Tendonitis, Emergency Medicine

Basics

Description

- The term "tendinitis " has been used to describe chronic painful tendon injuries before the underlying pathology was understood. This term has led to confusion about the cause, chronicity, and treatment of the underlying disorder. The terms "tendinosis " or "tendinopathy " should be used to describe chronic tendon disorders. - Overuse syndrome: - Clinical syndrome of chronic pain and tendon thickening - Synovial cells increase in thickness - Excess synovial fluid collection - Constant irritation

- Mechanical overload or repetitive microtrauma to the musculotendinous unit: - Intrinsic factors: - Inflexibility - Muscle weakness or imbalance

- Defined as inflammation of the tendon only - There is a poor distinction between tendonitis and tenosynovitis (degree of inflammation). These are now termed as tendinopathies. - Clinical findings: - Warmth - Presence of an effusion - Decreased range of motion - Instability - Pain on motion - Tenderness over tendon site

- Inflammatory changes of the synovial lining between tendons and the retinaculum - De Quervain tenosynovitis: - Inflammation of the abductor pollicis longus and extensor pollicis brevis - Finkelstein test: - Patient makes fist with thumb curled in palm. - Wrist is deviated in the direction of the ulna. - Pain occurs in 1st extensor compartment.

- Achilles tendinopathy: - Overuse injury commonly seen in males - Trauma or systemic disease causing inflammation - With repeated stress, scar tissue formation and degeneration of the tendon will occur. - Patient will have pain, reduced range of motion, or morning stiffness

- Achilles tendon rupture - Seen more commonly in 30 " 40-yr-old recreational athletes - "Popping sensation " - Acute weakness, inability to continue activity - Feels like being kicked or hit in back of leg - May initially have a gap by palpation, followed by ecchymosis and a boggy sensation - Inability to plantar flex the foot with complete rupture - Thompson test: - Patient lies prone with the feet hanging over the edge of the bed. - Physician squeezes the calf muscles and looks for plantar flexion - 20 " 30% of Achilles tendon ruptures are missed at the initial visit because the clinician was falsely reassured by the patients ability to plantar flex or walk. - The Matles Test: the patient lies prone with knees flexed to 90 °. Observe whether the affected foot is dorsiflexed or neutral (both are abnormal) compared to the uninjured side, where the foot should appear plantarflexed.

- Avascular necrosis (AVN): - Presents with pain and swelling around a joint - Can occur at various locations - Well-recognized sites: - Capitellum of the humerus - Head of the femur - Tarsal navicular - Metatarsal head - Diagnosis is made by plain radiographs. - Radiographs are often required to rule out fracture, AVN, osteochondritis dissecans, or bony tumor.

- Ultrasound - Evaluate joint effusions - More sensitive than MRI - Used more frequently in the emergency setting - Focal tendon thickening - Focal hypoechoic areas - Irregular and ill-defined borders - Peritendinous edema

- MRI: - Internal morphology of the tendon and the surrounding structures - Helps diagnose retrocalcaneal bursitis and insertional tendonitis - Reveals tendon thickening and increased signal with chronic tendon abnormalities

- General: - Rest - NSAIDs - Ice (10 " 20 min intervals) - Range of motion exercises - Eccentric exercise is the application of a load (i.e., muscular exertion) to a lengthening muscle. - Local injection for pain control - Outpatient management - Admit only for surgery or severe disability - Allow 6 " 12 wk to heal - Recent studies have described successful investigational therapies - Prolotherapy, an ultrasound-guided injection of dextrose and lidocaine to stimulate repair. - Sclerotherapy injections of Polidocanol, a sclerosing substance to reduce neovascularity - Aprotinin is a broad-spectrum protease and matrix metalloproteinase (MMP) inhibitor, injected peritendinously

- Achilles tendonitis: - Rest, ice, NSAIDs - Orthotics or heel wedges - Cryotherapy has shown to be useful in controlling inflammation. - Achilles rupture should be splinted posteriorly in slight plantar flexion: - Refer to orthopedics, as patients often need surgery

The term "tendinitis " has been used to describe chronic painful tendon injuries before the underlying pathology was understood. This term has led to confusion about the cause, chronicity, and treatment of the underlying disorder. The terms "tendinosis " or "tendinopathy " should be used to describe chronic tendon disorders.
Overuse syndrome:Clinical syndrome of chronic pain and tendon thickeningSynovial cells increase in thicknessExcess synovial fluid collectionConstant irritation
If no further injury occurs, the acute process may last from 48 hr " 2 wk.
Tendinopathy is described as fibrosis being present without inflammatory cells and symptoms persist longer than 3 mo.

Etiology

Mechanical overload or repetitive microtrauma to the musculotendinous unit:Intrinsic factors:InflexibilityMuscle weakness or imbalanceExtrinsic factors:Excessive deviation, frequency, or activityIn tendinopathies, the collagen is in a state of disrepair, with proliferation and chronic irritation of neurovascular repair tissue in the tendon and its linings.
Chemotactive and vasoactive chemical mediators are released:Vasodilatation and cellular edema increasing the number and activity of PMNs

Diagnosis

Signs and Symptoms

History

The patients history should explain what movement led to the injury.
Repetitive stress and mechanical overload
The classic inflammatory signs include pain, warmth, erythema, and swelling.
Pain will resolve quickly after initial movement, only to become a throbbing pain after exercise.

Physical Exam

Defined as inflammation of the tendon only
There is a poor distinction between tendonitis and tenosynovitis (degree of inflammation). These are now termed as tendinopathies.
Clinical findings:WarmthPresence of an effusionDecreased range of motionInstabilityPain on motionTenderness over tendon site

Specific Conditions Supraspinatus Tendinopathy

Supraspinatus and other rotator cuff tendons:

Compressed between humerus and acromion
Overuse of the extremity may lead to microtrauma of the tendons and fibers.
Neer classification:Stage 1:Age <25Involved in sports requiring repetitive overhead motion (e.g., swimmers or pitchers)Edema and hemorrhage of the tendonFlexion " abduction motion will elicit pain. "Dull aches "Stage 2:Age 25 " 40Pain is constant and worsens at night.Active motion is limited by pain.Passive range of motion is preserved.Diffuse, intense painFibrosis and thickening of the tendonStage 3:Partial or complete tendon tearsRaising the humerus in a forced forward flexion while preserving scapular rotation causes impingement.

Calcific Tendonitis

Age older than 40 yr with unknown etiology.
Any tendon of the rotator cuff can be affected, but there is a predisposition for the supraspinatus.
Most cases are asymptomatic and are found on routine radiographs.
Calcium is deposited within the tendon over time, undergoes spontaneous resorption, causing pain.
Acute attacks may develop from crystal release.

Bicipital Tendinopathy

Pain to the anterior shoulder, which radiates down the radius
Discomfort when rolling on the shoulder or trying to reach a hip pocket or back zipper
Focal tenderness is between the greater and lesser tuberosities of the humerus.
Yergason test:Elbow at 90 ° and arm against the bodyPain increases with resisted supination of the wrist.
Speed test:Pain along the bicipital groove with resisted forward flexion and forearm supination

Lateral Epicondylitis (Tennis Elbow)

Rotational repetitive motion causes pain.
Dull ache on the outside of the elbow that increases with grasping and twisting
Inflammation at the insertion of the common extensor tendon at lateral epicondyle of humerus
Resisted active dorsiflexion of the wrist on extension of the middle finger against resistance can reproduce pain with the elbow extended.
Inflammation at site of insertion of the flexor carpi radialis on the medial epicondyle:Bowlers, golfers, pitchersActive flexing of the wrist against resistance causes pain.

Wrist/Hand

Inflammatory changes of the synovial lining between tendons and the retinaculum
De Quervain tenosynovitis:Inflammation of the abductor pollicis longus and extensor pollicis brevisFinkelstein test:Patient makes fist with thumb curled in palm.Wrist is deviated in the direction of the ulna.Pain occurs in 1st extensor compartment.Osteoarthritis of the carpal metacarpal joints or GC tenosynovitis causes the same pain.

Trigger Finger

Proximal portion of the palmar flexor tendon sheath becomes stenosed and catches as the finger is moved.
Symptoms vary from pain to locking in flexion.

Ankle

Achilles tendinopathy:Overuse injury commonly seen in malesTrauma or systemic disease causing inflammationWith repeated stress, scar tissue formation and degeneration of the tendon will occur.Patient will have pain, reduced range of motion, or morning stiffness
Achilles tendon ruptureSeen more commonly in 30 " 40-yr-old recreational athletes "Popping sensation "Acute weakness, inability to continue activityFeels like being kicked or hit in back of legMay initially have a gap by palpation, followed by ecchymosis and a boggy sensationInability to plantar flex the foot with complete ruptureThompson test:Patient lies prone with the feet hanging over the edge of the bed.Physician squeezes the calf muscles and looks for plantar flexion20 " 30% of Achilles tendon ruptures are missed at the initial visit because the clinician was falsely reassured by the patients ability to plantar flex or walk.The Matles Test: the patient lies prone with knees flexed to 90 °. Observe whether the affected foot is dorsiflexed or neutral (both are abnormal) compared to the uninjured side, where the foot should appear plantarflexed.

Apophysitis occurs in children at an ossification center subject to traction:Little League elbow at the medial epicondyleOsgood " Schlatter syndrome at tibial tubercle
Avascular necrosis (AVN):Presents with pain and swelling around a jointCan occur at various locationsWell-recognized sites:Capitellum of the humerusHead of the femurTarsal navicularMetatarsal headDiagnosis is made by plain radiographs.Radiographs are often required to rule out fracture, AVN, osteochondritis dissecans, or bony tumor.

Essential Workup

Physical exam

Diagnosis Tests & Interpretation

Lab

CBC, C-reactive protein (CRP), ESR only if more serious infection suspected

Imaging

Radiographs:Extra-articular from articular etiologies "SECONDS " :Soft tissue swellingErosionsCalcificationsOsteoporosisNarrowingDeformitySeparation
UltrasoundEvaluate joint effusionsMore sensitive than MRIUsed more frequently in the emergency settingFocal tendon thickeningFocal hypoechoic areasIrregular and ill-defined bordersPeritendinous edema
MRI:Internal morphology of the tendon and the surrounding structuresHelps diagnose retrocalcaneal bursitis and insertional tendonitisReveals tendon thickening and increased signal with chronic tendon abnormalities
Scintigraphy:99 Technetium pertechnetate phosphate (binds with plasma protein) and concentrates in joint space (bursitis)

Differential Diagnosis

Septic arthritis
Fracture
Osteoarthritis

Treatment

Pre-Hospital

Immobilize injured extremity as indicated.

Initial Stabilization/Therapy

Ice, immobilization pending work-up

Ed Treatment/Procedures

General:RestNSAIDsIce (10 " 20 min intervals)Range of motion exercisesEccentric exercise is the application of a load (i.e., muscular exertion) to a lengthening muscle.Local injection for pain controlOutpatient managementAdmit only for surgery or severe disabilityAllow 6 " 12 wk to healRecent studies have described successful investigational therapiesProlotherapy, an ultrasound-guided injection of dextrose and lidocaine to stimulate repair.Sclerotherapy injections of Polidocanol, a sclerosing substance to reduce neovascularityAprotinin is a broad-spectrum protease and matrix metalloproteinase (MMP) inhibitor, injected peritendinously
Calcific tendonitisLow-energy radio shock-wave therapy has recently shown significant pain relief:Thought to increase the resorption of calciumCimetidine has been used to decrease pain and calcium deposits.
Trigger finger:Conservative treatments such as rest, splinting (thumb spica) and NSAIDs for mostSome physicians suggest cortisone injections, (84 " 91% cure rate).Surgical release of A-1 Pulley may be required.
De Quervain tenosynovitisRest, ice, NSAIDsThumb spica splint for 3 " 5 days often helps
Achilles tendonitis:Rest, ice, NSAIDsOrthotics or heel wedgesCryotherapy has shown to be useful in controlling inflammation.Achilles rupture should be splinted posteriorly in slight plantar flexion:Refer to orthopedics, as patients often need surgery

Medication

Ibuprofen: 400 " 800 mg PO q6 " 8h (max. 2,400 mg per day); peds: 5 " 10 mg/kg/dose PO q4 " 6h (max. 50 mg/kg/d)
Acetaminophen: 10 " 15 mg/kg/dose every 4 " 6 hr as needed; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10 " 15 mg/kg acetaminopen in 24 hr)

Follow-Up

Disposition

Admission Criteria

Admit patients if require surgery or other more serious illness/injury

Discharge Criteria

Most patients may be managed as outpatients with appropriate referral.

Issues for Referral

All complete tendon ruptures merit referral for surgical consultation.
Partial tendon tears and chronic tendinopathy that fail to improve with 3 " 6 mo of conservative treatment may benefit from consultation with a specialized runners ' clinic, physical medicine and rehabilitation specialist, physical therapist, or orthopedic surgeon

Followup Recommendations

Prevention of reinjury is central to follow-up care.

Pearls and Pitfalls

Fluoroquinolones
Tendinopathy and tendon rupture have been reported uncommonly in adults given fluoroquinolones but have been reported with most fluoroquinolones.

Additional Reading

Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: Aetiology and management. J R Soc Med. 2004;97(10):472 " 476.
Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2006;40:81 " 85.
Wilder RP, Sethi S. Overuse injuries: Tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55 " 81.
Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med. 2007;41:188 " 198.

Codes

ICD9

726.0 Adhesive capsulitis of shoulder
726.10 Disorders of bursae and tendons in shoulder region, unspecified
726.90 Enthesopathy of unspecified site
726.12 Bicipital tenosynovitis
726.32 Lateral epicondylitis
727.03 Trigger finger (acquired)
727.04 Radial styloid tenosynovitis
727.82 Calcium deposits in tendon and bursa

ICD10

M65.819 Other synovitis and tenosynovitis, unspecified shoulder
M75.30 Calcific tendinitis of unspecified shoulder
M77.9 Enthesopathy, unspecified
M75.20 Bicipital tendinitis, unspecified shoulder
M65.30 Trigger finger, unspecified finger
M65.4 Radial styloid tenosynovitis [de Quervain]
M76.60 Achilles tendinitis, unspecified leg
M77.10 Lateral epicondylitis, unspecified elbow

SNOMED

34840004 Tendinitis (disorder)
202852009 shoulder tendinitis (disorder)
27741009 Calcific tendinitis of shoulder (disorder)
202856007 biceps tendinitis (disorder)
11654001 Achilles tendinitis (disorder)
1539003 acquired trigger finger (disorder)
202855006 Lateral epicondylitis (disorder)
21794005 Radial styloid tenosynovitis
331000119106 Tendinitis of elbow or forearm (disorder)