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 Tendonitis Pain due to tendonitis or bursitis, commonly involving the shoulder, elbow, wrist, hip, knee and ankle, may be quite severe, often occurs suddenly and is usually made worse by movement. This inflammation of the soft‐tissue tendons and bursae located near joints often will be mistaken for arthritis. However, while it can be recurrent or chronic in some cases, it is usually a temporary condition, particularly if treated early. Fast Facts • Tendonitis and bursitis are inflammations of the soft tissue around muscles and bones, usually in the shoulder, elbow, wrist, hip, knee or ankle. • The pain of bursitis or tendonitis can be severe and should be treated quickly. • Failure to rest the inflamed limb or the joint, at least temporarily, may result in longer‐term problems. What is tendonitis? Tendonitis is inflammation of the cord‐like structure located where a muscle narrows down to join a bone. This structure, the tendon, is more fibrous and dense than the elastic and fleshy muscle. It transmits the pull of the muscle to the bone to cause movement. Inflammation of the tendon (increased blood flow through the area with warmth, swelling, pain and loss of function) can be spelled “tendonitis” or “tendinitis.” What is bursitis? Bursitis is inflammation of a bursa, a small sac that acts as a cushion or pad between moving structures (bones, muscles, tendons or skin). If a muscle or tendon is pulling around a corner, or over a bone, then a bursa serves to protect it from fraying and stress. Irritation or inflammation of this small sac is called bursitis (“itis" means inflammation). Tendonitis Page 1 Who gets tendonitis and bursitis? Tendonitis can be caused by sudden intense injury, but is most often the result of a repetitive, minor injury of the affected area. For example, a middle‐aged sedentary man who spends four hours painting a ceiling may develop a tendonitis or bursitis in the shoulder. A typist who spends long hours working at a keyboard with poorly positioned hands and wrists may develop tendonitis. The early season game of tennis can result in a backhand which strains the tendon on the outside of the elbow. Bursitis may occur at the knee from kneeling on a hard surface or kneeling longer than is usual. In other instances, infection can occur in a bursa or tendon sheath. Crystals, which are associated with gout, can sometimes be found in a bursa, and, like infection, may occur without any precipitating event. Tendonitis or bursitis may occur in individuals with diseases such as rheumatoid arthritis, gout, psoriatic arthritis, thyroid disease and diabetes. How are tendonitis and bursitis diagnosed? Diagnosis of tendonitis and bursitis requires a medical history and careful physical examination. On physical examination, The green portion of the image there often will be tenderness along the involved tendon or its illustrates the bursa, which becomes sheath (outer covering) or at one particular point within the inflamed in bursitis. tendon and pain when the muscle to which the tendon is attached is worked against resistance. X‐rays do not show bursae or tendons, but may be useful in excluding other bone or joint problems. Blood tests are of little value in detecting these conditions and are not used. While magnetic resonance imaging (MRI) and diagnostic ultrasound may be useful in the detection of these conditions, they generally are not required. Not infrequently, shoulder X‐rays show the presence of a calcium deposit within a tendon sheath or around the shoulder joint. Tendonitis in the shoulder most often can be resolved without any specific attention to the calcium deposit. Many people have calcium deposits in the shoulder that do not produce any symptoms. How are tendonitis and bursitis treated? Treatment of these two conditions is based on the underlying cause. In overuse or injury, reduction of the causing force or stress is mandatory. A typist may need to review the postural position that is used on a daily basis. Resting a painful hip from strengthening exercises may be required to allow the problem to settle prior to resumption of the strengthening program. Failure to rest invariably will result in continuing symptoms. Splints or braces for the affected part are means of achieving rest and reduction of stress on the part, especially in the hand and wrist area. Tendonitis Page 2 Off‐the‐shelf supports may be sufficient, or custom fashioned braces may be required. Treatments, particularly ice, may help reduce inflammation and pain. Ultrasound is often beneficial. The ultrasound referred to here is “treatment ultrasound,” which is distinct from diagnostic ultrasound and most commonly is administered by a physical therapist. In the lower limb, stressful weight bearing activities may need to be reduced on a temporary basis to allow the inflammation to lessen. The use of a cane in the opposite hand can assist a painful hip. Orthotics may be required to reduce the stress at the ankle or within the foot. An orthotic is an adaptive device that is placed inside the shoe between the foot and the shoe, which serves to change the support and the angle of the foot, to improve foot mechanics and relieve pain or pressure. They can be custom made or off the shelf. If an infection is present, there is usually an intense inflammation present with redness, warmth and swelling (a blood test will contribute to this diagnosis). Treatment with an appropriate antibiotic is necessary, and daily drainage (withdrawal of fluid with a needle) or surgery of the tendon or bursa may be required. If crystals of gout are identified in joint fluid, treatment with medication that will control crystals is effective. A potentially serious complication of tendonitis is rupture of a tendon with the most common being a tear of the Achilles tendon in the lower calf, which usually requires surgery. Recently, new topical applications of anti‐inflammatory medications have become available. Topical diclofenac (Voltaren, Emugel) can be applied to the skin over the This illustration of a biceps shows the white tendons that attach muscle to involved tendon or bursa. This may make it possible to use bone. In tendonitis, it is these structures anti‐inflammatory medication locally for these problems which become inflamed. with less risk of side effects. A limited number of tendon problems do not settle with the usual conservative measures mentioned above and may require surgery. A "frozen shoulder" is preventable if the tendonitis or bursitis, which is its usual precursor, is addressed early on. Lying down, on your back, clasp the fingers together and use the non‐painful arm to assist the painful arm above the head to the fullest extent. Full shoulder movement is bringing the upper arm up alongside the ear. Lower and repeat 5 times. If standing, you can walk the fingers of the involved arm up the wall in front of you to the highest tolerated position and then stretch the shoulder to the fullest extent by holding it in this stretched position for 20 seconds and then lowering. Repeat 5 times. Prevention Warming up and stretching prior to strenuous exercise will help to prevent these problems from Tendonitis Page 3 occurring. Therefore, activities should be begun slowly prior to expending maximum effort. For example, golfers should warm up at the driving range before driving the ball on the first tee. Typists who spend long hours at the keyboard should ensure that the keyboard is at an appropriate height. Wrists rests should not be used; instead typing should be done with wrists extended in a neutral or slightly flexed position. Typists also should take breaks. Stretching and strengthening are very helpful to address any areas of muscle imbalance. Proper posture and body mechanics are important at work or during exercise. Proper conditioning of involved muscles is another component of treatment. Broader health impacts It is important to complete a daily range of motion exercise program to preserve mobility, particularly in the shoulder joint, as a tendonitis or bursitis in the shoulder not infrequently becomes a greater problem if the shoulder becomes stiff. Living with tendonitis/bursitis Seeking attention early will result in a faster resolution of the problem and prevent joint stiffness and chronic problems that may follow. The pain of bursitis or tendonitis can be severe; just because it is not arthritis does not mean it is less important. Failure to rest the limb or the joint at least temporarily usually will result in the problem taking longer to resolve. Points to remember • Rest the painful tendon; avoid heavy activity and any painful activity. • Ice the area for 10 – 15 minutes once or twice a day. • Seek medical assistance if the problem does not improve in 8‐12 weeks. • Avoid repetitive motion and overuse of an extremity. • Warm up by exercising at a relaxed pace prior to more strenuous activity. To find a rheumatologist For more information about rheumatologists, click here. Learn more about rheumatologists and rheumatology health professionals. For more information If you want more information on this or any other form of arthritis, contact the Arthritis Foundation at (800) 283‐7800 or visit the Arthritis Foundation Web site at www.arthritis.org. Updated August 2009 Written by Bruce M. Clark, RPT, and reviewed by the American College of Rheumatology Patient Education Task Force This patient fact sheet is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnoses and treatment of a medical or health condition. ©2010 American College of Rheumatology Tendonitis Page 4