Tendon Problems Flashcards by Joanne McEwan

what can cause a rotator cuff pathology

extrinsic compression
intrinsic degeneration
inflammation of subacromial bursa

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what are the clinical findings in a rotator cuff pathology?

achy pain down the arm
difficulty sleeping on affected side, reaching overhead etc
painful arc +/- weakness
tenderness over shoulder around glenohumeral joint and AC joint
positive impingement tests (Hawkins-Kennedy, Jobes and scarf tests)

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how is rotator cuff pathology managed?

conservative - physio, injections

surgical - subacromial decompression

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what is the gold standard imaging for rotator cuff pathology?

MRI and arthroscopy also used

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what causes biceps tendinopathy?

tendinosis leads to inflammation
overuse
instability
impingement
trauma

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what are the possible types of biceps tendinopathy?

tendonitis
tendonosis
rupture
tenosynovitis

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what are the symptoms of biceps tendinopathy?

pain in the anterior shoulder radiating to the elbow

aggravated by shoulder flexion, forearm pronation and elbow flexion
snapping sensation with shoulder movements if subluxation

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which head of the biceps is most commonly affected by tendinopathy?

long head where it passes through the bicipital groove on the anterior proximal humerus - where most inflammation/friction occurs

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how is biceps tendinopathy diagnosed?

clinical exam

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how is biceps tendinopathy managed?

conservative or surgical

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what is the clinical sign of biceps rupture?

popeye sign

bulge at opposite end of muscle

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how biceps rupture managed?

mainstay = conservative with rest and physio

surgical repair if conservative doesn’t work but carries high risk

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what is lateral epicondylitis?

“tennis elbow”

eccentric overload at common extensor tendon origin due to overuse causing tendinosis and inflammation at ECRB origin

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what is the pathophysiology of tennis elbow?

peritendinous inflammation > angiofibroblastic hyperplasia > breakdown/fibrosis

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what are the clinical features of tennis elbow?

commonly in dominant arm
pain and tenderness over lateral epicondyle (worse when stretching muscles)
pain with resisted extension of middle finger

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how is tennis elbow managed?

self limiting - rest, physio, steroid injections

surgical release and debridement of ERCB origin

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how is tennis elbow diagnosed?

mainly clinical - mills sign positive

US and MRI can be needed

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what is medial epicondylitis?

“golfers elbow”
inflammation of the flexor forearm muscles
repetitive stress leads to peritendinous inflammation > angiofibroblastic hyperplasia > breakdown/fibrosis
at origin of wrist flexors at medial epicondyle

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what are the features of golfers elbow?

medial elbow pain - tender point over origin of the flexors
- aggravated by wrist flexion and pronation and using muscles (opening a jar)
can have associated ulnar neuropathy/weakness

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how is golfers elbow managed?

conservative - rest, physio, modification of activities
avoid injections - ulnar nerve
debridement surgery can be used in refractory cases

what is De Quervains Tenosynovitis and what causes it?

pathology of first extensor compartment (APL and EPB) of the tendon sheath
caused unknown but more common in females - possible pregnancy related

what are the features of De Quervains tenosynovitis?

pain whilst using thumb
tender over compartment
pain on resisted active thumb extension
positive finklesteins test

how is De Quervains diagnosed?

X ray

how is De Quervains managed?

splint
rest
physio
anagesics
injections
surgical decompression

what can cause an extensor tendon rupture?

RA | autoimmune attack on synovium > tendon degeneration > rupture

what are the features of RA extensor tendon rupture and how is it treated?

weak wrist extension or dropped finger tendon transfer (can be prevented by synovectomy)

what is the most common hand tendon rupture?

EPL rupture | occurs a few weeks after an undisplaced distal radius fracture

what happens in an EPL rupture?

watershed area of tendon as it passes around Lister's tubercle fracture haematoma hinders perfusion causes loss of function of thumb extension, but not always too bad

how is EPL rupture managed?

may need tendon transfer

how does trigger finger occur?

stenosing tenosynovitis > fibrocartilaginous metaplasia > nodule on FDS tendon > nodule catches on A1 pulley > clicking and locking during flexion/extension of finger

what are the features of trigger finger?

pain and tenderness over tendon sheath at level of MCPs | can have fixed flexion contracture (esp. in diabetics)

how is trigger finger managed?

observe inject (cures most) surgical release of A1 pulley - not in RA as can exacerbate ulnar drift so use synovectomy instead

rule for quads, patellar and achilless tendons tendonitis?

don't inject!

how does a quads or patella tendon rupture present?

palpable gap cant do straight leg raise may be high or low patella on X ray

how is quads or patella tendon rupture managed?

surgical repair through open approach

what is Osgood schlatters disease?

traction apophysitis at the tibial tubercle (inflammation of the bony prominence at the growth plate due to chronic traction of the tendon at its insertion at the growth plate)

what are the features of traction apophysitis?

leaves prominent bony lump growing pains usually in active adolescent boys

how does an achilles tendon rupture usually present?

middle aged sudden acceleration/deceleration feels like being kicked or shot

what are the risk factors for achilles tendon rupture?

RA steroids tendonitis

what are the clinical findings in achilles tendon rupture?

palpable gap unable to plantarflex +ve Simmonds test

how is achilles tendon rupture diagnosed?

clinical examination usually enough but may need US or MRI if complex

how is an achilles tendon rupture managed?

serial plater casts | surgical repair

how does tibialis posterior rupture occur and what can it lead to?

tenosynovitis > progressive elongation > rupture > progressive flat foot and valgus hindfoot

how is tibialis posterior rupture managed?

``` NSAIDs orthotics/casts injections debridement may be helped by tendon transfer ```

what is the function of tendons and how are they made up?

link muscle to bone to enable joint function microfibrils > subfibrils > fibrils > fascicles > tendon unit tendon unit surrounded by endotendon which contains nerves and small blood vessels endotendon surrounded by epitenon - connective tissue, within the tendon sheath

what are tendons composed of?

water type 1 collagen proteoglycans

what cells are present in tendons?

fibroblasts - produce collagen and proteoglycan

what is the blood supply to tendons?

poor supply | watershed areas linked to tendon pathology and rupture

what are the 5 types of tendon disease?

``` tendinopathy = disease of a tendon tendonitis = inflammation of a tendon tendonosis = chronic tendon injury with damage to a tendon ECM tenosynovitis = inflammation of the tendon sheath enthesopathy = inflammation of the tendon origin or insertion into bone ```