Tendinitis is a painful inflammation of tendons and of tendon-muscle attachments to bone, usually in the shoulder rotator cuff, hip, Achilles tendon, or hamstring. Bursitis is a painful inflammation of one or more of the bursae — closed sacs lubricated with small amounts of synovial fluid that facilitate the motion of muscles and tendons over bony prominences. Bursitis usually occurs in the subdeltoid, olecranon, trochanteric, calcaneal, or prepatellar bursae.
Tendinitis commonly results from overuse or injury (such as strain during sports activity), another musculoskeletal disorder (such as rheumatic diseases or congenital defects), or aging.
Bursitis can occur at any age but usually occurs in older individuals due to an inflammatory joint disease (such as rheumatoid arthritis or gout) or recurring trauma that stresses or pressures a joint. Chronic bursitis follows attacks of acute bursitis or repeated trauma and infection. Septic bursitis may result from wound infection or from bacterial invasion of skin over the bursa.
The patient with tendinitis of the shoulder complains of restricted shoulder movement, especially abduction, and localized pain, which is most severe at night and usually interferes with sleep. The pain extends from the acromion (the shoulder’s highest point) to the deltoid muscle insertion, predominantly in the so-called painful arc — that is, when the patient abducts his arm between 50 and 130 degrees. Fluid accumulation causes swelling. In calcific tendinitis, calcium deposits in the tendon cause proximal weakness and, if calcium erodes into adjacent bursae, acute calcific bursitis.
In bursitis, fluid accumulation in the bursae causes irritation, inflammation, sudden or gradual pain, and limited movement. Other symptoms vary according to the affected site. Subdeltoid bursitis impairs arm abduction, prepatellar bursitis (housemaid’s knee) produces pain when the patient climbs stairs, and hip bursitis makes crossing the legs painful.
In tendinitis, X-rays may be normal at first but later show bony fragments, osteophyte sclerosis, or calcium deposits. Arthrography is usually normal, with occasional small irregularities on the undersurface of the tendon. Computed tomography scan and magnetic resonance imaging (MRI) have replaced X-ray and even arthrography of the shoulder as diagnostic tools. An MRI will usually identify tears, partial tears, inflammation, or tumor but cannot reveal irregularities of the tendon sheath itself. Diagnosis of tendinitis must rule out other causes of shoulder pain, such as myocardial infarction, cervical spondylosis, degenerative changes, and tendon tear or rupture. Significantly, in tendinitis, heat aggravates shoulder pain; in other painful joint disorders, heat usually provides relief.
Localized pain and inflammation and a history of unusual strain or injury 2 to 3 days before onset of pain are the bases for diagnosing bursitis. During early stages, X-rays are usually normal, except in calcific bursitis, where X-rays may show calcium deposits.
Treatment to relieve pain includes resting the joint (by immobilization with a sling, splint, or cast), nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, application of cold or heat, ultrasound, or local injection of an anesthetic and corticosteroids to reduce inflammation. A mixture of a corticosteroid and an anesthetic such as lidocaine generally provides immediate pain relief. Extended-release injections of a corticosteroid, such as triamcinolone or prednisolone, offer longer-term pain relief. Until the patient is free of pain and able to perform range-of-motion exercises easily, treatment also includes oral NSAIDs, such as ibuprofen, naproxen, indomethacin, or oxaprozin. Short-term analgesics include propoxyphene, codeine, acetaminophen with codeine and, occasionally, oxycodone.
Supplementary treatment includes fluid removal by aspiration and heat therapy; for calcific tendinitis, ice packs, physical therapy, ultrasonography, or hydrotherapy generally helps maintain or regain range of motion. It may be necessary to delay treatment until the acute attack is over to ensure maximum patient compliance. Rarely, calcific tendinitis requires surgical removal of calcium deposits. Long-term control of chronic bursitis and tendinitis may require changes in lifestyle to prevent recurring joint irritation.
When treating patients with tendinitis or bursitis, remember to consider the following:
❑ Assess the severity of pain and the range of motion to determine effectiveness of the treatment.
❑ Before injecting corticosteroids or local anesthetics, ask the patient about his drug allergies.
❑ Assist with intra-articular injection. Scrub the patient’s skin thoroughly with povidone-iodine or a comparable solution. After the injection, massage the area to ensure penetration through the tissue and joint space. Apply ice intermittently for about 4 hours to minimize pain. Avoid applying heat to the area for 2 days.
❑ Tell the patient to take anti-inflammatory agents with milk to minimize GI distress and to report any signs of distress immediately.
❑ Advise the patient to perform strengthening exercises and avoid activities that aggravate the joint.
❑ Remind the patient to wear a splint or sling during the first few days of an attack of subdeltoid bursitis or tendinitis to support the arm and protect the shoulder, particularly at night. Demonstrate how to wear the sling so it won’t put too much weight on the shoulder.
❑ Advise the patient to maintain joint mobility and prevent muscle atrophy by performing exercises or physical therapy when he’s free of pain.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
» Next page: Tendinitis and bursitis (Handbook of Diseases)
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