Flashcards in Tendon problems Deck (91):
What is "teninopathy"?
Disease of a tendon
What is "tendonitis"?
Inflammation of a tendon
What is "tendonosis"?
Chronic tendon injury with damage to a tendon at a cellular level
What is "tenosynovitis"?
Inflammation of the tendon sheath
What is "enthesopathy"?
Inflammation of the tendon origin or the insertion into bone
What is the function of a tendon?
To link muscle (motor unit) to the bone to enable joint function (motion)
What shape are tendons usually?
Cylindrical in shape with slight widening and flattening at the musculotendinous junction and their bony insertions
What is the predominant cell in tendoons?
What is the function of fibroblasts?
Production and manitance of collagen and other proteins which confer the flexibility and tensile strength of tendons
Describe the structure of tendons
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.
Why is the blood supply to tendons important?
For healing and maintenance.
Where does the blood supply to the tendons come from? (3)
The periosteal insertion of the tendon
Is tendanosis always painful?
No, can be present and not painful.
What is tendanosis histologically?
Histologic degeneration of collagen and extracellular matrix
Describe the conservative management of tendon disease:
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)
What injections are useful in tendon disease?
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)
Why are steroid injections controversial?
Steroid toxic t tenocytes tenocytes produce collagen)
Too many steroid injectiosn may amage tendon
What may have to be done if a tendon ruptures?
What are the surgical principles of management of tendanopathies? (4)
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)
What are the muscles of the rotator cuff? (4)
Supraspinatus, infraspinatous, subscapularis and teres minor
Who gets rotator cuff pathology?
Manual workers (painters)
What are the clinical findings of rotator cuff pathology?
Pain in 4 tendons of Rotator Cuff
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)
What muscle is most commonly affected by a rotator cuff tear?
What intrinsic factors can cause rotator cuff tears?
What extrinsic factors can cause rotator cuff tears?
Anatomical features (e.g. the morphology of the acromion)
Biomechanical factors (e.g. kinetics and performance)
How are rotator cuff pathologies managed conservatively?
Rest, physio, steroid and LA injections
How are rotator cuff pathologies managed surgically?
Either arthroscopic or open subacromial decompression and rotator cuff repair.
If not settling --> sub-acromial decompression
What is the gold standard imaging of the rotator cuff?
A dynamic scan can detect impingement too
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).
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.
What are the clinical signs of biceps tendon rupture?
Popeye sign and extensive bruiding.
"Popeye sign" = Biceps "buncing up too much"
What three places can a biceps tendinopathy occur in?
Long head of biceps
Short head of biceps
Proximal end of biceps
What causes biceps tendinopathies?
What investigations are used to diagnose biceps tendinopathies?
What is the mainstay of treatment of biceps tendinopathy?
(Conservative) Rst and Physio
What high risks are associated with surgical repair of biceps tendinopathy?
Neurovascular complications, especially the distal end
What is the other name for lateral epicondyitis?
Are mos cases of lateral epicondylitis (tennsi elvow) unilateral or bilateral.
Predominantly unilateral but 10-20% bilateral
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)
What is the lateral epicondyle the origin of?
The forearm extensors
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
What is a positive Mill's test indicative of?
Which test sign is positive in lateral epicondylitis?
What investigations are used in the diagnosis of lateral epicondylitis (tennis elbow)?
(diagnosis is predimonantly clinical but if uncertainty:)
Utrasound Scan (USS)
Nerve conduction study (NCS) (if there are nerve symptoms)
What are important parts of the management of tennis elbow and golfer's elbow (in the "management ladder"?
Rest + Physio
Injection of LA and steroids
Surgical release for refractory cases
What is the other name for medial epicondylitis?
What is tennis elbow?
What is golfer's elbow?
Inflammation of the flexor forearm muscles
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)
What can cause medial epicondylitis?
Repetitive stress at the muscle-tendon junction (e.g. golf)
What age range is the peak incidence of medial epicondylitis?
Is medial epiconylitis self-limiting or does it require intervention.
Medial epicondylitis is a self-limiting condition
what 2 things may also bee associated with some cases of medial epicondylitis?
If a diagnosis of medial epicondylitis is uncertain, how may it be investigated?
Ultrasound Scan (USS)
Nerve conduction study (NCS) (if ulnar nerve symptoms are present)
What is affected in De Quervain's Tenosynovitis?
The first compartment which contains APL (abductor pollicis longus) and EPB (extensor pollicis brevis).
Where is pain felt in De Quervain's Tenosynovitis?
Radial Styloid Process
What is De Quervain's Tenosynovitis also known as?
Who most commonly gets De Quervain's thumb?
Women (between ages 30 and 50)
Is associated with pregnancy and RA
Which test is indicative of De Quervain's Tenosynovitis?
(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
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)
When can Extensor Pollocis Longus rupture occur?
After colles fracture
What is the treatment for EPL rupture?
Requires tendon transfer (EIP) (extensor indicus proprius)
How does RA cause tendon rupture?
Autoimmune attack on synovium --> tendon degeneration --> rupture
What type of surgery may prevent extensor tendon rupture?
How does "trigger finger" come about?
Stenosing tenosynovitis --> Fibrocartilaginous metaplasia --> nodule FDS tendon
Nodule catches on A1 pulley --> triggering
What ages get "trigger finger"?
Any age (incl. children)
How do you treat "trigger finger"?
What is the extensor mechanism of the knee made up of?
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)
What age group are tendon ruptures most common in?
Middle aged population
(more common in those who play running or jumping sports)
What can tendon rupture be associated with?
Blunt or penetrating trauma
Steroid or antibiotic use
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
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)
Should you inject tendonitis?
What do you inject to treat tendonitis?
Don't inject tendonitis
How is surgical repair of the quadriceps and patellar tendons typically done?
Using sutures with bony anchors through an open approach
What is apophysitis?
Irritation and inflammation of the apophysis, a secondary ossification center which acts as an insertion site for a tendon.
What is traction apophysitis at the tibial tubercle also called?
What is Osgood-Schlatter's disease?
Traction apophysitis at tibial tubercle.
(insertion of patellar tendon into tibial tuberosity)
(leaves predominant bony lump)
(Can alos occur in patella and achilles)
Which type of patient's commonly get Osgood-Schlatter's disease?
Adolescent active boys
What conditions are associated with achilles tendon rupture?
Commoner in patients with
Those on steroids
Patient with tendonitis
What are the clinical findings in achilles tendon rupture?
Patient unable to tip to stand
Positive Simmond's test
If diagnosis of achilles tendon rupture uncertain, which investigations can be useful?
Management of achilles tendon rupture
Conservative or by surgical repair
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)
Which test is positive in achilles tendon rupture?
Thompson's / Simond's
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)
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
How does tibialis posterior rupture come about?
Tenosynovitis --> progressive elongation --> rupture
What does tibialis posterior rupture lead to?
Leads to progressive flat foot and valgus hindfoot (laterally)