Periarticular Disorders of the Extremities

By: Fereshteh Sotva

Medical student

Bursitisfunction of the bursa is to facilitate movement of tendons and muscles over bony prominences.

Excessive frictional forces from overuse, trauma, systemic disease (e.g., rheumatoid arthritis, gout), or infection may cause bursitis.

1.Subacromial bursitis (subdeltoid bursitis)

is the most common form of bursitis.

The subacromial bursa, which is contiguous with the subdeltoidbursa, is located between the undersurface of the acromion and the humeral head and is covered by the deltoid muscle.

Bursitis is caused by repetitive overhead motion and often accompanies rotator cuff tendinitis.

2.trochanteric bursitis

Involvement of the bursa around the insertion of the gluteus medius onto the greater trochanter of the femur.

Patients experience pain over the lateral aspect of the hip and upper thigh and have tenderness over the posterior aspect of the greater trochanter.

External rotation and resisted abduction of the hip elicit pain.

3. Olecranon bursitis

occurs over the posterior elbow, and when the area is acutely inflamed, infection or gout should be excluded by aspirating the bursa and performing a Gram stain and culture on the fluid as well as examining the fluid for urate crystals.

4.Achilles bursitis

involves the bursa located above the insertion of the tendon to the calcaneus and results from overuse and wearing tight shoes.

5. Retrocalcaneal bursitis

involves the bursa that is located between the calcaneus and posterior surface of the Achilles tendon. The pain is experienced at the back of the heel, and swelling appears on the medial and/or lateral side of the tendon.

It occurs in association with spondyloarthropathies,rheumatoid arthritis, gout, or trauma.

6.Ischial bursitis (weaver's bottom)

affects the bursa separating the gluteus medius from the ischialtuberosity and develops from prolonged sitting and pivoting on hard surfaces.

7. Iliopsoas bursitis

affects the bursa that lies between the iliopsoas muscle and hip joint and is lateral to the femoral vessels.

Pain is experienced over this area and is made worse by hip extension and flexion.

8.Anserine bursitis

is an inflammation of the sartorius bursa located over the medial side of the tibia just below the knee and under the conjoint tendon and is manifested by pain on climbing stairs.

Tenderness is present over the insertion of the conjoint tendon of the sartorius, gracilis, and semitendinosus.

9. Prepatellar bursitis

(housemaid's knee) occurs in the bursa situated between the patella and overlying skin and is caused by kneeling on hard surfaces. Gout or infection may also occuar at this site.

Treatment of bursitis consists of:

1.prevention of the aggravating situation.2.rest of the involved part.3.administration of a nonsteroidal anti-inflammatory drug (NSAID) where appropriate for an individual patient, or local glucocorticoid injection.

Rotator Cuff Tendinitis and Impingement Syndrome

Tendinitis of the rotator cuff is the major cause of a painful shoulder and is currently thought to be caused by inflammation of the tendon(s).

The rotator cuff consists of the tendons of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles, and inserts on the humeral tuberosities.

The process begins with edema and hemorrhage of the rotator cuff, which evolves to fibrotic thickening and eventually to rotator cuff degeneration with

.tendon tears and bone spurs

:Rotator Cuff Tendinitis and Impingement SyndromeSubacromial bursitis also accompanies this syndrome.

Symptoms usually appear after injury or overuse, especially with activities involving elevation of the arm with some degree of forward flexion.

Those over age 40 are particularly susceptible.

Patients complain of a dull aching in the shoulder, which may interfere with sleep. Severe pain is experienced when the arm is actively abducted into an overhead position. The arc between 60° and 120° is especially painful.

:Rotator Cuff Tendinitis and Impingement Syndrome

Patients may tear the supraspinatus tendon acutely by falling on an outstretched arm or lifting a heavy object.

Symptoms are pain along with weakness of abduction and external rotation of the shoulder.

Atrophy of the supraspinatus muscles develops.

The diagnosis is established by arthrogram, ultrasound, or MRI.

:Calcific Tendinitis

This condition is characterized by deposition of calcium salts, primarily hydroxyapatite, within a tendon.

The supraspinatus tendon is most often affected because it is frequently impinged on and has a reduced blood supply when the arm is abducted.

The condition usually develops after age 40.

Calcification within the tendon may evoke acute inflammation, producing sudden and severe pain in the shoulder.

Bicipital Tendinitis and Rupture

Bicipital tendinitis, or tenosynovitis, is produced

by friction on the tendon of the long head of

the biceps as it passes through the bicipital

groove.

When the inflammation is acute, patients

experience anterior shoulder pain that radiates down

the biceps into the forearm.

1.Abduction and external rotation of the arm are painful and limited.

2.The bicipital groove is very tender to palpation.

3.Pain may be elicited along the course of the tendon by resisting supinationof the forearm with the elbow at 90° (Yergason's supination sign).

4.Acute rupture of the tendon may occur with vigorous exercise of the arm and is often painful.

De Quervain's Tenosynovitis

In this condition, inflammation involves the abductor pollicis longus and the extensor pollicis brevis as these tendons pass through a fibrous sheath at the radial styloid process.

1.The usual cause is repetitive twisting of the wrist.

2. Patients experience pain on grasping with their thumb, such as with pinching. 3.Swelling and tenderness are often present over the radial styloid process.

4. The Finkelstein sign is positive, which is elicited by having the patient place the thumb in the palm and close the fingers over it. The wrist is then ulnarlydeviated, resulting in pain over the involved tendon sheath in the area of the radial styloid.

It may occur in pregnancy, and it also occurs in mothers who hold their babies with the thumb outstretched.

Patellar Tendinitis (Jumper's Knee)

Tendinitis involves the patellar tendon at its attachment to the lower pole of the patella.

Patients may experience pain when jumping during basketball or volleyball, going up stairs, or doing deep knee squats. Tenderness is noted on examination over the lower pole of the patella.

Treatment consists of rest, icing, and NSAIDs, followed by strengthening and increasing flexibility.

Iliotibial Band Syndrome

The iliotibial band is a thick connective tissue that runs from the ilium to the fibula.

Patients with iliotibial band syndrome most cammonly present with aching or burning pain at the site where the band courses over the lateral femoral condyle of the knee; pain may also radiate up the thigh, toward the hip.

Predisposing factors for iliotibial band syndrome include a varus alignment of the knee, excessive running distance, poorly fitted shoes, or continuous running on uneven terrain.

Adhesive Capsulitis :

Often referred to as "frozen shoulder," adhesive capsulitis is characterized by pain and restricted movement of the shoulder, usually in the absence of intrinsic shoulder disease.

Adhesive capsulitis may follow bursitis or tendinitis of the shoulder or be associated with systemic disorders such as chronic pulmonary disease, myocardial infarction, and diabetes mellitus.

Adhesive Capsulitis :

Prolonged immobility of the arm contributes to the development of adhesive capsulitis.

Pathologically, the capsule of the shoulder is thickened, and a mild chronic inflammatory infiltrate and fibrosis may be present.

Adhesive capsulitis occurs more commonly in women after age 50.Pain and stiffness usually develop gradually but progress rapidly in some

patients.

Night pain is often present in the affected shoulder and pain may interfere with sleep.

Adhesive Capsulitis :

The shoulder is tender to palpation, and both active and passive movement are restricted.

Radiographs of the shoulder show osteopenia.

The diagnosis is typically made by physical examination but can be confirmed if necessary by arthrography, in that only a limited amount of contrast material, usually <15 mL, can be injected under pressure into the shoulder joint.

Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis, or tennis elbow, is a painful condition involving the soft tissue over the lateral aspect of the elbow.

The pain originates at or near the site of attachment of the common extensors to the lateral epicondyle and may radiate into the forearm and dorsum of the wrist.

The pain usually appears after work or recreational activities involving repeated motions of wrist extension and supination against resistance. .

Medial Epicondylitis (golfer's elbow)

Medial epicondylitis is an overuse syndrome resulting in pain over the medial side of the elbow with radiation into the forearm.

The cause of this syndrome is considered to be repetitive resisted motions of wrist flexion and pronation, which lead to microtears and granulation tissue at the origin of the pronator teres and forearm flexors, particularly the flexor carpi radialis.

This overuse syndrome is usually seen in patients >35 years and is much less common than lateral epicondylitis.

Medial Epicondylitis (golfer's elbow)

It occurs most often in work-related repetitive activities but also occurs with recreational activities such as swinging a golf club (golfer's elbow) or throwing a baseball.

On physical examination, there is tenderness just distal to the medial epicondyleover the origin of the forearm flexors.

Pain can be reproduced by resisting wrist flexion and pronation with the elbow extended.

Medial Epicondylitis (golfer's elbow) :

Radiographs are usually normal.

The differential diagnosis of patients with medial elbow symptoms include tears of the pronator teres, acute medial collateral ligament tear, and medial collateral ligament instability.

Ulnar neuritis has been found in 25–50% of patients with medial epicondylitis and is associated with tenderness over the ulnar nerve at the elbow as well as hypesthesiaand paresthesia on the ulnar side of the hand.

Plantar Fasciitis

Plantar fasciitis is a common cause of foot pain in adults, with the peak incidence occurring in people between the ages of 40 and 60 years.

Several factors that increase the risk of developing plantar fasciitis include:

obesity, pes planus (flat foot or absence of the foot arch when standing), pes cavus(high-arched foot), limited dorsiflexion of the ankle, prolonged standing, walking on hard surfaces, and faulty shoes. In runners, excessive running and a change to a harder running surface may precipitate plantar fasciitis.

Plantar Fasciitis

The pain originates at or near the site of the plantar fascia attachment to the medial tuberosity of the calcaneus.

Patients experience severe pain with the first steps on arising in the morning or following inactivity during the day.

Pain is made worse on walking barefoot or up stairs.

On examination, maximal tenderness is elicited on palpation over the inferior heel corresponding to the site of attachment of the plantar fascia.

Imaging studies may be indicated when the diagnosis is not clear;(Plain radiographs may show heel spurs, which are of little diagnostic significance).

The differential diagnosis of inferior heel pain includes calcaneal stress fractures, the spondyloarthritides, rheumatoid arthritis, gout, neoplastic or infiltrative bone processes, and nerve compression/entrapment syndromes.