Dr Budi Enoch

 A number of periarticular disorders have become

increasingly common over the past two to three
decades, due in part to greater participation in
recreational sports by individuals of a wide range of
ages.
 Periarticular disorders most commonly affect the knee
or shoulder. With the exception of bursitis, hip pain is
most often articular or is being referred from disease
affecting another structure
 Bursitis
 Bursitis is inflammation of a bursa, which is a thin-walled sac
lined with synovial tissue. The function 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. Subacromial bursitis (subdeltoid bursitis) is the
most common form of bursitis.
 The subacromial bursa, which is contiguous with the
subdeltoid bursa, 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.
 Another frequently encountered form is trochanteric bursitis,
which involves the bursa around the insertion of the gluteus
medius onto the greater trochanter of the femur
 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.
 Achilles bursitis involves the bursa located above the insertion of
the tendon to the calcaneus and results from overuse and wearing
tight shoes.
 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.
 Ischial bursitis (weaver's bottom) affects the bursa separating the
gluteus medius from the ischial tuberosity and develops from
prolonged sitting and pivoting on hard surfaces.
 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
 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. 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 occur at this site. Treatment of bursitis
consists of prevention of the aggravating situation, rest
of the involved part, 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.
 Of the tendons forming the rotator cuff, the
supraspinatus tendon is the most often affected,
probably because of its repeated impingement
(impingement syndrome) between the humeral head
and the undersurface of the anterior third of the
acromion and coracoacromial ligament above as well as
the reduction in its blood supply that occurs with
abduction of the arm
 The tendon of the infraspinatus and that of the long head of the biceps
are less commonly involved. 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.
 Subacromial 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.
 Impingement syndrome occurs in persons participating in baseball,
tennis, swimming, or occupations that require repeated elevation of the
arm. 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. Tenderness is present over the lateral aspect of the humeral
head just below the acromion. NSAIDs, local glucocorticoid injection,
and physical therapy may relieve symptoms. Surgical decompression of
the subacromial space may be necessary in patients refractory to
conservative treatment.
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. Surgical repair may be necessary in patients
who fail to respond to conservative measures. In patients with moderate-to-severe tears
and functional loss, surgery is indicated.
Calcific Tendinitis
 This condition is characterized by deposition of calcium
salts, primarily hydroxyapatite, within a tendon.
 The exact mechanism of calcification is not known but may
be initiated by ischemia or degeneration of the 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.
However, it may be asymptomatic or not related to the
patient's symptoms
 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.
 Abduction and external rotation of the arm are painful and
limited. The bicipital groove is very tender to palpation. Pain
may be elicited along the course of the tendon by resisting
supination of the forearm with the elbow at 90° (Yergason's
supination sign).
 Acute rupture of the tendon may occur with vigorous exercise
of the arm and is often painful. In a young patient, it should be
repaired surgically. Rupture of the tendon in an older person
may be associated with little or no pain and is recognized by
the presence of persistent swelling of the biceps ("Popeye"
muscle) produced by the retraction of the long head of the
biceps. Surgery is usually not necessary in this setting.
 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. The usual
cause is repetitive twisting of the wrist.
 It may occur in pregnancy, and it also occurs in mothers who
hold their babies with the thumb outstretched.
 Patients experience pain on grasping with their thumb, such as
with pinching. Swelling and tenderness are often present over the
radial styloid process. 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 ulnarly deviated,
resulting in pain over the involved tendon sheath in the area of
the radial styloid. Treatment consists initially of splinting the
wrist and an NSAID. When severe or refractory to conservative
treatment, glucocorticoid injections can be very effective.
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 commonly
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.
 Treatment consists of rest, NSAIDs, physical therapy, and
addressing risk factors such as shoes and running surface.
Glucocorticoid injection into the area of tenderness can
provide relief, but running must be avoided for at least two
weeks after the injection. Surgical release of the iliotibial
band has been helpful in rare patients for whom
conservative treatment has failed.
 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.
 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. 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.
 Most patients with this disorder injure themselves in
activities other than tennis, such as pulling weeds, carrying
suitcases or briefcases, or using a screwdriver. The injury in
tennis usually occurs when hitting a backhand with the
elbow flexed. Shaking hands and opening doors can
reproduce the pain. Striking the lateral elbow against a
solid object may also induce pain.
Medial Epicondylitis
 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. 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 epicondyle over the origin of the forearm flexors. Pain can be
reproduced by resisting wrist flexion and pronation with the elbow
extended. 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
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.
 It is also seen more frequently in a younger population
consisting of runners, aerobic exercise dancers, and ballet
dancers.
 The pain originates at or near the site of the plantar fascia
attachment to the medial tuberosity of the calcaneus.
 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.
 The diagnosis of plantar fasciitis can usually be made on
the basis of history and physical examination alone.
 Patients experience severe pain with the first steps on
arising in the morning or following inactivity during the
day.
 The pain usually lessens with weight-bearing activity
during the day, only to worsen with continued activity. 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. Ultrasonography in plantar
fasciitis can demonstrate thickening of the fascia and
diffuse hypoechogenicity, indicating edema at the
attachment of the plantar fascia to the calcaneus. MRI is a
sensitive method for detecting plantar fasciitis, but it is
usually not required for establishing the diagnosis
 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.
 Resolution of symptoms occurs within 12 months in more than
80% of patients with plantar fasciitis. The patient is advised to
reduce or discontinue activities that can exacerbate plantar
fasciitis.
 Initial treatment consists of ice, heat, massage, and stretching.
Stretching of the plantar fascia and calf muscles are commonly
employed and can be beneficial. Orthotics provide medial arch
support and can be effective. Foot strapping or taping are
commonly performed, and some patients may benefit by
wearing a night splint designed to keep the ankle in a neutral
position. A short course of NSAIDs can be given to patients
when the benefits outweigh the risks. Local glucocorticoid
injections have also been shown to be efficacious but may carry
an increased risk for plantar fascia rupture.
 Plantar fasciotomy is reserved for those patients who have failed
to improve after at least 6–12 months of conservative treatment.
Thanks for your attention