Periarticular Disorders of the Extremities¶
Chapter 387 | Part 11: Immune-Mediated, Inflammatory, and Rheumatologic Disorders
KEY CLINICAL POINTS¶
- Bursitis is inflammation of a bursa, with common types including subacromial, retrocalcaneal, and ischial bursitis, often caused by overuse or trauma.
- Rotator cuff tendinitis and impingement syndrome are the leading causes of painful shoulder, with supraspinatus tendon involvement being most common.
- Plantar fasciitis is a common cause of foot pain, characterized by morning pain and thickening of the plantar fascia at the calcaneal insertion.
- Adhesive capsulitis (frozen shoulder) presents with pain and restricted shoulder motion, often associated with diabetes or thyroid disease.
- Drug-induced tendinopathies are linked to quinolones, corticosteroids, statins, and aromatase inhibitors, with Achilles tendon involvement being most common.
1. DEFINITION & OVERVIEW¶
Periarticular disorders involve soft tissues around joints, including bursae, tendons, and ligaments. These conditions encompass bursitis, tendinitis, adhesive capsulitis, and calcific tendinitis. They are common musculoskeletal abnormalities affecting all ages, often linked to overuse, trauma, or systemic diseases.
Common Bursitis Types and Locations¶
| Bursa Type | Location | Common Causes |
|---|---|---|
| Subacromial | Between acromion and humeral head | Rotator cuff tendinitis, impingement |
| Retrocalcaneal | Behind the calcaneus | Repetitive movement, trauma |
| Ischial | Between gluteus medius and ischial tuberosity | Prolonged sitting on hard surfaces |
| Iliopsoas | Anterior hip joint | Overuse, systemic disease |
| Anserine | Medial tibial plateau | Repetitive knee flexion |
1.1 Bursitis¶
Inflammation of bursae, with subtypes including subacromial (most common), retrocalcaneal, ischial, iliopsoas, anserine, and olecranon. Causes include overuse, trauma, infection, or systemic diseases like gout.
1.2 Tendinitis¶
Inflammation of tendons, including rotator cuff tendinitis, lateral/medial epicondylitis, patellar tendinitis, and iliotibial band syndrome. Often caused by repetitive motion or occupational strain.
1.3 Adhesive Capsulitis¶
Stiffness and pain in the shoulder joint due to thickening and fibrosis of the capsule, typically occurring after immobilization, trauma, or systemic conditions like diabetes.
2. EPIDEMIOLOGY¶
Bursitis and tendinitis are common in adults, with subacromial bursitis most prevalent. Rotator cuff tears occur in 2-5% of adults over 60. Plantar fasciitis affects 10-20% of adults, with higher prevalence in obese individuals. Adhesive capsulitis occurs more frequently in women over 50, often associated with diabetes or thyroid disease.
2.1 Risk Factors¶
Overuse, repetitive motion, occupational strain, diabetes, thyroid disorders, and systemic diseases like rheumatoid arthritis or gout.
2.2 Demographics¶
Subacromial bursitis: Middle-aged adults; Plantar fasciitis: Obese individuals; Adhesive capsulitis: Women over 50; De Quervain’s tenosynovitis: Pregnant women or parents with thumb-stretched posture.
3. ETIOLOGY & PATHOPHYSIOLOGY¶
Bursitis results from friction, trauma, infection, or systemic inflammation. Rotator cuff tendinitis involves impingement of the supraspinatus tendon between the acromion and humeral head. Calcific tendinitis features calcium hydroxyapatite deposits in tendons, with unknown etiology. Drug-induced tendinopathy is linked to quinolones, corticosteroids, and statins, causing collagen degeneration.
3.1 Pathogenesis¶
Repetitive microtrauma in tendinitis; calcium deposition in calcific tendinitis; collagen breakdown in drug-induced tendinopathy.
3.2 Molecular Mechanisms¶
Inflammatory cytokines in bursitis; mechanical stress and oxidative damage in tendinitis; collagen cross-linking disruption in drug-induced tendinopathy.
4. CLINICAL FEATURES¶
Symptoms vary by condition: shoulder pain with rotator cuff issues, elbow pain with epicondylitis, heel pain with plantar fasciitis, and shoulder stiffness with adhesive capsulitis. Physical exam findings include localized tenderness, restricted motion, and specific provocative tests (e.g., Yergason’s test for bicipital tendinitis).
4.1 Pain Patterns¶
Subacromial bursitis: Anterolateral shoulder; Plantar fasciitis: Morning heel pain; De Quervain’s: Radial styloid tenderness.
4.2 Physical Exam Findings¶
Tenderness over bursae or tendons, restricted range of motion, positive provocative tests (e.g., Finkelstein test for De Quervain’s).
5. DIFFERENTIAL DIAGNOSIS¶
For shoulder pain: cervical radiculopathy, osteoarthritis, fractures. For elbow pain: lateral/medial epicondylitis vs. nerve entrapment. For heel pain: plantar fasciitis vs. tarsal tunnel syndrome. For hip pain: trochanteric bursitis vs. hip joint arthritis.
5.1 Shoulder Pain¶
Rotator cuff tear vs. adhesive capsulitis; cervical radiculopathy vs. impingement syndrome.
6. INVESTIGATIONS & DIAGNOSIS¶
Diagnosis is primarily clinical, with imaging (ultrasound/MRI) for confirmation. Aspiration of bursae may reveal urate crystals (gout) or infection. Ultrasound guides corticosteroid injections. MRI identifies rotator cuff tears and tendon integrity.
6.1 Diagnostic Tests¶
Ultrasound for bursitis, tendinitis, and rotator cuff tears; MRI for tendon structure; plain radiographs for heel spurs in plantar fasciitis.
6.2 Aspiration Criteria¶
Indicated for acute bursitis with redness/warmth, gout suspicion, or infection. Gram stain and culture for infection; urate crystals for gout.
7. MANAGEMENT & TREATMENT¶
Conservative management includes rest, NSAIDs, physical therapy, and corticosteroid injections. Surgical options: subacromial decompression for rotator cuff issues, bursa aspiration, or tendon release. Plantar fasciitis responds to orthotics, stretching, and night splints. Adhesive capsulitis requires early mobilization and physical therapy.
Treatment Algorithms for Common Conditions¶
| Condition | Initial Treatment | Surgical Indication |
|---|---|---|
| Rotator Cuff Tendinitis | Rest, NSAIDs, physical therapy | Refractory cases with functional loss |
| Plantar Fasciitis | Orthotics, stretching, night splint | Failed conservative therapy >6-12 months |
| Adhesive Capsulitis | Early mobilization, corticosteroids | Severe stiffness unresponsive to therapy |
7.1 Pharmacologic Therapy¶
NSAIDs for inflammation; corticosteroid injections for acute bursitis; topical analgesics for epicondylitis.
7.2 Surgical Interventions¶
Subacromial decompression, bursa excision, tendon repair, or fasciotomy for refractory cases.
8. PROGNOSIS & COMPLICATIONS¶
Most bursitis and tendinitis resolve with conservative management. Adhesive capsulitis improves in 1-3 years. Complications include chronic pain, tendon rupture, or joint stiffness. Drug-induced tendinopathy may lead to tendon rupture, requiring surgical repair.
8.1 Recovery Time¶
Plantar fasciitis: 12 months in >80%; Adhesive capsulitis: 1-3 years; Rotator cuff tears: 6-12 weeks for partial tears.
8.2 Long-Term Risks¶
Chronic pain, joint dysfunction, or tendon rupture with prolonged corticosteroid use or drug-induced tendinopathy.
9. SPECIAL CONSIDERATIONS¶
Pregnancy: De Quervain’s tenosynovitis; Pediatrics: Epicondylitis in athletes; Elderly: Increased risk of rotator cuff tears. Corticosteroid injections should be avoided in active tendons. Drug-induced tendinopathy requires discontinuation of causative agents.
9.1 Pregnancy¶
De Quervain’s tenosynovitis is common; corticosteroid injections may be used cautiously.
9.2 Drug-Induced Risks¶
Quinolones, corticosteroids, and statins increase tendon rupture risk; avoid rechallenge after tendon injury.
10. KEY POINTS & CLINICAL PEARLS¶
- Subacromial bursitis is the most common bursitis, often associated with rotator cuff tendinitis. 2. Plantar fasciitis responds to orthotics and stretching but requires avoiding hard surfaces. 3. Adhesive capsulitis improves with early mobilization and physical therapy. 4. Drug-induced tendinopathy mandates discontinuation of causative agents. 5. Ultrasound is preferred for diagnosing bursitis and guiding injections.