Week 9 - Joints and Bones Systems I

1. Week 9 - Joints and Bones Systems I • Dr. Alex Alexander

2. Next Week: Muscle and Connective Tissue • Tendinitis and Bursitis • Epicondylitis • Achilles Contracture • Carpal Tunnel • Torticollis • Rhabdomyolysis

3. Tendinitis and Bursitis • Tendinitis is a painful inflammation of the tendon-muscle attachment to the bone, usually in the shoulder, achilles or hamstring. • Bursitis is the painful inflammation of one or more bursae--closed sacs lubricated with small amounts of synovial fluid that facilitate the motion of muscles and tendons over bony prominences.

4. Toma(y)to-Toma(h)to • The term tendinosis was first used in the 1940s by a group of German researchers, however the term did not receive much attention until it was used again in the mid 1980s to describe a non-inflammatory tendon condition. The more commonly used term of tendinitis has since been proven to be a misnomer for several reasons. The first of which is that there is a lack of inflammatory cells in conditions that were typically called a tendonitis. Since inflammation is the key pathological process involved with that term, and the discovery that there in fact were no, or very few, inflammatory cells present in the condition, a new term was adopted tendinosis. This has a much greater impact then just the name one calls a condition, it also has a profound impact on how the condition is treated.

5. Tendinopathy • Etiology • Although tendinopathy affects millions of people, its etiology is not clear. While multiple factors including age, genetics, body weight, and muscle weakness are believed to be involved, repetitive mechanical loading of tendons is considered the major risk factor in the development of tendinopathy. • Tendons serve several functions including mechanical force transmission, joint stabilization, and shock absorption to limit muscle damage. Tendons consist of collagens, proteoglycans, glycoproteins, water, and cells. They are able to alter their structure and composition in response to mechanical loads. While appropriate mechanical loading of tendons is beneficial, overuse (chronic, repetitive mechanical loading placed on tendons) results in pathologic changes.

6. Diagnostic Approach • Clinical diagnosis of tendinopathy is based on careful palpation of the tendon in question. Presentation and exam features of tendinopathy at common sites are detailed below. • Imaging is not required to make a diagnosis but may assist in managing recalcitrant cases. It is important to view imaging studies in the context of their clinical findings. • Plain radiographs may show calcium deposits in calcific tendinopathy, but are not useful in soft-tissue evaluation. • Ultrasound and MRI are generally not needed but may be utilized to demonstrate tendinosis in cases that are not straightforward. • Ultrasound is quick and inexpensive, but it is highly operator dependent. • Although MRI is expensive, it allows evaluation of the surrounding structures and may aid in the diagnosis.

7. Tendinopathy • Treatment Approach • The main goal in the treatment of tendinopathy is to reduce pain and allow return to activity. Tendinopathies are not complicated injuries, but can be difficult to manage. Patients need to be monitored by the physician on a regular basis for response to therapy. General principles of therapy are shared among all tendinopathy sites, but details within each treatment modality vary by anatomic site. • Treatment begins with relative rest and activity modification, with ice and nonsteroidal anti-inflammatory drugs (NSAIDs) for acute pain relief. Physical therapy may be enhanced by corticosteroid injections, topical nitroglycerin, and/or specialized modalities, depending on anatomic site and response to initial therapy.

8. Tendinopathy • Relative rest and activity modification • Since tendinopathy is an overuse injury, the main initial treatment is relative rest and activity modification. • Goal is to decrease the mechanical overload to promote tendon healing and pain relief. • Also important to evaluate and correct athletic overtraining errors. • For some anatomic sites, a brace or heel lift may be useful. In epicondylitis, a counterforce brace over the proximal lower arm may decrease pain and improve function. In Achilles tendinopathy, heel lifts help with pain by decreasing the amount of stretch on the Achilles tendon. In cases where dorsiflexion is diminished (tight gastrocnemius-soleus complex), a night splint may be used to hold the foot in neutral to dorsiflexion for 6 to 8 weeks to maintain passive dorsiflexion.

9. Bursitis • History and exam • Patients with acute bursitis typically complain of pain localized to the site of the bursa, particularly on movement. There may be a history of trauma, repetitive occupational activity, autoimmune disease, or crystal arthropathy. Infection may follow a penetrating injury or foreign body. If the bursa is superficial, swelling and erythema may be evident. In bursitis secondary to crystal deposition, the bursa is usually particularly erythematous, painful, and warm to the touch. • Chronic bursitis may last for several months and flare up many times. If inflammation persists near a joint, the patient is likely to have a limited range of active movement. Typically in bursitis, the passive range of motion is preserved, whereas active movement is limited. • Septic bursitis is most common in the prepatellar and olecranon bursae due to their superficial position. Symptoms suggestive of septic bursitis include a low-grade temperature, local erythema, swelling, and warmth, sometimes with local cellulitis. • Subacromial bursitis: classically in subacromial bursitis, the patient will complain of a painful arc on abduction of the arm due to impingement of the bursa under the coracoacromial arch. This can also occur with rotator cuff tears, and the two conditions may coexist.

10. Bursitis • Trochanteric bursitis: there may be risk factors present causing an alteration in gait. Diagnostic criteria have been proposed, but their sensitivity, specificity, and predictive value have not been established. The criteria propose that lateral hip pain and tenderness around the greater trochanter must be present in combination with 1 of the following: • Pain at the extremes of rotation, abduction, or adduction • Pain of contraction of the hip abductors against resistance • Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh. • Bursae of the knee: with anserine bursitis, the patient will typically complain of tenderness on the upper medial tibia at a point 3 cm to 5 cm distal to the medial knee joint line. A valgus deformity may be noted. • With prepatellar and infrapatellar bursitis, the prepatellar bursa is located between the skin and patella, and the infrapatellar bursa is between the skin and tibial tuberosity. Swelling and erythema are common, and the patella may be impalpable if a lot of fluid is present. • Olecranon bursitis: a superficial bursa, susceptible to infection and usually accompanied by significant swelling. The patient may recall direct trauma to the elbow. • Retrocalcaneal bursitis: tenderness along the distal portion of the Achilles tendon associated with swelling is typical. There may be a palpable bump, and poorly fitting shoes may play a role.

11. Septic Bursitis • If septic bursitis is suspected, the fluid should be aspirated and sent for laboratory analysis with Gram stain and culture. If fluid is aspirated, it is recommended that some also be sent for crystal analysis, especially if there is a history of gout or pseudogout. Aspiration should be carried out in an aseptic manner. Superficial bursae such as the prepatellar and olecranon bursa can easily be drained, but ultrasound guidance may be useful if the bursa is deeper.

12. Risk Factors • occupation that causes mechanical stress on bursa • rheumatoid arthritis • gout or pseudogout • penetrating injury • osteoarthritis of the hip • infection in a nearby joint • lower limb length discrepancy • iliotibial band contracture • lumbar spondylosis • valgus knee deformity • low-riding shoes • anatomic or functional impingement within the coracoacromial arch

13. Key Diagnostic Features • pain at site of bursa • common • tenderness to palpation at site of bursa • common • decreased active range of motion

14. Treatment • The first step in the treatment of nonseptic bursitis is to modify activity and lifestyle to minimize mechanical stress on the inflamed bursa. This involves avoiding activities that worsen symptoms (e.g., kneeling with prepatellar bursitis) and protecting the area where possible (e.g., kneepads to help avoid further trauma in prepatellar bursitis). Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick useful. It is also advisable to try to identify any predisposing risk factors that can be corrected to reduce the chance of recurrence, such as leg length discrepancy in trochanteric bursitis. It is important to rest the affected area to allow the inflammation to settle, but physical therapy may also be of benefit. Evidence from controlled trials is lacking to recommend a particular regimen; the duration of rest, and type and intensity of exercise is patient dependent. This combination of activity modification, intermittent rest, and physical therapy is often effective. • Ice may be used in the first 24 hours to reduce swelling. It can be applied topically to the area for 10 minutes at a time, every few hours (but not directly onto the skin; a thin towel is placed between ice and skin). • Simple analgesia such as acetaminophen or NSAIDs may also be required. Topical NSAIDs may be tried initially in preference to systemic NSAIDs if acetaminophen is insufficient.

15. Epicondylitis • Typically occurs during the 4th and 5th decades of life. Patients describe a history of activities contributing to overuse of the forearm muscles that originate at the elbow. • Patients with epicondylitis report pain during or following elbow flexion and extension. • People with lateral epicondylitis are tender approximately 2 cm distal and anterior to the lateral epicondyle. They report pain during resisted wrist and digit extension, and during passive wrist flexion with the elbow extended. • People with medial epicondylitis have tenderness along the medial elbow, approximately 5 mm distal and anterior to the medial epicondyle. Pain is exacerbated with resisted forearm pronation and resisted wrist flexion. • Most patients will have complete resolution of symptoms with arm rest and nonsteroidal anti-inflammatory drug (NSAID) therapy. Patients with continued symptoms may require further treatment, including physical therapy, injection therapy, or surgical debridement. • The principal complication is continued pain. All other complications may arise from interventions attempting to alleviate the pain.

16. Epicondylitis • Definition • Epicondylitis of the elbow is a condition associated with repetitive forearm and elbow activities. Both lateral epicondylitis (commonly known as tennis elbow), and medial epicondylitis (commonly known as golfer's elbow), are characterized by elbow pain during or following elbow flexion and extension. A combination of poor mechanics, microtears in areas of hypoperfusion, and a delayed healing response contribute to the pathophysiology of the condition.

17. Classification • Classification according to anatomic location • Lateral • Prevalence is 1.3% to 3% in people aged 30 to 64 years. • Overuse injury commonly occurs within the origin of the extensor carpi radialis brevis, but may also originate in the extensor digitorum communis or extensor carpi radialis longus tendon. Associated with activities requiring wrist extension or supination.

18. Classification • Medial • Prevalence is 0.4% to 5% in people aged 30 to 64 years. • Overuse injury may occur in the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. • Associated with activities requiring wrist flexion/pronation, particularly when there is a valgus strain at the elbow.

19. Diagnostic Approach • A diagnosis of lateral and medial epicondylitis can be made with a comprehensive history and physical exam. • General findings on clinical evaluation • Pain at either the lateral or medial aspect of the elbow is the main complaint. Patients will report pain during or following elbow flexion and extension. • Typically all patients describe a history of repetitive recreational or occupational activity. These activities exacerbate their pain. Other risk factors strongly associated with the development of epicondylitis may be present and include: • Age 40 to 60 years • Past medical history of epicondylitis • Inadequate physical conditioning for the activities they are undertaking • Poor mechanics during a repeated activity • Smoking. • Grip strength may be decreased in either medial or lateral epicondylitis, without pain associated with this function. Additionally, grip strength can be diminished without a change in the typical epicondylitis pain. Therefore, measurement of grip strength may be used as an objective tool to assess recovery. Although a rare finding, if symptoms are severe the patient's elbow may have mild swelling. Checking for Tinel sign is recommended. This is performed by tapping lightly on the medial elbow over the ulnar nerve. It is described as positive if testing generates paresthesia without pain. A negative Tinel sign can help rule out cubital tunnel or other neurologic conditions.

20. Lateral Epicondylitis • Specific findings in lateral epicondylitis • Lateral epicondylitis is characterized by: • Tenderness over the common extensor tendon typically localized to the extensor carpi radialis brevis; maximal tenderness occurs approximately 2 to 5 cm distal and anterior to the midpoint of the lateral epicondyle • Normal sensation • Complete range of motion at the elbow and wrist, but possibly a weak wrist extension secondary to pain • Pain during resisted wrist and digit extension, and during passive wrist flexion with the elbow extended • Positive extensor carpi radialis brevis stretch test: reproducible pain over the origin of the common extensor mass when the arm is placed in extension while the examiner maximally flexes the wrist.

21. Medial Epicondylitis • Specific findings in medial epicondylitis • In medial epicondylitis: • The pain may have a more insidious onset • Tenderness is present distal and lateral to the medial epicondyle, over the pronator teres and flexor carpi radialis • Pain may radiate along the medial elbow and be increased with resisted forearm pronation or wrist flexion • Patients will also have normal sensation and strength, and complete range of motion.

22. Treatment • Rest, Ice, NSAIDS, brace • Steroid injections

23. Achilles Contracture • Shortening of the achilles tendon that causes foot pain and limits ankle dorsiflexion • Women who wear high heeled shoes • Joggers who land on balls of feet and not heels

24. Signs and Symptoms • Sharp spasmodic pain during dorsiflexion • Treat conservatively: Gradually lower the heels of the patient if that is the etiology. • Surgery is last resort

25. Carpal Tunnel • Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.

29. epidemiology • Affects an estimated 3 percent of adult Americans • Three times more common in women than in men • High prevalence rates have been reported in persons who perform certain repetitive wrist motions (frequent computer users) • 30% hand paresthesias • 10% clinical criteria for carpal tunnel syndrome • 3.5% abnormal nerve conduction studies

31. Clinical Features • Pain • Numbness • Tingling • Symptoms are usually worse at night and can awaken patients from sleep. • To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer (flick sign).

33. Clinical Features • Pain and paresthesias may radiate to the forearm, elbow, and shoulder. • Decreased grip strength may result in loss of dexterity, and thenar muscle atrophy may develop if the syndrome is severe.

34. Atrophy

35. Physical examination • Phalen’s maneuver • Tinel’s sign • weak thumb abduction. • two-point discrimination

36. Phalen’s maneuver

37. Tinel’s sign

38. Diagnostic • History • Physical examination • Nerve Conduction Study

39. Differential Diagnostics • Tendonitis • Tenosynovitis • Diabetic neuropathy • Compression of the Median nerve at the elbow

40. Treatment • CONSERVATIVE TREATMENTS • GENERAL MEASURES • WRIST SPLINTS • ORAL MEDICATIONS • LOCAL INJECTION • ULTRASOUND THERAPY • Predicting the Outcome of Conservative Treatment • SURGERY

41. GENERAL MEASURES • Avoid repetitive wrist and hand motions that may exacerbate symptoms or make symptom relief difficult to achieve. • Not use vibratory tools • Ergonomic measures to relieve symptoms depending on the motion that needs to be minimized

43. WRIST SPLINTS • Probably most effective when it is applied within three months of the onset of symptoms • Optimal splinting regimen ?

44. WRIST SPLINTS

45. DO NOT WORK !!! ORAL MEDICATIONS • Diuretics • Nonsteroidal anti-inflammatory drugs (NSAIDs) • pyridoxine (vitamin B6) • Orally administered corticosteroids • Prednisolone • 20 mg per day for two weeks • followed by 10 mg per day for two weeks

46. LOCAL INJECTION • A mixture of 10 to 20 mg of lidocaine (Xylocaine) without epinephrine and 20 to 40 mg of methylprednisolone acetate (Depo-Medrol) or similar corticosteroid preparation is injected with a 25-gauge needle at the distal wrist crease (or 1 cm proximal to it).

47. LOCAL INJECTION

48. LOCAL INJECTION

49. LOCAL INJECTION • Splinting is generally recommended after local corticosteroid injection. • If the first injection is successful, a repeat injection can be considered after a few months • Surgery should be considered if a patient needs more than two injections

50. ULTRASOUND THERAPY • May be beneficial in the • long term management • More studies are needed • to confirm it’s usefulness