Bursitis, Tendonitis, Fibromyalgia, and RSD

Joe Lex, MD, FAAEM

Temple University School of Medicine Philadelphia, PA joe@joelex.net

Objectives
1. Explain how bursitis and tendonitis are similar 2. Explain how bursitis and tendonitis differ from from another 3. List phases in development and healing of bursitis and tendonitis

Objectives
4. List common types of bursitis and tendonitis found at the:
Shoulder Elbow Wrist Hip Knee Ankle

5. List indications / contraindications for injection therapy of bursitis and tendonitis

Objectives
6. Describe typical findings in a patient with fibromyalgia 7. Describe typical findings in a patient with reflex sympathetic dystrophy

Sports
Society more athletic Physical activity health benefits Overuse syndromes increase 25% to 50% of participants will experience tendonitis or bursitis

Workplace
Musculoskeletal disorders from repetitive motions localized contact stress awkward positions vibrations forceful exertions Ergonomic design incidence

Bursae
Closed, round, flat sacs Lined by synovium May or may not communicate with synovial cavity Occur at areas of friction between skin and underlying ligaments / bone

Bursae
Permit lubricated movement over areas of potential impingement Many are nameless ~78 on each side of body New bursae may form anywhere from frequent irritation

Bursitis
Inflamed by
chronic friction trauma crystal deposition infection
systemic disease: rheumatoid arthritis, psoriatic arthritis, gout ankylosing spondylitis

Bursitis
Inflammation causes bursal synovial cells to thicken Excess fluid accumulates inside and around affected bursae

Tendons
Tendon sheaths composed of same synovial cells as bursae Inflamed in similar manner Tendonitis: inflammation of tendon only Tenosynovitis: inflammation of tendon plus its sheath

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

Tendons
Most overuse syndromes are NOT inflammatory Biopsy: no inflammatory cells High glutamate concentrations NSAIDs / steroids: no advantage TendonITIS a misnomer

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

Bursitis / Tendonitis
Intrinsic 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 Phase
Release of chemotactic and vasoactive chemical mediators Vasodilation and cellular edema PMNs perpetuate process Lasts 48 hours to 2 weeks Repetitive insults prolong inflammatory stage

Healing Phase
Classic inflammatory signs: pain, warmth, erythema, swelling Healing goes through proliferative and maturation 6 to 12 weeks: organization and collagen cross-linking mature to preinjury strength

History
Changes in sports activity, work activities, or workplace Cause not always found Pregnancy, quinolone therapy, connective tissue disorders, systemic illness

History
Most common complaint: PAIN Acute or chronic Frequently more severe after periods of rest May resolve quickly after initial movement only to become throbbing pain after exercise

Articular vs. Periarticular

In joint capsule Joint pain / warmth / swelling Worse with active & passive movement All parts of joint involved Periarticular Pain not uniform across joint Pain only certain movements Pain character & radiation vary

Physical Exam
Careful palpation Range of motion Heat, warmth, redness

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

Synovial Fluid
Especially crystalline, suppurative etiology Appearance, cell count and diff, crystal analysis, Grams stain
Positive Grams: diagnostic Negative Grams: cannot rule out

Management
Rest Pain relief: meds, heat, cold No advantage to NSAIDs Exceptions: olecranon bursitis and prepatellar bursitis have a moderate risk of being infected (Staphylococcus aureus)

Management
Shoulder: immobilize few days
Risk of adhesive capsulitis

Lateral epicondylitis: forearm brace Olecranon bursitis: compression dressing

Management
De Quervains: splint wrist and thumb in 20o dorsiflexion Achilles tendonitis: heel lift or splint in slight plantar flexion

Local Injection

Local Injection
Lidocaine or steroid injection can overcome refractory pain Steroids universally given, often with great success No good prospective data to support or refute therapeutic benefit

Local Injection
Short course of oral steroid may produce statistically similar results Primary goal of steroid injection: relieve pain so patient can participate in physical rehab

Local Injection
Adjunct to other modalities: pain control, PT, exercise, OT, relative rest, immobilization Additional pain control: NSAIDs, acupuncture, ultrasound, ice, heat, electrical nerve stimulation

Local Injection
Analgesics + exercise: better results than exercise alone Eliminate provoking factors Avoid repeat steroid injection unless good prior response Wait at least 6 weeks between injections in same site

Indications
Diagnosis Obtain fluid for analysis Eliminate referred pain Therapy Give pain relief Deliver therapeutic agents

Contraindication: Absolute
Bacteremia Infectious arthritis Periarticular cellulitis Adjacent osteomyelitis Significant bleeding disorder Hypersensitivity to steroid Osteochondral fracture

Contraindication: Relative
Violation of skin integrity Chronic local infection Anticoagulant use Poorly controlled diabetes Internal joint derangement Hemarthrosis Preexisting tendon injury Partial tendon rupture

Preparations
Local anesthetic Hydrocortisone / corticosteroid Rapid anti-inflammatory effect Categorized by solubility and relative potency High solubility short duration
Absorbed, dispersed more rapidly

Preparations
Triamcinolone hexacetonide: least soluble, longest duration
Potential for subcutaneous atrophy Intra-articular injections only

Methylprednisolone acetate (DepoMedrol): reasonable first choice for most ED indications

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

Site Preparation
Use careful aseptic technique Mark landmarks with skin pencil, tincture of iodine, or thimerosal (Merthiolate) (sterile Q-tip) Clean point of entry: povidoneiodine (Betadine) and alcohol Do not need sterile drapes

Technique
Make skin wheal: 1% lidocaine or 0.25% bupivacaine OR use topical vapocoolant: e.g., Fluori-Methane Use Z-tract technique: limits risk of soft tissue fistula Agitate syringe prior to injection: steroid can precipitate or layer

Complications: Acute
Reaction to anesthetic: rare
Treat as in standard textbooks

Accidental IV injection Vagal reaction: have patient flat Nerve injury: pain, paresthesias Post injection flare: starts in hours, gone in days (~2%)

Complications: Delayed
Localized subcutaneous or cutaneous atrophy at injection site Small depression in skin with depigmentation, transparency, and occasional telangiectasia
Evident in 6 weeks to 3 months Usually resolve within 6 months Can be permanent

Complications: Delayed
Tendon rupture: low risk (<1%) Dose-related Related to direct tendon injection? Limit injections to no more than once every 3 to 4 months Avoid major stress-bearing tendons: Achilles, patellar

Complications: Delayed
Systemic absorption slower than with oral steroids Can suppress hypopituitaryadrenal axis for 2 to 7 days Can exacerbate hyperglycemia in diabetes Abnormal uterine bleeding reported

Some specific entities

Bicipital Tendonitis
Risk: repeatedly flex elbow against resistance: weightlifter, swimmer Tendon goes through bicipital (intertubercular) groove Pain with elbow at 90 flexion, arm internally / externally rotated

Bicipital Tendonitis
Range of motion: normal or restricted Strength: normal Tenderness: bicipital groove Pain: elevate shoulder, reach hip pocket, pull a back zipper

Bicipital Tendonitis
Lipman test: "rolling" bicipital tendon produces localized tenderness Yergason 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 Bursitis

Calcific (calcareous) tendonitis: hydroxyapatite deposits in one or more rotator cuff tendons
Commonly supraspinatus

Sometimes rupture into adjacent subacromial bursa Acute deltoid pain, tenderness

Calcific Tendonitis

Supraspinatus Tendonitis
Subacromial Bursitis

Clinically similar: difficult to differentiate Rotator cuff: teres minor, supraspinatus, infraspinatus, subscapularis
Insert as conjoined tendon into greater tuberosity of humerus

Calcific Tendonitis

Supraspinatus Tendonitis
Subacromial Bursitis

Jobes sign, AKA empty can test Abduct arm to 90o in the scapular plane, then internally rotate arms to thumbs pointed downward Place downward force on arms: weakness or pain if supraspinatus

Calcific Tendonitis

Supraspinatus Tendonitis
Subacromial Bursitis

Other tests: Neer, Hawkins Passively abduct arm to 90, then passively lower arm to 0 and ask patient to actively abduct arm to 30

Calcific Tendonitis

Supraspinatus Tendonitis
Subacromial Bursitis

If can abduct to 30 but no further, suspect deltoid If cannot get to 30, but if placed at 30 can actively abduct arm further, suspect supraspinatus If uses hip to propel arm from 0 to beyond 30, suspect supraspinatus

Calcific Tendonitis

Supraspinatus Tendonitis

Subacromial Bursitis
Subacromial bursa: superior and lateral to supraspinatus tendon Tendon and bursa in space between acromion process and head of humerus Prone to impingement

Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis Patient holds arm protectively against chest wall May be incapacitating All ROM disturbed, but internal rotation markedly limited Diffuse perihumeral tenderness X-ray: hazy shadow

Rotator Cuff Tear

Drop arm test: arm passively abducted at 90o, patient asked to maintain dropped arm represents large rotator cuff tear Shrug sign: attempt to abduct arm results in shrug only

Elbow and Wrist

Lateral Epicondylitis
Pain at insertion of extensor carpi radialis and extensor digitorum muscles Radiohumeral bursitis: tender over radiohumeral groove Tennis elbow: tender over lateral epicondyle

Lateral Epicondylitis
History repetitive overhead motion: golfing, gardening, using tools Worse when middle finger extended against resistance with wrist and the elbow in extension Worse when wrist extended against resistance

Medial Epicondylitis
Golfer's elbow or pitchers elbow similar Much less common Worse when wrist flexed against resistance Tender medial epicondyle

Cubital Tunnel Syndrome

Ulnar nerve passes through cubital tunnel just behind ulnar elbow Numbness and pain small and ring fingers Initial treatment: rest, splint

Olecranon Bursitis
Student's or barfly elbow Most frequent site of septic bursitis Aseptic: motion at elbow joint complete and painless Septic: all motion usually painful

Olecranon Bursitis
Aseptic olecranon bursitis Cosmetically bothersome, usually resolves spontaneously If bothersome, aspiration and steroid injection speed resolution Oral NSAID after steroid injection does not affect outcome

Septic Olecranon Bursitis

Most common septic bursitis: olecranon and prepatellar 2o to acute trauma / skin breakage Impossible to differentiate acute gouty olecranon bursitis from septic bursitis without laboratory analysis

Ganglion Cysts
Swelling on dorsal wrist ~60% of wrist and hand soft tissue tumors Etiology obscure Lined with mesothelium or synovium Arise from tendon sheaths or near joint capsule

Carpal Tunnel Syndrome

Median nerve compression in fibro-osseous tunnel of wrist Pain at wrist that sometimes radiates upward into forearm Associated with tingling and paresthesias of palmar side of index and middle fingers and radial half of the ring finger

Carpal Tunnel Syndrome

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

Carpal Tunnel Syndrome

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

Carpal Tunnel Syndrome

May be idiopathic Known causes: rheumatoid arthritis pregnancy, diabetes, hypothyroidism, acromegaly

Carpal Tunnel Syndrome

Insert needle just radial or ulnar to palmaris longus and proximal to distal wrist crease Ulnar preferred: avoids nerve Direct needle at 60 to skin surface, point toward tip of middle finger

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

de Quervains Disease
1st dorsal compartment Radial border of anatomic snuffbox 1st compartment may cross over 2nd compartment (ECRL/B) proximal to extensor retinaculum Steroid injections relieve most symptoms

Trigger Finger
Digital flexor tenosynovitis Stenosed tendon sheath
Palmar surface over MC head

Intermittent tendon catch Locks on awakening Most frequent: ring and middle

Trigger Finger
Tendon sheath walls lined with synovial cells Tendon unable to glide within sheath Initial treatment: splint, moist heat, NSAID Steroid for recalcitrant cases

Hip and Groin

Trochanteric Bursitis
Second leading cause of lateral hip pain after osteoarthritis Discrete tenderness to deep palpation Principal bursa between gluteus maximus and posterolateral prominence of greater trochanter

Trochanteric Bursitis
Pain usually chronic Pathology in hip abductors May radiate down thigh, lateral or posterior Worse with lying on side, stepping from curb, descending steps

Trochanteric Bursitis
Patrick fabere sign (flexion, abduction, external rotation, and extension) may be negative Passive ROM relatively painless Active abduction when lying on opposite side pain Sharp external rotation pain

Ischiogluteal Bursitis
Weaver's bottom / tailors seat: pain center of buttock radiating down back of leg Often mistaken for back strain, herniated disk Pain worse with sitting on hard surface, bending forward, standing on tiptoe

Ischiogluteal Bursitis
Tenderness over ischial tuberosity Ischiogluteal bursa adjacent to ischial tuberosity, overlies sciatic / posterior femoral cutaneous nerves

Legs and Feet

Prepatellar Bursitis
Housemaids knee / nuns knee: swelling with effusion of superficial bursa over lower pole of patella Passive motion fully preserved Pain mild except during extreme knee flexion or direct pressure

Prepatellar Bursitis
Pressure from repetitive kneeling on a firm surface: rug cutter's knee Rarely direct trauma Second most common site for septic bursitis

Bakers Cyst
Pseudothrombophlebitis syndrome Herniated fluid-filled sacs of articular synovial membrane that extend into popliteal fossa Causes: trauma, rheumatoid arthritis, gout, osteoarthritis Pain worse with active knee flexion

Bakers Cyst
Can mimic deep venous thrombosis Ultrasound eseential Many resolve over weeks May require surgery Steroid injections not performed: risk of neurovascular injury

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

Anserine Bursitis
Abrupt knee pain, local tenderness 4 to 5 cm below medial aspect of tibial plateau Knee flexion exacerbates

Iliotibial Band Syndrome

Lateral knee pain Cyclists, dancers, distance runners, football players Pain worse climbing stairs Tenderness when patient supine, knee flexed to 90o

Ankle and Foot

Peroneal Tendonitis
Peroneal tendons cross behind lateral malleolus Running, jumping, sprain Holding foot up and out against downward pressure causes pain

Peroneal Tendon Rupture

Torn retinaculum Have patient dorsiflex and plantar flex with foot in inversion Feel for snapping behind lateral malleolus

Retrocalcaneal Bursitis
Ankle overuse: excessive walking, running, or jumping Heel pain: especially with walking, running, palpation Haglund disease: bony ridge on posterosuperior calcaneus Treatment: open heels (clogs), bare feet, sandals, or heel lift

Plantar Fasciitis
Policeman's heel / soldier's heel: associated with heel spurs Degenerated plantar fascial band at origin on medial calcaneous Heel pain worse in morning and after long periods of rest May be relieved with activity

Plantar Fasciitis
Microtears in fascia from overuse? Eliminate precipitators, rest, strength and stretching exercises, arch supports, and night splints Sometimes need steroid injection Risk of plantar fascia rupture and fat pad atrophy

Tarsal Tunnel Syndrome

Between medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periods Tender along course of nerve

Tarsal Tunnel Syndrome

Between medial malleolus and flexor retinaculum Vague pain in sole of foot: burning or tingling Worse with activity, especially standing, walking for long periods Tender along course of nerve

Fibromyalgia

Fibromyalgia
Pain in muscles, joints, ligaments and tendons Tender points
Knees, elbows, hips, neck

5% of population, including kids Main symptom: sensitivity to pain

Fibromyalgia
Pain: chronic, deep or burning, migratory, intermittent Fatigue, poor sleep Numbness or tingling Poor blood flow Sensitivity to odors, bright lights, loud noises, medicines

Fibromyalgia
Jaw pain Dry eyes Difficulty focusing Dizziness Balance problems Chest pain Rapid or irregular heartbeat

Fibromyalgia
Shortness of breath Difficulty swallowing Heartburn Gas Cramping abdominal pain Alternating diarrhea & constipation Frequent urination

Fibromyalgia
Pain in bladder area Urgency Pelvic pain Painful menstrual periods Painful sexual intercourse Depression Anxiety

Compare to Somatization
Somatization Fibromyalgia

Vomiting Abdominal pain Nausea Bloating Diarrhea Leg / arm pain

Back pain

Compare to Somatization
Somatization Fibromyalgia

Joint pain Dysuria Headaches Breathlessness Palpitations Chest pain

Dizziness

Compare to Somatization
Somatization Fibromyalgia

Amnesia Dysphagia Vision changes Weak muscles Sexual apathy Dyspareunia

Impotence

Compare to Somatization
Somatization Fibromyalgia

Dysmenorrhea Irregular menstruation Excessive menstrual flow

Fibromyalgia
Treatment

Reflex Sympathetic Dystrophy

Causalgia Shoulder-hand syndrome Sudeck's atrophy Post-traumatic pain syndrome Complex regional pain syndrome type I and type II Sympathetically maintained pain

Reflex Sympathetic Dystrophy

Distal extremity pain, tenderness Bone demineralization, trophic skin changes, vasomotor instability Precipitating event in 2/3: injury, stroke, MI, local trauma, fracture Associated with emotional liability, depression, anxiety

Reflex Sympathetic Dystrophy

Treatments: medication, physical therapy, sympathetic nerve blocks, psychological support
Possible sympathectomy or dorsal column stimulator

Pain Clinic with coordinated plan may be helpful