Download Soft tissue rheumatism Part 2: tendinitis, tenosynovitis, ligament

MODERN MEDICINE
CPD ARTICLE NUMBER TWO: 1 point
Soft tissue rheumatism Part 2:
tendinitis, tenosynovitis,
ligament sprains
and muscle strains
R O D G E R L A U R E N T , MB ChB, MD, F R A C P
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
The recurrence of soft tissue injuries can be minimised
by finding the precipitating cause, and adequately
stretching and strengthening the involved structure
before returning to the offending activity.
Causes
The causes of tendinitis are
overuse of the tendon and abnormal biomechanics.
paratenon surrounds the tendon
and epitenon and is a series of thin
membranes that allows movement
of the tendon over adjacent tissues. When it becomes inflamed, it
thickens and reduces the movement of the tendon.
Symptoms and signs
The symptoms and signs of tendinitis include:
• pain over the involved part of
the tendon
• swelling and tenderness over the
involved region
• pain on isometric contraction of
the relevant muscle.
Tendinitis involves the tendon
and paratenon. It usually commences in the tendon, with the
paratenon
then
becoming
inflamed, thickened and adherent
to the tendon. Central degeneration is usually the primary cause
in older people, with secondary
involvement of the paratenon.
The problem can also begin in
the paratenon, with inflammation
Dr Laurent
is Senior
Staff
Specialist
in
and thickening
of the paratenon
Rheumatology
and Musculoskeletal
and
minimal
involvement
of the
Medicine,
Department
of Rheumatology,
tendon. This is the pattern of tenRoyal
North
Shore Hospital,
Sydney,
Australia.
dinitis associated with overuse.
Treatment
Prolonged rest or immobilisation of a tendon after an
injury is detrimental to the
tendon because there is a
rapid loss of collagen. It is
important to prevent this,
even though the exercises in
the initial stages are minimal.
Treatment of tendinitis
involves:
• reducing or stopping the
activity responsible for the
pain
• nonsteroidal anti-inflammatory
drugs (NSAIDs) - can be used
for the first few days, although
they usually provide only minimal benefit
• applying cold packs for ten to 15
minutes over the involved area,
two or three times a day - this
should be done after exercise,
including stretching exercises
• a course of ultrasound - sometimes relieves pain
• beginning concentric muscle
exercises as the pain resolves
^ This two-part article is a guide
to identifying the involved structure in soft tissue rheumatism,
isolating and correcting the precipitating cause, and treating and
preventing soft tissue injuries.
Last month, Part 1 provided an
overview of diagnosis and
management, as well as
describing features specific to enthesitis and bursitis. This month, the
author focuses on tendinitis, tenosynovitis, ligament sprains and muscle
strains.
Tendinitis
Site of injury
A tendon consists of collagen fibres with occasional
tenocytes. The main blood supply
is from the epitenon, which is the
vascular connective tissue surrounding the tendon. The ends of
the tendon also receive a blood
supply from the muscle and bone
attachments. However, there may
be a relatively avascular area that
is often subject to tendinitis. The
S E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A
25
Soft tissue
rheumatism: part 2
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continued
I
• starting eccentric muscle exercises after the tendinitis has
become asymptomatic with concentric muscle exercises
• sport- or work-specific exercises, to
achieve maximum strength of the
musculotendinous unit involved
• correcting any precipitating
causes, eg sports technique or
repetitive movements in the
workplace.
Common examples
of tendinitis
Common examples of tendinitis
include:
• Achilles tendinitis
• shoulder rotator cuff tendinitis.
Achilles tendinitis
Site of injury
The Achilles tendon commences at
about midcalf and consists of a
superficial layer from the gastrocenemius muscle and a deep
layer from the soleus muscle. The
tendon inserts into the posterior
calcaneum. The gastrocnemius
muscle crosses two joints. The
area from two to six centimetres
above the insertional site is the
area with the poorest blood supply
and is the region where tendinitis
usually begins (Figure 1).
26
Tendinitis should not be confused with
Achilles tendon enthesitis which occurs
at the insertional site of the tendon.
Figure
2. The
anatomy
of the rotator
Tendinitis should not be confused with Achilles tendon enthesitis which occurs at the insertional
site of the tendon.
Cause
The most common cause of
Achilles tendinits is overuse. There
are several predisposing factors,
including biomechanical abnormalities of the hip, knee and foot (especially overpronation), that produce
abnormal movement of the tendon.
A tight Achilles tendon with
limited ankle dorsiflexion increases the stress on the tendon, as do
training errors, inadequate warmup, a sudden increase in activity
and inadequate footwear with
poor heel support.
Symptoms and signs
Symptoms and signs of Achilles
tendinitis include:
• pain over the lower part of the
tendon
• swelling and tenderness over the
involved region (Figure 1)
M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002
cuff
tendons
• pain on stretching the Achilles
tendon by dorsifexion at the
ankle
• pain on isometric contraction of
the gastrocnemius and soleus
muscles.
Treatment
The general measures for treating
tendinitis outlined earlier apply to
the treatment of Achilles tendinitis.
In addition, a heel raise, usually a
sponge insert, may be helpful by
reducing the stretch on the tendon.
Corticosteroids should not be
injected around the Achilles tendon because of the risk of tendon
rupture.
Shoulder rotator cuff
tendinitis
Rotator cuflf tendinitis is probably
the most common cause of shoulder pain, and usually involves the
supraspinatus and infraspinatus
tendons.
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Soft tissue
rheumatism: part 2
continued
I
I
•
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I
Tenosynovitis can result in fibrin
deposition on the tendon and the
producing thickness and
nodule formation.
It may also be associated with any
swelling due to previous tears of
Site of injury
The rotator cuff consists of the tenthe tendon, and loss of the normal inflammatory arthritis (eg rheumatoid arthritis or psoriatic arthritis).
dons of the supraspinatus, infrahumeral head depression mechspinatus, subscapularis and teres
anism.
minor muscles. These tendons
Symptoms and signs
form a broad band and insert into Tenosynovitis
The symptoms and signs of
the greater and lesser tuberosity
tenosynovitis include;
and the ligament that covers the Site of injury
• pain on active movement; if the
bicipital groove. The supraspina- In areas where there is considerproblem is severe, there will also
tus tendon passes between the able movement of the tendon, espebe pain at rest
head of the humerus and the coraco- cially over ligaments and bone, the
• tenderness over the involved
acromial arch. The subacromial bursa tendon runs through afibrous tunarea of the tendon
facilitates movement between the
• swelling - this is usually mild if
nel that allows easy movement and
subacromial arch and the rotator
the injury is related to overuse
reduces friction on the tendon. The
cuff tendons of the supra- and
(Figure 4); however, if the
fibrous
tunnel
and
tendon
sheath
infraspinatus muscles (Figure 2).
tenosynovitis
is due to infection
The rotator cuff functions to sta- are covered with synovium which
or
sodium
urate
crystals, swelling
bilise the shoulder joint and add also forms synovial fluid.
may be marked, with surroundTenosynovitis
is
inflammation
of
power to glenohumeral rotation
ing oedema and erythema
the tendon sheath and is distinct
and elevation.
•
pain on stretching the tendon or
from tendinitis which is inflammaThe primary problem in the tion of the tendon and the
on isometric contraction of the
rotator cuff is probably central
musculotendinous unit
paratenon.
degeneration with swelling
• in chronic tenosynovitis,
of the tendons. This causes
crepitus can be felt over
impingement of the tendon
the tendon; this is the
between the humeral head New low dose oestrogen only therapy:
result of fibrin deposition
and coracoacromial arch,
within the tendon sheaths
which is the main cause of
• restricted movement the pain. Weakness of the
this may occur in both
rotator cuff can lead to furacute
and
chronic
ther impingement because
tenosynovitis.
of a reduction in the ability Because it should be natural for you to
1
to depress the humeral prescribe hormone replacement cherapy
Treatment
head during abduction.
Treatment
of tenosynovitis
Subacromial bursitis is
due
to
repeated
use or
\
J
B
L
usually secondary to the
excessive
stress
involves:
tendinitis.
• identification of the precipitating
Tenosynovitis can result in fibrin
activity, particularly if the
Causes
deposition on the tendon and the
tenosynovitis is due to overuse Causes of rotator cuff tendinitis sheath, producing thickness and
these movements should be
include:
nodule formation. These may result
reduced or stopped until the
• overuse or trauma - rotator cuff in the tendon catching as it passes
tenosynovitis has resolved
tendinitis is more common in through afibrous pulley. This is the • injection of a mixture of local
people who use their shoulders cause of 'trigger finger', when the
anaesthetic and corticosteroid
in an abducted position of finger flexor tendons are involved
into the tendon sheath, but not
greater than 90° (eg swimmers)
the tendon, when there is signifi(Figure 4).
• advancing age - in the middlecant pain or restriction of moveThe most common tendons
aged and elderly there is often
ment
involved are the abductor pollicis
no obvious precipitating cause
•
ultrasound and NSAIDs,
longus and the extensor pollicis
(the tendons degenerate with
although they provide only miniage, especially in the middle, brevis tendons at the wrist, the
mal benefit in this situation
and the tendinitis can become finger flexor tendons, and the tib- • a regimen of stretching and genialis posterior and common perchronic)
tle exercises - this is important
for maintaining a full range of
• structural abnormalities - these oneal tendons at the ankle.
movement of the musculotendican cause increased impingeCauses
nous unit.
ment on the tendon (examples
The same treatment is used for
include abnormal scapula posi- The most common cause of
tion associated with thoracic tenosynovitis is repeated use or tenosynovitis associated with
inflammatory arthritis. Treatment
excessive stress on the tendon.
kyphosis, chronic tendon
esti*$fem
28
M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002
Ligaments are usually damaged
when there is a sudden stress that
does not allow sufficient time for
muscle support.
Figure
3. Rotator
of abduction.
cuff
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
of the inflammatory arthritis will
also control the tenosynovitis.
An example of tenosynovitis:
de Quervain's tenosynovitis
De Quervain's tenosynovitis
involves the abductor poilicis
longus and the extensor poilicis
brevis tendons at the wrist. It
occurs at the radial styloid where
the tendons, invested in a common
synovial sheath, run along a
groove in the bone (Figure 5). With
repeated use of the wrist and
thumb, there can be increased friction on the tendon.
Signs and symptoms
The symptoms and signs of de
Quervain's tenosynovitis include:
• pain felt over the radial border of
the wrist and possibly radiating
down to the thumb
• pain produced by thumb movements, particularly the pinch grip
• swelling and tenderness over the
radial styloid
• pain reproduced on ulnar deviation of the wrist, with the thumb
held flexed and adducted so that
it is across the palm of the hand
(Figure 6).
Treatment
Treatment of de Quervain's
tenosynovitis involves:
• a resting splint or an appropriately applied crepe bandage to
reduce movement of the thumb
in the acute stage
tendinitis:
the painful
arc
is Figure
from
index
• corticosteroid injections, particularly in the early inflammatory
phase
• stretching and strengthening
exercises to restore normal
movement; if exercise is not commenced early, there can be fibrosis and restriction of thumb
movement
• surgical decompression - may
occasionally be required; however, it can usually be prevented
by early commencement of an
exercise programme.
about
60° to tenosynovitis
12ff
4 Flexor
in the
finger
- the result
of overuse.
ament complex of the ankle, particularly the talofibular component
of the ligament (Figure 7).
Sprain of the lateral
ligament of the ankle
Symptoms and signs
The symptoms and
signs
Ligament sprains
Site of injury
Ligaments are structurally similar
to tendons, being predominantly
made up of type 1 collagen and
fibrocytes. Ligaments provide stability to the joint and determine the
limits of its range of movement.
Ligaments slowly elongate under
pressure and support the joint until
muscle support takes over.
Ligaments are usually damaged
when there is a sudden stress that
does not allow sufficient time for
muscle support. The level of injury
can range from a simple stretch of
the ligament, through varying
degrees of tearing, to a complete
rupture.
Ligaments are important in proprioception and contain nociceptors that can be damaged when
the ligament is injured.
The most common ligament
injury is a sprain of the lateral ligS E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A
29
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Soft tissue
rheumatism: part 2
continued
Exercises must be continued after
symptoms have resolved, as it probably
takes nine months for ligaments to
return to normal strength.
Anterior talofibular
Fibula
Posterior
talofibular
ligament
Calcaneum
Talus
ligament
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Figure
6. Pain in de Ouervain's
reproduced
by flexion
and adduction
ulnar deviation
of the wrist.
indicating a sprain of the lateral
ligament of the ankle include:
• pain over the region of the ligament, made worse on inversion
and supination of the foot
• swelling over the ligament
• tenderness over the ligament
and its attachments
• restriction of movement of the
ankle and the subtalar joint,
usually due to muscle spasm.
Treatment
Treatment of a lateral ligament
strain of the ankle involves:
• for the acute injury, the standard regimen of rest, ice, compression and elevation
• NSAIDs - may be helpful
• commencing exercise as soon as
possible - prolonged rest results
in significant loss of collagen
(exercise and stretches should be
within the limits of pain)
• gentle mobilising exercises for
the ankle and the subtalar joint
• strengthening exercises for the
peroneus longus and brevis muscles
• strapping of the ankle with
adhesive tape which restricts
inversion and eversion of the
hindfoot, supporting the ligament and helping proprioception
32
Figure
tenosynovitis
of the thumb
7. Diagram
is
and
• proprioceptive exercises, including balance boards and different
stepping activities, to correct
functional instability
• exercises must be continued
after symptoms have resolved,
as it probably takes nine months
for ligaments to return to normal strength.
of lateral
ankle
ligaments.
Ischial
Musculotendinous junction
injuries
Muscle strains occur most frequently at the musculotendinous
junction. The most common muscle strain is that of the hamstring
muscles. This muscle lies across
two joints, which may be why it is
more susceptible to strain.
Semitendinosus
Hamstring strain
Site of injury
The hamstrings consist of three
muscles: semitendinosus, semimembranosus and biceps femoris
(Figure 8). At the musculotendinous
junction, the muscle cells connect
directly to the tendon. The muscle
cell membrane at this site is folded
so that the muscle cell and extracellular collagen interdigitate. This
folding increases the surface area,
M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002
Musculotendinous
junctions
Figure
string
8. Anatomy
muscles
of
the
ham-
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1. l^lqueker, J ci al. Improvement in gastrointestinal (tiierability of Hie Sdtective cyclooxygenase (COXJ-2 inhibitor, meloxicam, compared with piiowum:results ol the safety and cHu.jn,1 large-scate evaluation ol
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341567
Soft tissue
rheumatism: part 2
continued,
I
I
|
reducing the stress per unit area at
the musculotendinous junction.
Causes
Causes of hamstring
include:
strain
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• eccentric contraction - injuries
are more likely to occur during
eccentric contraction because the
force generated then is greater
than that generated during concentric contraction
• muscle crossing two joints injuries are more common in
muscles that cross joints (eg
hamstring or gastrocnemius
muscles)
• muscle weakness, which predisposes to injury
• weakness of a muscle relative to
its antagonist, which results in
strength imbalance - imbalance
between the strengths of the
Returning to the precipitating
activity before the muscle has healed
i e a c [ s fQ recurrence of injury.
quadriceps and hamstring muscles is important, and can be secondary to exercise programmes
that emphasise quadriceps exercises but do not include adequate
hamstring exercises
• fatigue, which results in physiological shortening of the muscle
• poor warm-up technique, wliich
reduces flexibility and makes
the muscle more susceptible to
strain.
Returning to the precipitating
activity before the muscle has
healed leads to recurrence of
injury. Once the pain has resolved,
muscle strength is still not normal.
the structure involved,finding the
precipitating cause (activity), and
embarking on a regimen of
stretching and strengthening exercises designed to combat the particular weakness. Returning to the
precipitating activity before the
structure has regained normal
strength andflexibility can lead to
recurrence. Muscles may take two
to three months to return to normal; tendons and ligaments take
even longer.
Part 1 of tliis article provided an
overview of soft tissue rheumatism
and described the specific features
of enthesitis and bursitis. •
Conclusion
Recurrence of soft tissue injuries
can be minimised by identifying
CPD
questions
appear
on page
35
QUESTIONS FOR CPD ARTICLE NUMBER TWO
CPD: 1 point
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Soft tissue rheumatism
Part 2: tendinitis, tenosynovitis,
ligament sprains and muscle strains
Part 3. T h e following statements are true of tenosynovitis:
a. Tenosynovitis may be associated with psoriatic arthritis.
b. In chronic tenosynovitis, crepitus may be felt over the
tendon.
Instructions
c. Tenosynovitis may be treated by injection of local anaes1. Before
you fill
out the computer
answer
form, thetic
mark and corticosteroid into the tendon, rather than the
your answers
in the box on this page.
This
providestendon sheath.
you with your own record.
d. De Quervain's tenosynovitis involves abductor poilicis
2. The answer
form
is perforated
and bound Into longus
this and extensor poilicis longus tendons at the wrist.
e. De Quervain's tenosynovitis should be managed by
journal.
Tear it out carefully.
early exercise.
3. Read the instructions
on the answer
form
and folPart 4. T h e following statements are true of muscle and
low them carefully.
ligament strains:
4. Your
answers
for the September
issue
must reach
a. Muscle strains usually occur at the musculotendinous
MOOEEN
MEDICINE,
PO BOX 2271.
Clareinch
7740,
by
junction.
Decembers!. 20QQ,
b. An imbalance between the strength of the quadriceps
and hamstring muscles can cause a hamstring strain.
5. You must score
at least
60% in order
to be awarded the a s s i g n e d CPD points.
c. Exercises should be commenced as early as possible in
managing a lateral ligament strain of the ankle.
d. Lateral ligament
Answer
true or false
to parts
(a) to (e) of the following
ques- strain of the ankle should be treated
with adhesive tape to restrict inversion and eversion of
tions.
the hindfoot.
Part 1. T h e following statements are true of tendinitis:
e. In the treatment of lateral ligament strain of the ankle,
a. Tendinitis may manifest as pain on isometric contraction
exercises may be discontinued as soon as symptoms
of the muscle.
have resolved.
b. In the treatment of tendinitis prolonged rest is necessary
to allow the inflammation to resolve.
c. Nonsteroidal anti-inflammatory drugs (NSAIDs) usually
provide dramatic benefit.
C P D Article 2
d. Tendinitis may be managed by applying cold packs to
the affected tendon.
e. Rehabilitation should include eccentric muscle exercises
for the involved musculotendinous unit.
Part 2. T h e following statements are true of specific
forms of tendinitis:
a. A heel raise, usually a sponge insert, may be helpful in
the treatment of Achilles tendinitis.
b. Achilles tendinitis may be managed by corticosteroid
injection into the Achilles tendon.
c. Shoulder rotator cuff tendinitis is common in swimmers.
d. Rotator cuff tendinitis in the elderly usually has an obvious precipitating cause.
e. Thoracic kyphosis may predipose to rotator cuff tendinitis.
See tear-out
sheet
for
details.
S E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A
35
COUNSELLING
- A KEY TO USER SATISFACTION
Dr Mary O'Flynn
MICGP, Mallow, Ireland
The concept means freedom for both patients and doctors — freedom from
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• the worry of sub-optimal contraception
• the side-effects of contraception (whether real or perceived)
• the tyrannies of menstrual cycle problems.
Never before has there been such need for optimal contraception, when our planet's increase in population - estimated at approximately 85 million per annum - is threatening to exceed its nutritional resources. A WHO report
estimates that 64% of pregnancies throughout the world are either unplanned or unwanted and as a consequence, a
significantly high number of the 580 000 maternal deaths that occur each year could and should be avoided by the
use of suitable contraception', In addition, in the western world, the feminist movement has fought for developments to free women from the bondage of their fertility.
36
Mirena fulfils most of the criteria for the ideal contraceptive. It is safe, effective, available, independent of intercourse, forgettable, reversible and has beneficial side-effects. Its more untoward side-effects become more acceptable with good counselling, thus imparting knowledge to the patient, prior tofitting. This is the price of achieving
freedom and pre-supposes that the patient has already been fully informed to exercise her own and possibly her
partner's choice of method. Remember, 'we are the advisers, we are the suppliers, but we are not the deciders.'
Thefirst published research on user satisfaction and compliance for the LNGIUS cites changes in bleeding
patterns as the commonest cause of discontinuation. Again in newer research published in 2000, excessive bleeding or spotting was by far the commonest reason for premature removal3. When used as a therapy for menturhagia,
satisfaction and continuation rates appear higher - nuisance bleeding becomes more tolerable when the alternative
is perhaps hysterectomy. The most recent work of Backman and colleagues would indicate that women were up to
five times more satisfied when forewarned oi the occurrence of bleeding changes (personal communication)'.
If the patient is given background knowledge on a normal menstrual cycle, then explanation of the mode of action
and possibility of the side-effects occurring become apparent. She is then prepared to accept and deal with them,
in the full knowledge that they are not dangerous and usually transient.
Achieving this level of awareness in patients, together with mastering thefitting technique, is the great challenge
for the practitioner. It does take time, but the time invested in good counselling is well rewarded by the freedom
achieved by the patient - and patient satisfaction, in turn, will confer freedom on the doctor.
We, in Ireland, are very proud of our continuation rates for use of the LNG IUS. Perhaps it relates to the Irish
characteristic of enjoying conversation - an essential element of good counselling, but not always recognised as
the most basic skill in the art of medicine.
References:
' World Health Organisation: Division of (Reproductive Health) Safer Motherhood Progress Report 1993-1995. Geneva: WHO; 1996
2 Luukkainen T, Allonen H, Haukkamaa M et al. Five years experience with levonorgestrel-releasing IUDs. Contraception 1986; 33,139-78.
5 Backman T, Huhtala S, Tuominen J, Luoto R, Erkkola R, Blom T, Rauramo I, Koskenvuo M. Length of use and symptoms associated
with premature removal of levonorgestrele-releasing intrauterine system: a nationwide study of 17 360 users. Brit J Obstet Gynaecol 2000;
107: 335-9.
4 Dr Tiina Backn i n, Turku, Finland. To be published.
M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002
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