368 Periarticular Disorders of the Extremities

HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 20TH ED

ARTHRITIS ASSOCIATED WITH directed guidance of glucocorticoid

SYSTEMIC DISEASE injection
 BURSITIS Treatment: prevention of any
 ROTATOR CUFF TENDINITIS AND aggravating situation, rest of the
IMPINGEMENT SYNDROME involved part, administration of a
 CALCIFIC TENDINITIS nonsteroidal anti-inflammatory drug
 BICIPITAL TENDINITIS AND (NSAID) where appropriate for an
RUPTURE individual patient, or local
 DE QUERVAIN’S TENOSYNOVITIS glucocorticoid injection
 PATELLAR TENDINITIS
 DRUG-INDUCED ROTATOR CUFF TENDINITIS AND
TENDINOPATHIES IMPINGEMENT SYNDROME
 ILIOTIBIAL BAND SYNDROME  Tendinitis of the rotator cuff is the major
 ADHESIVE CAPSULITIS cause of a painful shoulder and is
 LATERAL EPICONDYLITIS currently thought to be caused by
 MEDIAL EPICONDYLITIS inflammation of the tendon(s)
 PLANTAR FASCIITIS  rotator cuff: tendons of the
supraspinatus, infraspinatus,
BURSITIS subscapularis, and teres minor muscles
 inflammation of a bursa, which is a thin-  supraspinatus tendon is the most often
walled sac lined with synovial tissue affected
 Bursa function is to facilitate movement  Symptoms can appear without a
of tendons and muscles over bony triggering cause or after injury or
prominences overuse, especially with activities
 Excessive frictional forces from involving elevation of the arm with
overuse, trauma, systemic disease (e.g., some degree of forward flexion
rheumatoid arthritis, gout), or infection  aged >40 years are particularly
may cause bursitis susceptible
 Subacromial bursitis (subdeltoid  NSAIDs, local glucocorticoid injection,
bursitis) is the most common form of and physical therapy may relieve
bursitis symptoms
 Other forms:
CALCIFIC TENDINITIS
 Trochanteric bursitis  characterized by deposition of calcium
 Olecranon bursitis salts, primarily hydroxyapatite, within a
 Achilles bursitis tendon
 Retrocalcaneal bursitis  initiated by ischemia or degeneration of
 Ischial bursitis the tendon
 Iliopsoas bursitis  supraspinatus tendon is most often
 Anserine bursitis affected because it is frequently
 Prepatellar bursitis impinged on and has a reduced blood
Diagnosis: history and physical supply when the arm is abducted
examination, but visualization by  develops after age 40
ultrasound may play a useful role in Diagnosis: ultrasound or radiograph
selected instances for diagnosis and

PGI MIGUEL, KENNETH JAMES B.

 368 Periarticular Disorders of the Extremities
HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 20TH ED
Treatment: self-limited and respond to
conservative therapy with physical
therapy and/ or NSAIDs
BICIPITAL TENDINITIS AND RUPTURE
 produced by friction on the tendon of
the long head of the biceps as it passes
through the bicipital groove
 patients experience anterior shoulder
pain that radiates down the biceps into
the forearm
 Yergason’s supination sign - Pain may
be elicited along the course of the
tendon by resisting supination of the
forearm with the elbow at 90°
 Surgery is usually not necessary in this
setting
DE QUERVAIN’S TENOSYNOVITIS
 inflammation involves the abductor
pollicis longus and the extensor pollicis
brevis as these tendons pass through a
fibrous sheath at the radial styloid
process
 usual cause is repetitive twisting of the
wrist
 Patients experience pain on grasping
with their thumb, such as with pinching
 Positive Finkelstein sign - 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: splinting the wrist and an
NSAID
 When severe or refractory to
conservative treatment,
glucocorticoid injections can be
very effective
PATELLAR TENDINITIS
 Tendinitis involves the patellar tendon at
its attachment to the lower pole of the
patella
 Patients may experience pain when
jumping during sports, going up stairs,
or doing deep knee squats
 Tenderness over the lower pole of the
patella
Treatment: rest, icing, and NSAIDs,
followed by strengthening and
increasing flexibility
DRUG-INDUCED TENDINOPATHIES
 drug classes most associated with
tendinopathies include quinolones,
glucocorticoids, aromatase inhibitors,
and statins
 the tendons of the lower extremities are
most often impacted, particularly the
Achilles tendon
 Presenting features include pain and
potentially swelling over the tendon,
although some patients may first present
with tendon rupture
 potential agent should be withdrawn
 Tendon ruptures may require surgery
Diagnosis: Ultrasound and MRI
ILIOTIBIAL BAND SYNDROME
 iliotibial band - thick connective tissue
that runs from the ilium to the fibula
 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: varus alignment of
the knee, excessive running distance,
poorly fitted shoes, or continuous
running on uneven terrain
Treatment: rest, NSAIDs, physical
therapy, and addressing risk factors such
as shoes and running surface
ADHESIVE CAPSULITIS
 “frozen shoulder”
 characterized by pain and restricted
movement of the shoulder, usually in the
absence of intrinsic shoulder disease
PGI MIGUEL, KENNETH JAMES B.
368 Periarticular Disorders of the Extremities
HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 20TH ED
 capsule of the shoulder is thickened, and
a mild chronic inflammatory infiltrate
and fibrosis may be present
 more commonly in women aged >50
years
Diagnosis: physical examination but can
be confirmed by arthrography
Treatment: physical therapy
 glucocorticoids and NSAIDs
may also provide relief of
symptoms
 injection of contrast material
into the joint may lyse
adhesions and stretch the
capsule, resulting in
improvement of shoulder
motion
LATERAL EPICONDYLITIS
 tennis elbow
 painful condition involving the soft
tissue over the lateral aspect of the
elbow
 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
 pain usually appears after work or
recreational activities involving repeated
motions of wrist extension and
supination against resistance
Treatment: rest along with
administration of an NSAID
 Ultrasound, icing, and friction
massage may also help relieve
pain
MEDIAL EPICONDYLITIS
 overuse syndrome resulting in pain over
the medial side of the elbow with
radiation into the forearm
 Cause is 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
 seen in patients aged >35 years
 occurs most often in work-related
repetitive activities and also occurs with
recreational activities such as swinging a
golf club or throwing a baseball
 tenderness just distal to the medial
epicondyle over the origin of the
forearm flexors
Treatment: conservative, involving rest,
NSAIDs, friction massage, ultrasound,
and icing
PLANTAR FASCIITIS
 common cause of foot pain in adults
 peak incidence occurs between ages 40
and 60 years
 pain originates at or near the site of the
plantar fascia attachment to the medial
tuberosity of the calcaneus
 Risk factors: obesity, pes planus, pes
cavus , limited dorsiflexion of the ankle,
prolonged standing, walking on hard
surfaces, and faulty shoes
Diagnosis: History and PE
 maximal tenderness is elicited
on palpation over the inferior
heel corresponding to the site of
attachment of the plantar fascia
 Plain radiographs: heel spurs
 Ultrasonography: thickening of
the fascia and diffuse
hypoechogenicity
Treatment: ice, heat, massage,
stretching, and eliminating activities that
can exacerbate plantar fasciitis
 Orthotics provide medial arch
support and can be effective
 Plantar fasciotomy - failed to
improve after at least 6–12
months of conservative
treatment
PGI MIGUEL, KENNETH JAMES B.