL (abductor pollicis longus) and EPB (extensor pollicis brevis).
56
Where is pain felt in De Quervain's Tenosynovitis?
Radial Styloid Process
57
What is De Quervain's Tenosynovitis also known as? | 3
Blackberry thumb Gamer's thumb Mother's wrist (and more)
58
Who most commonly gets De Quervain's thumb?
Women (between ages 30 and 50) | Is associated with pregnancy and RA
59
Which test is indicative of De Quervain's Tenosynovitis?
Finklestein's test (The patient makes a fist over the thumb (thumb inside) and the hand is ulnar deviated to reproduce pain,) (if in anatomical positition --> ulnar deviated = medially) Pain reproduced = Positive Finklestein's test
60
How is De Quervain's Tenosynovitis investigated?
``` Ultrasound Scan (USS) X-ray (to rule out (carpometacarpal) CMC joint OA which can mimic De Quervain's) ```
61
When can Extensor Pollocis Longus rupture occur?
With RA | After colles fracture
62
What is the treatment for EPL rupture?
Requires tendon transfer (EIP) (extensor indicus proprius)
63
How does RA cause tendon rupture?
Autoimmune attack on synovium --> tendon degeneration --> rupture
64
What type of surgery may prevent extensor tendon rupture?
Synovectomy
65
How does "trigger finger" come about?
Stenosing tenosynovitis --> Fibrocartilaginous metaplasia --> nodule FDS tendon Nodule catches on A1 pulley --> triggering
66
What ages get "trigger finger"?
Any age (incl. children)
67
How do you treat "trigger finger"?
Observe Inject Surgical release
68
What is the extensor mechanism of the knee made up of? | 4
Quadriceps muscle Quadriceps tendon Patella Patellar tendon
69
What will the patient struggle to do if there is injury to any component of the extensor mechanism of the knee?
SLR (straight leg raise)
70
What age group are tendon ruptures most common in?
Middle aged population | more common in those who play running or jumping sports
71
What can tendon rupture be associated with? | 3
Blunt or penetrating trauma Steroid or antibiotic use Diabetes
72
What investigations can be used to investigate knee extensor mechanism tendinopathy?
X-ray ( may show an effusion or the patella sitting in the wrong place) USS or MRI (may show a partial or complete tear) Clinical examination may show a palpable gap and no straight leg raise
73
Management of tendon tear in knee extensor mechanism:
Predominantly surgical repair with gradual increas in range of movement post-operatively as part of physiotherapy regime. (However, small partial tears of quadriceps may just require immobilisation and physio)
74
Should you inject tendonitis?
No
75
What do you inject to treat tendonitis?
lol trick question Don't inject tendonitis
76
How is surgical repair of the quadriceps and patellar tendons typically done?
Using sutures with bony anchors through an open approach
77
What is apophysitis?
Irritation and inflammation of the apophysis, a secondary ossification center which acts as an insertion site for a tendon.
78
What is traction apophysitis at the tibial tubercle also called?
Osgood-Schlatter''s disease.
79
What is Osgood-Schlatter's disease?
Traction apophysitis at tibial tubercle. (insertion of patellar tendon into tibial tuberosity) (leaves predominant bony lump) (painful) (Can alos occur in patella and achilles)
80
Which type of patient's commonly get Osgood-Schlatter's disease?
Adolescent active boys
81
What conditions are associated with achilles tendon rupture? | 3
Commoner in patients with RA Those on steroids Patient with tendonitis
82
What are the clinical findings in achilles tendon rupture?
Bruising Palpable gap Patient unable to tip to stand Positive Simmond's test
83
If diagnosis of achilles tendon rupture uncertain, which investigations can be useful?
USS | MRI
84
Management of achilles tendon rupture
Conservative or by surgical repair
85
What is a positive Thompson's/Simmond's test?
When squeeze calf muscles, foot should planter flex. If no/reduced movement (plantar flexion) --> positive sign (positive in achilles tendon rupture)
86
Which test is positive in achilles tendon rupture?
Thompson's / Simond's
87
What is a positive Thompson's/Simmond's test indicative of?
Achilles tendon rupture | When squeeze calf muscles, foot should planter flex. If no/reduced movement (plantar flexion) --> positive sign
88
Other than surgical repair, in achilles tendon rupture, what can be used to bring foot back up to neutral position?
Equinus cast with several casts
89
How does tibialis posterior rupture come about?
Tenosynovitis --> progressive elongation --> rupture
90
What does tibialis posterior rupture lead to?
Leads to progressive flat foot and valgus hindfoot (laterally)
91
Treatment of tibialis posterior rupture:
NSAIDs Orthotics/cast Inject Debride (may be helped by tendon transfer)

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