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Periarticular Disorders of the Extremities

Chapter 387 | Part 11: Immune-Mediated, Inflammatory, and Rheumatologic Disorders · Part 11 – Rheumatology & Immunology · Chapter 387

Key Clinical Points

  1. Adhesive capsulitis occurs more commonly in women over age 50 and is associated with systemic disorders such as diabetes mellitus, chronic pulmonary disease, myocardial infarction, and thyroid disease.
  2. De Quervain's tenosynovitis results from inflammation of the abductor pollicis longus and extensor pollicis brevis; it may occur in pregnancy or during infant care (holding babies with thumbs outstretched).
  3. Subacromial bursitis is the most common form of bursitis and often accompanies rotator cuff tendinitis; pain is typically in the anterolateral aspect of the shoulder.
  4. Drug-induced tendinopathies are most commonly associated with quinolones, glucocorticoids, aromatase inhibitors, and statins; the Achilles tendon is the most frequent site of involvement.
  5. Calcific tendinitis involves hydroxyapatite deposition within a tendon; the supraspinatus tendon is involved in 63% of cases.
  6. Plantar fasciitis typically sees resolution of symptoms in >80% of patients within 12 months; initial management includes ice, heat, massage, stretching, and eliminating inciting activities.
  7. Trochanteric bursitis involves the gluteus medius and/or minimus; pain is located over the lateral aspect of the hip and upper thigh.
  8. Olecranon bursitis involves the posterior elbow; if acutely inflamed with redness or warmth, infection or gout must be excluded via aspiration.
  9. Rotator cuff tears may be acute (sports, falling on an outstretched arm, lifting heavy objects), subacute, or chronic.
  10. Medial epicondylitis is an overuse syndrome of the medial side of the elbow; it is much less common than lateral epicondylitis and often results from repetitive work activities.

DEFINITION & OVERVIEW

• Periarticular Disorders: Common musculoskeletal abnormalities affecting all ages. • Bursae: ◦ Defined as thin-walled sacs lined with synovial tissue. ◦ Function: Facilitate movement of tendons and muscles over bony prominences. ◦ Quantity: Humans typically have over 150 bursae. ◦ Causes of Inflammation: Overuse, trauma, systemic disease (e.g., rheumatoid arthritis, gout), or infection. • Rotator Cuff Anatomy: ◦ Composed of the tendons of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles. ◦ Insertion: These tendons insert on the humeral tuberosities. ◦ Supraspinatus Tendon: Most frequently affected due to potential for impingement between the humeral head and the acromion/coracoacromial ligament. ◦ Other Structures: Infraspinatus and long head of biceps are less commonly involved; subacromial bursitis often accompanies rotator cuff tendinitis. • Adhesive Capsulitis (Frozen Shoulder): ◦ Characterized by pain and restricted movement, usually without intrinsic shoulder disease. ◦ Etiology: Often follows reduced mobility from bursitis, tendinitis, fractures, or surgery; can occur spontaneously. • Bicipital Tendinitis: Produced by friction on the tendon of the long head of the biceps as it passes through the bicipital groove. • De Quervain's Tenosynovitis: Inflammation of the abductor pollicis longus and extensor pollicis brevis as they pass through a fibrous sheath at the radial styloid process.

EPIDEMIOLOGY

• General: Affects patients across all age groups. • Adhesive Capsulitis: More common in women over age 50. • Calcific Tendinitis: Typically develops after age 40. • Medial Epicondylitis: Usually seen in patients aged >35 years; significantly less common than lateral epicondylitis. • De Quervain's Tenosynovitis: Common in pregnancy and in parents holding babies with thumbs outstretched. • Olecranon Bursitis: Associated with overuse or trauma. • Iliotibial Band Syndrome: Associated with distance running, poorly fitted shoes, or running on uneven terrain.

ETIOLOGY & PATHOPHYSIOLOGY

• Bursitis Mechanisms: Driven by excessive frictional forces from overuse, trauma, systemic disease (e.g., rheumatoid arthritis, gout), or infection. • Calcific Tendinitis: ◦ Characterized by deposition of calcium salts, primarily hydroxyapatite, within a tendon. ◦ Pathogenesis: Mechanism of initiation is unknown; not typically due to overuse or systemic disease. ◦ Associations: Linked with diabetes and thyroid disorders; genetic predisposition is questioned. ◦ Clinical Presentation: Can be asymptomatic or cause acute, severe pain. ◦ Site: Supraspinatus tendon involved in 63% of patients. • Adhesive Capsulitis Pathology: ◦ Characterized by a thickened capsule with mild chronic inflammatory infiltrate and fibrosis. • Drug-Induced Tendinopathies: ◦ Mechanism unknown; presents as pain, swelling, or occasionally tendon rupture. ◦ High-risk Drug Classes (Table 387-2): ◦ Quinolones: Fluoroquinolones (common site: Achilles tendon). ◦ Glucocorticoids: Systemic or local (common site: Achilles tendon). ◦ Aromatase Inhibitors: Anastrozole, Letrozole (common site: Achilles tendon). ◦ Statins: HMG-CoA reductase inhibitors (common site: Achilles tendon). • Iliotibial Band Syndrome: Predisposing factors include varus alignment of the knee, distance running, poorly fitted shoes, or uneven terrain.

CLINICAL FEATURES

• Subacromial Bursitis: Pain in the anterolateral aspect of the shoulder. • Trochanteric Bursitis: ◦ Pain over the lateral aspect of the hip and upper thigh. ◦ Tenderness over the posterior aspect of the greater trochanter (most noticeable when lying on side). ◦ Provocation: External rotation and resisted abduction of the hip; direct pressure to the bursa. • Olecranon Bursitis: Visible swelling over the olecranon. • Achilles Bursitis: Pain at the back of the heel; swelling along the medial/lateral side of the tendon. • Ischial Bursitis: Result of prolonged sitting on hard surfaces. • Iliopsoas Bursitis: Pain over the area, worsened by hip extension and flexion (must be differentiated from intra-articular pain). • Anserine Bursitis: Pain elicited by climbing stairs or direct pressure ~5 cm below the medial knee joint line. • Prepatellar Bursitis: Swelling over the kneecap; may involve gout or infection. • Rotator Cuff Tendinitis: ◦ Symptoms can be spontaneous or follow injury/overuse. ◦ Pain: Severe during active abduction, especially in the 60° to 120° arc. ◦ Tenderness: Located over the lateral aspect of the humeral head just below the acromion. • Rotator Cuff Tears: ◦ Symptoms: Pain combined with weakness of abduction and external rotation. ◦ Diagnosis: No single finding; suggested by painful abduction arc >90°, drop arm test, or failure to control shoulder adduction. • Bicipital Tendinitis: ◦ Acute: Anterior shoulder pain radiating down the biceps into the forearm. ◦ Examination: Pain with resisted supination (Yergason's test) and tenderness over the bicipital groove. • De Quervain's Tenosynovitis: Pain on grasping or pinching; swelling/tenderness at the radial styloid process. • Plantar Fasciitis: ◦ Severe pain with first steps in the morning or after periods of inactivity. ◦ Pain lessens with weight-bearing but increases with continued activity. ◦ Exacerbated by walking barefoot or climbing stairs. • Medial Epicondylitis: Pain over the medial side of the elbow; tenderness distal to the medial epicondyle; worse with resisted wrist flexion/pronation.

DIFFERENTIAL DIAGNOSIS

• Olecranon Bursitis: If acutely inflamed (red/warm), must be differentiated from infection or gout via aspiration and analysis of fluid. • Adhesive Capsulitis: Diagnosis based on physical exam showing restricted range of motion; imaging used primarily to rule out other causes. • Rotator Cuff Tears: Confirmed via ultrasound or MRI. • Calcific Tendinitis: Identified via radiograph or ultrasound. • Plantar Fasciitis: ◦ Clinical diagnosis from history/exam. ◦ Ultrasound: Shows thickening and hypoechogenicity (edema). ◦ MRI: Highly sensitive but not always required. ◦ Radiographs: May show heel spurs (low diagnostic significance).

INVESTIGATIONS & DIAGNOSIS

  1. Clinical Examination: Primary method for diagnosing most periarticular disorders; includes specific maneuvers like the drop arm test or Yergason's test.
  2. Imaging: ◦ Radiography/Ultrasound: Used to identify calcific tendinitis and rule out other conditions in adhesive capsulitis. ◦ MRI/Ultrasound: Preferred for identifying rotator cuff tears.
  3. Aspiration: Required for olecranon bursitis if acute inflammation (redness/warmth) is present to rule out infection or gout.

MANAGEMENT & TREATMENT

  1. Non-Pharmacologic Management: ◦ General: Rest of the affected part and avoidance of aggravating factors. ◦ Plantar Fasciitis: Ice, heat, massage, stretching, and elimination of inciting activities.
  2. Pharmacologic Management: ◦ Administration of topical or systemic nonsteroidal anti-inflammatory drugs (NSAIDs) where appropriate.
  3. Interventional Management: ◦ Local glucocorticoid injections for localized inflammation.

PROGNOSIS & COMPLICATIONS

• Plantar Fasciitis: Resolution of symptoms in >80% of patients within 12 months. • Rotator Cuff Tears: ◦ Acute: Resulting from sports, falls on an outstretched arm, or lifting heavy objects. ◦ Subacute/Chronic: Gradual progression of tissue damage.

SPECIAL CONSIDERATIONS

• Systemic Associations: ◦ Adhesive Capsulitis: Associated with DM, pulmonary disease, MI, and thyroid disease. ◦ Calcific Tendinitis: Linked to DM and thyroid disorders. • Pregnancy: De Quervain's tenosynovitis is a recognized condition in pregnancy.

KEY PEARLS & CLINICAL TRAPS

• Calcific Tendinitis: High yield for hydroxyapatite deposition and 63% supraspinatus involvement. • De Quervain's: Involves abductor pollicis longus and extensor pollicis brevis; common in pregnancy. • Olecranon Bursitis: Critical to rule out infection/gout via aspiration if red/warm. • Plantar Fasciitis: High resolution rate (>80%) within 12 months; hallmark is morning pain with first steps. • Drug-Induced Tendinopathy: Key culprits are Quinolones, Glucocorticoids, Aromatase Inhibitors (Anastrozole/Letrozole), and Statins (HMG-CoA inhibitors).