Bursitis & Tendonitis-1

Bursitis & Tendonitis-1 - Bursitis, Tendonitis,...

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Unformatted text preview: Bursitis, Tendonitis, Fibromyalgia, and RSD Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA joe@joelex.net Emergency Medicine Objectives 1. Explain how bursitis and 1. Explain how bursitis and Explain Explain 2. 2. 3. 3. tendonitis are similar ttendonitis are similar tendonitis endonitis Explain how bursitis and Explain how bursitis and Explain Explain tendonitis differ from from another ttendonitis differ from from another tendonitis endonitis List phases in development and List phases in development and List List healing of bursitis and tendonitis healing of bursitis and tendonitis healing healing Emergency Medicine Objectives 4. List common types of bursitis and 4. List common types of bursitis and List List tendonitis found at the: ttendonitis found at the: tendonitis endonitis x Shoulder xHip x Shoulder x Elbow xKnee x Elbow x Wrist xAnkle x Wrist 5.. List indications // contraindications 5. List indications contraindications 5 5. ffor injection therapy of bursitis or injection therapy of bursitis and tendonitis and tendonitis and and Emergency Medicine Objectives 6. Describe typical findings in a 6. Describe typical findings in a Describe Describe patient with fibromyalgia patient with fibromyalgia patient patient 7. Describe typical findings in a 7. Describe typical findings in a Describe Describe patient with reflex sympathetic patient with reflex sympathetic dystrophy dystrophy dystrophy dystrophy Emergency Medicine Sports x Society more athletic x Society more athletic x Physical activity health benefits xPhysical activity health benefits Physical Physical x Overuse syndromes increase x Overuse syndromes increase x 25% to 50% of participants will x25% to 50% of participants will 25% 25% experience tendonitis or bursitis experience tendonitis or bursitis experience experience Emergency Medicine Workplace Musculoskeletal disorders from… Musculoskeletal disorders from… …repetitive motions …repetitive motions …localized contact stress …localized contact stress …awkward positions …awkward positions …vibrations …vibrations …forceful exertions …forceful exertions x Ergonomic design iincidence xErgonomic design ncidence Ergonomic Ergonomic Emergency Medicine Bursae x Closed, round, flat sacs x Closed, round, flat sacs x Lined by synovium x Lined by synovium x May or may not communicate with xMay or may not communicate with May May synovial cavity synovial cavity synovial synovial x Occur at areas of friction between xOccur at areas of friction between Occur Occur skin and underlying ligaments // skin and underlying ligaments bone bone Emergency Medicine Bursae x Permit lubricated movement over xPermit lubricated movement over Permit Permit areas of potential impingement areas of potential impingement areas areas x Many are nameless x Many are nameless x ~78 on each side of body x ~78 on each side of body x New bursae may form anywhere xNew bursae may form anywhere New New from frequent irritation ffrom frequent irritation from rom Emergency Medicine Bursitis Inflamed by… Inflamed by… …chronic friction …chronic friction …trauma …trauma …crystal …crystal crystal crystal deposition deposition deposition deposition …infection …infection …systemic …systemic systemic systemic disease: disease: rrheumatoid heumatoid arthritis, arthritis, psoriatic psoriatic arthritis, gout arthritis, gout ankylosing ankylosing spondylitis spondylitis spondylitis spondylitis Emergency Medicine Bursitis x IInflammation causes xInflammation causes nflammation Inflammation bursal synovial cells to bursal synovial cells to thicken tthicken thicken hicken x Excess fluid xExcess fluid Excess Excess accumulates inside and accumulates inside and around affected bursae around affected bursae around around Emergency Medicine Tendons x Tendon sheaths composed of xTendon sheaths composed of Tendon Tendon same synovial cells as bursae same synovial cells as bursae x Inflamed in similar manner x Inflamed in similar manner x Tendonitis: inflammation of tendon xTendonitis: inflammation of tendon Tendonitis: Tendonitis: only only only only x Tenosynovitis: inflammation of xTenosynovitis: inflammation of Tenosynovitis: Tenosynovitis: tendon plus its sheath ttendon plus its sheath tendon endon Emergency Medicine Tendons x IInflammatory changes involving xInflammatory changes involving nflammatory Inflammatory sheath well documented sheath well documented x IInflammatory lesions of tendon xInflammatory lesions of tendon nflammatory Inflammatory alone not well documented alone not well documented alone alone x Distinction uncertain: terms xDistinction uncertain: terms Distinction Distinction ttendonitis and tenosynovitis used endonitis and tenosynovitis used interchangeably iinterchangeably interchangeably nterchangeably Emergency Medicine Tendons x Most overuse syndromes are NOT xMost overuse syndromes are NOT Most Most inflammatory iinflammatory inflammatory nflammatory x Biopsy: no inflammatory cells x Biopsy: no inflammatory cells x High glutamate concentrations x High glutamate concentrations x NSAIDs // steroids: no advantage x NSAIDs steroids: no advantage x TendonITIS a misnomer x TendonITIS a misnomer Emergency Medicine Bursitis / Tendonitis x Most common causes: xMost common causes: Most Most mechanical overload and mechanical overload and rrepetitive microtrauma epetitive microtrauma x Most injuries xMost injuries Most Most multifactorial multifactorial multifactorial multifactorial Emergency Medicine Bursitis / Tendonitis x IIntrinsic factors: malalignment, xIntrinsic factors: malalignment, ntrinsic Intrinsic poor muscle flexibility, muscle poor muscle flexibility, muscle weakness or imbalance weakness or imbalance x Extrinsic factors: design of xExtrinsic factors: design of Extrinsic Extrinsic equipment or workplace and equipment or workplace and excessive duration, frequency, or excessive duration, frequency, or intensity of activity iintensity of activity intensity ntensity Emergency Medicine Immediate Phase x Release of chemotactic and xRelease of chemotactic and Release Release vasoactive chemical mediators vasoactive chemical mediators vasoactive vasoactive x Vasodilation and cellular edema x Vasodilation and cellular edema x PMNs perpetuate process x PMNs perpetuate process x Lasts 48 hours to 2 weeks x Lasts 48 hours to 2 weeks x Repetitive insults prolong xRepetitive insults prolong Repetitive Repetitive inflammatory stage iinflammatory stage inflammatory nflammatory Emergency Medicine Healing Phase x Classic inflammatory signs: pain, xClassic inflammatory signs: pain, Classic Classic warmth, erythema, swelling warmth, erythema, swelling x Healing goes through proliferative xHealing goes through proliferative Healing Healing and maturation and maturation and and x 6 tto 12 weeks: organization and x 6 to 12 weeks: organization and o to collagen cross-linking mature to collagen cross-linking mature to preinjury strength preinjury strength preinjury preinjury Emergency Medicine History x Changes in sports activity, work xChanges in sports activity, work Changes Changes activities, or workplace activities, or workplace activities, activities, x Cause not always found x Cause not always found x Pregnancy, quinolone therapy, xPregnancy, quinolone therapy, Pregnancy, Pregnancy, connective tissue disorders, connective tissue disorders, systemic illness systemic illness systemic systemic Emergency Medicine History x Most common complaint: PAIN xMost common complaint: PAIN Most PAIN Most PAIN x Acute or chronic x Acute or chronic x Frequently more severe after xFrequently more severe after Frequently Frequently periods of rest periods of rest periods periods x May resolve quickly after initial xMay resolve quickly after initial May May movement only to become movement only to become throbbing pain after exercise tthrobbing pain after exercise throbbing hrobbing Emergency Medicine Articular vs. Periarticular In joint capsule In joint capsule x Joint pain // warmth // x Joint pain warmth Joint Joint swelling swelling swelling swelling x Worse with active & x Worse with active & Worse Worse passive movement passive movement passive passive x All parts of joint x All parts of joint All All involved iinvolved involved nvolved Periarticular Periarticular Periarticular Periarticular x Pain not uniform x Pain not uniform Pain Pain across joint across joint across across x Pain only certain x Pain only certain Pain Pain movements movements movements movements x Pain character & x Pain character & Pain Pain radiation vary rradiation vary radiation adiation Emergency Medicine Physical Exam x Careful palpation x Careful palpation x Range of motion x Range of motion x Heat, warmth, redness x Heat, warmth, redness Emergency Medicine Lab Studies x Screening tests: CBC, CRP, ESR xScreening tests: CBC, CRP, ESR Screening Screening x Chronic rheumatic disease: mild xChronic rheumatic disease: mild Chronic Chronic anemia anemia anemia anemia x Rheumatoid factor, antinuclear xRheumatoid factor, antinuclear Rheumatoid Rheumatoid antibody, antistreptolysin O titers, antibody, antistreptolysin O titers, and Lyme serologies for follow-up and Lyme serologies for follow-up x Serum uric acid: not helpful x Serum uric acid: not helpful Emergency Medicine Synovial Fluid x Especially crystalline, suppurative xEspecially crystalline, suppurative Especially Especially etiology etiology etiology etiology x Appearance, cell count and diff, xAppearance, cell count and diff, Appearance, Appearance, crystal analysis, Gram’s stain crystal analysis, Gram’s stain crystal crystal – Positive Gram’s: diagnostic –Positive Gram’s: diagnostic Positive Positive – Negative Gram’s: cannot rule out – Negative Gram’s: cannot rule out Emergency Medicine Management x Rest xRest Rest Rest x Pain relief: meds, heat, cold x Pain relief: meds, heat, cold x No advantage to NSAIDs x No advantage to NSAIDs x Exceptions: olecranon bursitis and xExceptions: olecranon bursitis and Exceptions: Exceptions: prepatellar bursitis have a prepatellar bursitis have a moderate risk of being infected moderate risk of being infected ((Staphylococcus aureus)) Staphylococcus aureus Emergency Medicine Management x Shoulder: immobilize few days x Shoulder: immobilize few days – Risk of adhesive capsulitis – Risk of adhesive capsulitis x Lateral epicondylitis: forearm brace x Lateral epicondylitis: forearm brace x Olecranon bursitis: compression xOlecranon bursitis: compression Olecranon Olecranon dressing dressing dressing dressing Emergency Medicine Management x De Quervain’s: splint wrist and xDe Quervain’s: splint wrist and De De thumb in 20oo dorsiflexion tthumb in 20 dorsiflexion thumb humb x Achilles tendonitis: heel lift or splint xAchilles tendonitis: heel lift or splint Achilles Achilles in slight plantar flexion iin slight plantar flexion in n Emergency Medicine Local Injection Emergency Medicine Local Injection x Lidocaine or steroid injection can xLidocaine or steroid injection can Lidocaine Lidocaine overcome refractory pain overcome refractory pain overcome overcome x Steroids universally given, often xSteroids universally given, often Steroids Steroids with great success with great success with with x No good prospective data to xNo good prospective data to No No support or refute therapeutic support or refute therapeutic benefit benefit benefit benefit Emergency Medicine Local Injection x Short course of oral steroid may xShort course of oral steroid may Short Short produce statistically similar results produce statistically similar results produce produce x Primary goal of steroid injection: xPrimary goal of steroid injection: Primary Primary rrelieve pain so patient can elieve pain so patient can participate in physical rehab participate in physical rehab participate participate Emergency Medicine Local Injection x Adjunct to other modalities: pain xAdjunct to other modalities: pain Adjunct Adjunct control, PT, exercise, OT, relative control, PT, exercise, OT, relative rest, immobilization rrest, immobilization rest, est, x Additional pain control: NSAIDs, xAdditional pain control: NSAIDs, Additional Additional acupuncture, ultrasound, ice, heat, acupuncture, ultrasound, ice, heat, electrical nerve stimulation electrical nerve stimulation electrical electrical Emergency Medicine Local Injection x Analgesics + exercise: better xAnalgesics + exercise: better Analgesics Analgesics results than exercise alone rresults than exercise alone results esults x Eliminate provoking factors x Eliminate provoking factors x Avoid repeat steroid injection xAvoid repeat steroid injection Avoid Avoid unless good prior response unless good prior response unless unless x Wait at least 6 weeks between xWait at least 6 weeks between Wait Wait injections in same site iinjections in same site injections njections Emergency Medicine Indications Diagnosis Diagnosis x Obtain fluid for analysis x Obtain fluid for analysis x Eliminate referred pain x Eliminate referred pain Therapy Therapy x Give pain relief x Give pain relief x Deliver therapeutic agents x Deliver therapeutic agents Emergency Medicine Contraindication: Absolute x Bacteremia x Bacteremia x Infectious arthritis x Infectious arthritis x Periarticular cellulitis x Periarticular cellulitis x Adjacent osteomyelitis xAdjacent osteomyelitis Adjacent Adjacent x Significant bleeding disorder x Significant bleeding disorder x Hypersensitivity to steroid x Hypersensitivity to steroid x Osteochondral fracture x Osteochondral fracture Emergency Medicine Contraindication: Relative x Violation of skin integrity x Violation of skin integrity x Chronic local infection x Chronic local infection x Anticoagulant use x Anticoagulant use x Poorly controlled diabetes x Poorly controlled diabetes x Internal joint derangement x Internal joint derangement x Hemarthrosis x Hemarthrosis x Preexisting tendon injury x Preexisting tendon injury x Partial tendon rupture x Partial tendon rupture Emergency Medicine Preparations x Local anesthetic x Local anesthetic x Hydrocortisone // corticosteroid x Hydrocortisone corticosteroid x Rapid anti-inflammatory effect x Rapid anti-inflammatory effect x Categorized by solubility and xCategorized by solubility and Categorized Categorized relative potency rrelative potency relative elative x High solubility short duration xHigh solubility short duration High High – Absorbed, dispersed more rapidly – Absorbed, dispersed more rapidly Emergency Medicine Preparations x Triamcinolone hexacetonide: least xTriamcinolone hexacetonide: least Triamcinolone Triamcinolone soluble, longest duration soluble, longest duration soluble, soluble, – Potential for subcutaneous atrophy – Potential for subcutaneous atrophy – Intra-articular injections only – Intra-articular injections only x Methylprednisolone acetate (Depox Methylprednisolone acetate (DepoMedrol®): reasonable first choice Medrol®): reasonable first choice Medrol®): Medrol®): for most ED indications ffor most ED indications for or Emergency Medicine Dosage x Large bursa: subacromial, xLarge bursa: subacromial, Large Large olecranon, trochanteric: 40 – 60 olecranon, trochanteric: 40 – 60 mg methylprednisolone mg methylprednisolone x Medium or wrist, knee, heel xMedium or wrist, knee, heel Medium Medium ganglion: 10 – 20 mg ganglion: 10 – 20 mg ganglion: ganglion: x Tendon sheath: de Quervain, xTendon sheath: de Quervain, Tendon Tendon flexor tenosynovitis: 5 – 15 mg fflexor tenosynovitis: 5 – 15 mg flexor lexor Emergency Medicine Site Preparation x Use careful aseptic technique x Use careful aseptic technique x Mark landmarks with skin pencil, xMark landmarks with skin pencil, Mark Mark ttincture of iodine, or thimerosal incture of iodine, or thimerosal (Merthiolate®) (sterile Q-tip) ((Merthiolate®) (sterile Q-tip) (Merthiolate®) Merthiolate®) x Clean point of entry: povidonex Clean point of entry: povidoneiodine (Betadine®) and alcohol iodine (Betadine®) and alcohol x Do not need sterile drapes x Do not need sterile drapes Emergency Medicine Technique x Make skin wheal: 1% lidocaine or xMake skin wheal: 1% lidocaine or Make Make 0.25% bupivacaine OR… 0.25% bupivacaine OR… 0.25% 0.25% …use topical vapocoolant: e.g., …use topical vapocoolant: e.g., use use Fluori-Methane® Fluori-Methane® Fluori-Methane® Fluori-Methane® x Use Z-tract technique: limits risk of xUse Z-tract technique: limits risk of Use Use soft tissue fistula soft tissue fistula soft soft x Agitate syringe prior to injection: xAgitate syringe prior to injection: Agitate Agitate steroid can precipitate or layer steroid can precipitate or layer steroid steroid Emergency Medicine Complications: Acute x Reaction to anesthetic: rare x Reaction to anesthetic: rare – Treat as in standard textbooks – Treat as in standard textbooks x Accidental IV injection x Accidental IV injection x Vagal reaction: have patient flat x Vagal reaction: have patient flat x Nerve injury: pain, paresthesias x Nerve injury: pain, paresthesias x Post injection flare: starts in hours, xPost injection flare: starts in hours, Post Post gone in days (~2%) gone in days (~2%) gone gone Emergency Medicine Complications: Delayed x Localized subcutaneous or xLocalized subcutaneous or Localized Localized cutaneous atrophy at injection site cutaneous atrophy at injection site cutaneous cutaneous x Small depression in skin with xSmall depression in skin with Small Small depigmentation, transparency, and depigmentation, transparency, and occasional telangiectasia occasional telangiectasia occasional occasional – Evident in 6 weeks to 3 months – Evident in 6 weeks to 3 months – Usually resolve within 6 months – Usually resolve within 6 months – Can be permanent – Can be permanent Emergency Medicine Complications: Delayed x Tendon rupture: low risk (<1%) xTendon rupture: low risk (<1%) Tendon Tendon x Dose-related x Dose-related x Related to direct tendon injection? x Related to direct tendon injection? x Limit injections to no more than xLimit injections to no more than Limit Limit once every 3 to 4 months once every 3 to 4 months once once x Avoid major stress-bearing xAvoid major stress-bearing Avoid Avoid tendons: Achilles, patellar ttendons: Achilles, patellar tendons: endons: Emergency Medicine Complications: Delayed x Systemic absorption slower than xSystemic absorption slower than Systemic Systemic with oral steroids with oral steroids with with x Can suppress hypopituitaryx Can suppress hypopituitaryadrenal axis for 2 to 7 days adrenal axis for 2 to 7 days x Can exacerbate hyperglycemia in xCan exacerbate hyperglycemia in Can Can diabetes diabetes diabetes diabetes x Abnormal uterine bleeding xAbnormal uterine bleeding Abnormal Abnormal reported rreported reported eported Emergency Medicine Some specific entities… Emergency Medicine Shoulder Region Emergency Medicine Shoulder Region Emergency Medicine Bicipital Tendonitis x Risk: repeatedly flex elbow against xRisk: repeatedly flex elbow against Risk: Risk: resistance: weightlifter, swimmer rresistance: weightlifter, swimmer resistance: esistance: x Tendon goes through bicipital xTendon goes through bicipital Tendon Tendon (intertubercular) groove ((intertubercular) groove (intertubercular) intertubercular) x Pain with elbow at 90° flexion, arm xPain with elbow at 90° flexion, arm Pain Pain internally // externally rotated iinternally externally rotated internally nternally Emergency Medicine Bicipital Tendonitis x Range of motion: normal or xRange of motion: normal or Range Range restricted rrestricted restricted estricted x Strength: normal x Strength: normal x Tenderness: bicipital groove x Tenderness: bicipital groove x Pain: elevate shoulder, reach hip xPain: elevate shoulder, reach hip Pain: Pain: pocket, pull a back zipper pocket, pull a back zipper pocket, pocket, Emergency Medicine Bicipital Tendonitis x Lipman test: "rolling" bicipital xLipman test: "rolling" bicipital Lipman Lipman ttendon produces localized endon produces localized tenderness ttenderness tenderness enderness x Yergason test: pain along bicipital xYergason test: pain along bicipital Yergason Yergason groove when patient attempts groove when patient attempts supination of forearm against supination of forearm against rresistance, holding elbow flexed at esistance, holding elbow flexed at 90° against side of body 90° against side of body 90° 90° Emergency Medicine Yergason Test Emergency Medicine Injection for bicipital tendonitis Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis x Calcific (calcareous) tendonitis: xCalcific (calcareous) tendonitis: Calcific Calcific hydroxyapatite deposits in one or hydroxyapatite deposits in one or more rotator cuff tendons more rotator cuff tendons more more – Commonly supraspinatus – Commonly supraspinatus x Sometimes rupture into adjacent xSometimes rupture into adjacent Sometimes Sometimes subacromial bursa subacromial bursa subacromial subacromial x Acute deltoid pain, tenderness x Acute deltoid pain, tenderness Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis x Clinically similar: difficult to xClinically similar: difficult to Clinically Clinically differentiate differentiate differentiate differentiate x Rotator cuff: teres minor, xRotator cuff: teres minor, Rotator Rotator supraspinatus, infraspinatus, supraspinatus, infraspinatus, subscapularis subscapularis subscapularis subscapularis – IInsert as conjoined tendon into –Insert as conjoined tendon into nsert Insert greater tuberosity of humerus greater tuberosity of humerus greater greater Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis Jobe’s sign, AKA “empty can test” Jobe’s sign, AKA “empty can test” x Abduct arm to 90oo iin the scapular x Abduct arm to 90 n the scapular plane, then internally rotate arms plane, then internally rotate arms to thumbs pointed downward tto thumbs pointed downward to o x Place downward force on arms: xPlace downward force on arms: Place Place weakness or pain if supraspinatus weakness or pain if supraspinatus weakness weakness Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis x Other tests: Neer, Hawkins x Other tests: Neer, Hawkins x Passively abduct arm to 90°, then xPassively abduct arm to 90°, then Passively Passively passively lower arm to 0° and ask passively lower arm to 0° and ask patient to actively abduct arm to patient to actively abduct arm to 30° 30° 30° 30° Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis x IIff can abduct to 30° but no further, xIf can abduct to 30° but no further, If suspect deltoid suspect deltoid suspect suspect x IIff cannot get to 30°, but if placed at xIf cannot get to 30°, but if placed at If 30° can actively abduct arm 30° can actively abduct arm further, suspect supraspinatus ffurther, suspect supraspinatus further, urther, x IIff uses hip to propel arm from 0° to xIf uses hip to propel arm from 0° to If beyond 30°, suspect beyond 30°, suspect supraspinatus supraspinatus supraspinatus supraspinatus Emergency Medicine Calcific Tendonitis Supraspinatus Tendonitis Subacromial Bursitis x Subacromial bursa: superior and xSubacromial bursa: superior and Subacromial Subacromial lateral to supraspinatus tendon llateral to supraspinatus tendon lateral ateral x Tendon and bursa in space xTendon and bursa in space Tendon Tendon between acromion process and between acromion process and head of humerus head of humerus head head x Prone to impingement x Prone to impingement Emergency Medicine Lateral Approach – Subacromial Bursitis Emergency Medicine Posterior Approach – Subacromial Bursitis Emergency Medicine Calcific Tendonitis / Supraspinatus Tendonitis / Subacromial Bursitis x Patient holds arm protectively xPatient holds arm protectively Patient Patient against chest wall against chest wall against against x May be incapacitating x May be incapacitating x All ROM disturbed, but internal xAll ROM disturbed, but internal All All rotation markedly limited rrotation markedly limited rotation otation x Diffuse perihumeral tenderness x Diffuse perihumeral tenderness x X-ray: hazy shadow x X-ray: hazy shadow Emergency Medicine Calcific Tendonitis / Supraspinatus Calcific Tendonitis / Subacromial Bursitis Emergency Medicine Rotator Cuff Tear Emergency Medicine Rotator Cuff Tear x Drop arm test: arm passively xDrop arm test: arm passively Drop Drop abducted at 90oo,, patient asked to abducted at 90 patient asked to abducted patient abducted patient maintain dropped arm maintain dropped arm represents large rotator cuff tear rrepresents large rotator cuff tear represents epresents x Shrug sign: attempt to abduct arm xShrug sign: attempt to abduct arm Shrug Shrug results in shrug only rresults in shrug only results esults Emergency Medicine Elbow and Wrist Emergency Medicine Elbow and Wrist Emergency Medicine Lateral Epicondylitis x Pain at insertion of extensor carpi xPain at insertion of extensor carpi Pain Pain rradialis and extensor digitorum adialis and extensor digitorum muscles muscles muscles muscles x Radiohumeral bursitis: tender over xRadiohumeral bursitis: tender over Radiohumeral Radiohumeral radiohumeral groove rradiohumeral groove radiohumeral adiohumeral x Tennis elbow: tender over lateral xTennis elbow: tender over lateral Tennis Tennis epicondyle epicondyle epicondyle epicondyle Emergency Medicine Lateral Epicondylitis Emergency Medicine Lateral Epicondylitis x History repetitive overhead motion: xHistory repetitive overhead motion: History History golfing, gardening, using tools golfing, gardening, using tools golfing, golfing, x Worse when middle finger xWorse when middle finger Worse Worse extended against resistance with extended against resistance with wrist and the elbow in extension wrist and the elbow in extension wrist wrist x Worse when wrist extended xWorse when wrist extended Worse Worse against resistance against resistance against against Emergency Medicine Injection for Lateral Epicondylitis Emergency Medicine Radial Tunnel Syndrome Emergency Medicine Medial Epicondylitis x ““Golfer's elbow” or “pitcher’s x Golfer's elbow” or “pitcher’s Golfer's Golfer's elbow” similar elbow” similar elbow” elbow” x Much less common x Much less common x Worse when wrist flexed against xWorse when wrist flexed against Worse Worse resistance rresistance resistance esistance x Tender medial epicondyle x Tender medial epicondyle Emergency Medicine Medial Epicondylitis Emergency Medicine Injection for Medial Epicondylitis Emergency Medicine Cubital Tunnel Syndrome x Ulnar nerve passes through cubital xUlnar nerve passes through cubital Ulnar Ulnar tunnel just behind ulnar elbow ttunnel just behind ulnar elbow tunnel unnel x Numbness and pain small and ring xNumbness and pain small and ring Numbness Numbness fingers ffingers fingers ingers x Initial treatment: rest, splint x Initial treatment: rest, splint Emergency Medicine Cubital Tunnel Syndrome Emergency Medicine Cubital Tunnel Syndrome Emergency Medicine Olecranon Bursitis x ““Student's” or “barfly elbow” x Student's” or “barfly elbow” Student's” Student's” x Most frequent site of septic bursitis x Most frequent site of septic bursitis x Aseptic: motion at elbow joint xAseptic: motion at elbow joint Aseptic: Aseptic: complete and painless complete and painless complete complete x Septic: all motion usually painful x Septic: all motion usually painful Emergency Medicine Olecranon Bursitis Aseptic olecranon bursitis Aseptic olecranon bursitis x Cosmetically bothersome, usually xCosmetically bothersome, usually Cosmetically Cosmetically resolves spontaneously rresolves spontaneously resolves esolves x IIff bothersome, aspiration and xIf bothersome, aspiration and If steroid injection speed resolution steroid injection speed resolution steroid steroid x Oral NSAID after steroid injection xOral NSAID after steroid injection Oral Oral does not affect outcome does not affect outcome does does Emergency Medicine Olecranon Bursitis Emergency Medicine Septic Olecranon Bursitis x Most common septic bursitis: xMost common septic bursitis: Most Most olecranon and prepatellar olecranon and prepatellar olecranon olecranon x 2oo tto acute trauma // skin breakage x 2 o acute trauma skin breakage x IImpossible to differentiate acute xImpossible to differentiate acute mpossible Impossible gouty olecranon bursitis from gouty olecranon bursitis from septic bursitis without laboratory septic bursitis without laboratory analysis analysis analysis analysis Emergency Medicine Ganglion Cysts x Swelling on dorsal wrist x Swelling on dorsal wrist x ~60% of wrist and hand soft tissue x~60% of wrist and hand soft tissue ~60% ~60% tumors ttumors tumors umors x Etiology obscure x Etiology obscure x Lined with mesothelium or xLined with mesothelium or Lined Lined synovium synovium synovium synovium x Arise from tendon sheaths or near xArise from tendon sheaths or near Arise Arise joint capsule jjoint capsule joint oint Emergency Medicine Ganglion Cysts Emergency Medicine Ganglion Cysts Emergency Medicine Carpal Tunnel Syndrome x Median nerve compression in xMedian nerve compression in Median Median fibro-osseous tunnel of wrist ffibro-osseous tunnel of wrist fibro-osseous ibro-osseous x Pain at wrist that sometimes xPain at wrist that sometimes Pain Pain radiates upward into forearm rradiates upward into forearm radiates adiates x Associated with tingling and xAssociated with tingling and Associated Associated paresthesias of palmar side of paresthesias of palmar side of iindex and middle fingers and radial ndex and middle fingers and radial half of the ring finger half of the ring finger half half Emergency Medicine Carpal Tunnel Syndrome Emergency Medicine Carpal Tunnel Syndrome Emergency Medicine Carpal Tunnel Syndrome x Patient wakes during night with xPatient wakes during night with Patient Patient burning or aching pain, numbness, burning or aching pain, numbness, and tingling and tingling and and x Positive Tinel sign: reproduce xPositive Tinel sign: reproduce Positive Positive ttingling and paresthesias by ingling and paresthesias by ttapping over median nerve at volar apping over median nerve at volar crease of wrist crease of wrist crease crease Emergency Medicine Carpal Tunnel Syndrome Emergency Medicine Carpal Tunnel Syndrome x Positive Phalen test: flexed wrists xPositive Phalen test: flexed wrists Positive Positive held against each other for several held against each other for several minutes in effort to provoke minutes in effort to provoke symptoms in median nerve symptoms in median nerve distribution distribution distribution distribution Emergency Medicine Carpal Tunnel Syndrome Emergency Medicine Carpal Tunnel Syndrome x May be idiopathic x May be idiopathic x Known causes: rheumatoid xKnown causes: rheumatoid Known Known arthritis pregnancy, diabetes, arthritis pregnancy, diabetes, hypothyroidism, acromegaly hypothyroidism, acromegaly hypothyroidism, hypothyroidism, Emergency Medicine Carpal Tunnel Syndrome x IInsert needle just radial or ulnar to xInsert needle just radial or ulnar to nsert Insert palmaris longus and proximal to palmaris longus and proximal to distal wrist crease distal wrist crease distal distal x Ulnar preferred: avoids nerve x Ulnar preferred: avoids nerve x Direct needle at 60° to skin xDirect needle at 60° to skin Direct Direct surface, point toward tip of middle surface, point toward tip of middle finger ffinger finger inger Emergency Medicine Carpal Tunnel Syndrome Emergency Medicine de Quervain’s Disease Chronic tenoChronic tenosynovitis due to synovitis due to synovitis synovitis narrowed tendon narrowed tendon sheaths around sheaths around abductor policis abductor policis llongus and ongus and extensor pollicis extensor pollicis brevis muscles brevis muscles brevis brevis Emergency Medicine de Quervain’s Disease x 1st dorsal compartment x 1st dorsal compartment x Radial border of anatomic snuffbox x Radial border of anatomic snuffbox x 1st compartment may cross over x 1st compartment may cross over 2nd compartment (ECRL/B) 2nd compartment (ECRL/B) proximal to extensor retinaculum proximal to extensor retinaculum x Steroid injections relieve most xSteroid injections relieve most Steroid Steroid symptoms symptoms symptoms symptoms Emergency Medicine de Quervain’s Disease Finkelstein’s Test Emergency Medicine de Quervain’s Disease Emergency Medicine Trigger Finger x Digital flexor tenosynovitis xDigital flexor tenosynovitis Digital Digital x Stenosed tendon sheath x Stenosed tendon sheath – Palmar surface over MC head – Palmar surface over MC head x Intermittent tendon “catch” x Intermittent tendon “catch” x ““Locks” on awakening x Locks” on awakening x Most frequent: ring and middle x Most frequent: ring and middle Emergency Medicine Trigger Finger Emergency Medicine Trigger Finger x Tendon sheath walls lined with xTendon sheath walls lined with Tendon Tendon synovial cells synovial cells synovial synovial x Tendon unable to glide within xTendon unable to glide within Tendon Tendon sheath sheath x IInitial treatment: splint, moist heat, xInitial treatment: splint, moist heat, nitial Initial NSAID NSAID NSAID NSAID x Steroid for recalcitrant cases x Steroid for recalcitrant cases Emergency Medicine Hip and Groin Emergency Medicine Hip and Groin Emergency Medicine Hip and Groin Emergency Medicine Hip and Groin Emergency Medicine Trochanteric Bursitis x Second leading cause of lateral hip xSecond leading cause of lateral hip Second Second pain after osteoarthritis pain after osteoarthritis pain pain x Discrete tenderness to deep xDiscrete tenderness to deep Discrete Discrete palpation palpation palpation palpation x Principal bursa between gluteus xPrincipal bursa between gluteus Principal Principal maximus and posterolateral maximus and posterolateral prominence of greater trochanter prominence of greater trochanter prominence prominence Emergency Medicine Trochanteric Bursitis x Pain usually chronic x Pain usually chronic x Pathology in hip abductors x Pathology in hip abductors x May radiate down thigh, lateral or xMay radiate down thigh, lateral or May May posterior posterior posterior posterior x Worse with lying on side, stepping xWorse with lying on side, stepping Worse Worse from curb, descending steps ffrom curb, descending steps from rom Emergency Medicine Trochanteric Bursitis x Patrick fabere sign ((ffllexion, exion, x Patrick fabere sign llexion, exion, abduction, external rotation, and abduction, external rotation, and abduction, xternal otation, abduction, xternal otation, extension) may be negative extension) may be negative x Passive ROM relatively painless x Passive ROM relatively painless x Active abduction when lying on xActive abduction when lying on Active Active opposite side pain opposite side pain x Sharp external rotation pain xSharp external rotation pain Sharp Sharp Emergency Medicine Trochanteric Bursitis Emergency Medicine Ischiogluteal Bursitis x Weaver's bottom // tailor’s seat: xWeaver's bottom tailor’s seat: Weaver's Weaver's pain center of buttock radiating pain center of buttock radiating down back of leg down back of leg down down x Often mistaken for back strain, xOften mistaken for back strain, Often Often herniated disk herniated disk herniated herniated x Pain worse with sitting on hard xPain worse with sitting on hard Pain Pain surface, bending forward, standing surface, bending forward, standing on tiptoe on tiptoe on on Emergency Medicine Ischiogluteal Bursitis x Tenderness over ischial tuberosity x Tenderness over ischial tuberosity x IIschiogluteal bursa adjacent to xIschiogluteal bursa adjacent to schiogluteal Ischiogluteal iischial tuberosity, overlies sciatic // schial tuberosity, overlies sciatic posterior femoral cutaneous posterior femoral cutaneous nerves nerves nerves nerves Emergency Medicine Some Other Back Pains Emergency Medicine Legs and Feet Emergency Medicine Knee Emergency Medicine Bursae of the Knee Emergency Medicine Prepatellar Bursitis x Housemaid’s knee // nun’s knee: xHousemaid’s knee nun’s knee: Housemaid’s Housemaid’s swelling with effusion of superficial swelling with effusion of superficial bursa over lower pole of patella bursa over lower pole of patella bursa bursa x Passive motion fully preserved x Passive motion fully preserved x Pain mild except during extreme xPain mild except during extreme Pain Pain knee flexion or direct pressure knee flexion or direct pressure knee knee Emergency Medicine Prepatellar Bursitis x Pressure from repetitive kneeling xPressure from repetitive kneeling Pressure Pressure on a firm surface: rug cutter's knee on a firm surface: rug cutter's knee on on x Rarely direct trauma x Rarely direct trauma x Second most common site for xSecond most common site for Second Second septic bursitis septic bursitis septic septic Emergency Medicine Prepatellar Bursitis Emergency Medicine Prepatellar Bursitis Emergency Medicine Baker’s Cyst x Pseudothrombophlebitis syndrome x Pseudothrombophlebitis syndrome x Herniated fluid-filled sacs of xHerniated fluid-filled sacs of Herniated Herniated articular synovial membrane that articular synovial membrane that extend into popliteal fossa extend into popliteal fossa extend extend x Causes: trauma, rheumatoid xCauses: trauma, rheumatoid Causes: Causes: arthritis, gout, osteoarthritis arthritis, gout, osteoarthritis arthritis, arthritis, x Pain worse with active knee flexion x Pain worse with active knee flexion Emergency Medicine Baker’s Cyst x Can mimic deep venous xCan mimic deep venous Can Can thrombosis tthrombosis thrombosis hrombosis x Ultrasound eseential x Ultrasound eseential x Many resolve over weeks x Many resolve over weeks x May require surgery x May require surgery x Steroid injections not performed: xSteroid injections not performed: Steroid Steroid risk of neurovascular injury rrisk of neurovascular injury risk isk Emergency Medicine Baker’s Cyst Emergency Medicine Baker’s Cyst Emergency Medicine Anserine Bursitis x Cavalryman's disease // pes xCavalryman's disease pes Cavalryman's Cavalryman's bursitis // goosefoot bursitis: obese bursitis goosefoot bursitis: obese women with large thighs, athletes women with large thighs, athletes who run who run who who x Anteromedial knee, inferior to joint xAnteromedial knee, inferior to joint Anteromedial Anteromedial lline at insertion of sartorius, ine at insertion of sartorius, semitendinous, and gracilis tendon semitendinous, and gracilis tendon semitendinous, semitendinous, Emergency Medicine Anserine Bursitis x Abrupt knee pain, xAbrupt knee pain, Abrupt Abrupt llocal tenderness 4 ocal tenderness 4 tto 5 cm below o 5 cm below medial aspect of medial aspect of tibial plateau ttibial plateau tibial ibial x Knee flexion xKnee flexion Knee Knee exacerbates exacerbates exacerbates exacerbates Emergency Medicine Iliotibial Band Syndrome x Lateral knee pain x Lateral knee pain x Cyclists, dancers, distance xCyclists, dancers, distance Cyclists, Cyclists, runners, football players rrunners, football players runners, unners, x Pain worse climbing stairs x Pain worse climbing stairs x Tenderness when patient supine, xTenderness when patient supine, Tenderness Tenderness knee flexed to 90oo knee flexed to 90 knee knee Emergency Medicine Iliotibial Band Syndrome Emergency Medicine Iliotibial Band Syndrome Emergency Medicine Ankle and Foot Emergency Medicine Ankle Emergency Medicine Peroneal Tendonitis x Peroneal tendons cross behind xPeroneal tendons cross behind Peroneal Peroneal lateral malleolus llateral malleolus lateral ateral x Running, jumping, sprain x Running, jumping, sprain x Holding foot up and out against xHolding foot up and out against Holding Holding downward pressure causes pain downward pressure causes pain downward downward Emergency Medicine Ankle Emergency Medicine Peroneal Tendon Rupture x Torn retinaculum x Torn retinaculum x Have patient dorsiflex and plantar xHave patient dorsiflex and plantar Have Have flex with foot in inversion fflex with foot in inversion flex lex x Feel for “snapping” behind lateral xFeel for “snapping” behind lateral Feel Feel malleolus malleolus malleolus malleolus Emergency Medicine Foot Emergency Medicine Retrocalcaneal Bursitis x Ankle overuse: excessive walking, xAnkle overuse: excessive walking, Ankle Ankle running, or jumping rrunning, or jumping running, unning, x Heel pain: especially with walking, xHeel pain: especially with walking, Heel Heel running, palpation rrunning, palpation running, unning, x Haglund disease: bony ridge on xHaglund disease: bony ridge on Haglund Haglund posterosuperior calcaneus posterosuperior calcaneus posterosuperior posterosuperior x Treatment: open heels (clogs), xTreatment: open heels (clogs), Treatment: Treatment: bare feet, sandals, or heel lift bare feet, sandals, or heel lift bare bare Emergency Medicine Retrocalcaneal Bursitis Emergency Medicine Plantar Fasciitis x Policeman's heel // soldier's heel: xPoliceman's heel soldier's heel: Policeman's Policeman's associated with heel spurs associated with heel spurs associated associated x Degenerated plantar fascial band xDegenerated plantar fascial band Degenerated Degenerated att origin on medial calcaneous at origin on medial calcaneous at a x Heel pain worse in morning and xHeel pain worse in morning and Heel Heel after long periods of rest after long periods of rest after after x May be relieved with activity x May be relieved with activity Emergency Medicine Plantar Fasciitis Emergency Medicine Plantar Fasciitis Emergency Medicine Plantar Fasciitis x Microtears in fascia from overuse? x Microtears in fascia from overuse? x Eliminate precipitators, rest, xEliminate precipitators, rest, Eliminate Eliminate strength and stretching exercises, strength and stretching exercises, arch supports, and night splints arch supports, and night splints arch arch x Sometimes need steroid injection x Sometimes need steroid injection x Risk of plantar fascia rupture and xRisk of plantar fascia rupture and Risk Risk fat pad atrophy ffat pad atrophy fat at Emergency Medicine Tarsal Tunnel Syndrome Emergency Medicine Tarsal Tunnel Syndrome x Between medial malleolus and xBetween medial malleolus and Between Between flexor retinaculum fflexor retinaculum flexor lexor x Vague pain in sole of foot: burning xVague pain in sole of foot: burning Vague Vague orr tingling or tingling or o x Worse with activity, especially xWorse with activity, especially Worse Worse standing, walking for long periods standing, walking for long periods standing, standing, x Tender along course of nerve x Tender along course of nerve Emergency Medicine Tarsal Tunnel Syndrome x Between medial malleolus and xBetween medial malleolus and Between Between flexor retinaculum fflexor retinaculum flexor lexor x Vague pain in sole of foot: burning xVague pain in sole of foot: burning Vague Vague orr tingling or tingling or o x Worse with activity, especially xWorse with activity, especially Worse Worse standing, walking for long periods standing, walking for long periods standing, standing, x Tender along course of nerve x Tender along course of nerve Emergency Medicine Achilles Tendonitis Emergency Medicine Fibromyalgia Emergency Medicine Fibromyalgia Emergency Medicine Emergency Medicine Fibromyalgia x Pain in muscles, joints, ligaments xPain in muscles, joints, ligaments Pain Pain and tendons and tendons and and x ““Tender points“ x Tender points“ – Knees, elbows, hips, neck – Knees, elbows, hips, neck x 5% of population, including kids x 5% of population, including kids x Main symptom: sensitivity to pain x Main symptom: sensitivity to pain Emergency Medicine Fibromyalgia x Pain: chronic, deep or burning, xPain: chronic, deep or burning, Pain: Pain: migratory, intermittent migratory, intermittent migratory, migratory, x Fatigue, poor sleep x Fatigue, poor sleep x Numbness or tingling x Numbness or tingling x ““Poor blood flow” x Poor blood flow” x Sensitivity to odors, bright lights, xSensitivity to odors, bright lights, Sensitivity Sensitivity loud noises, medicines lloud noises, medicines loud oud Emergency Medicine Fibromyalgia x Jaw pain x Jaw pain x Dry eyes x Dry eyes x Difficulty focusing x Difficulty focusing x Dizziness x Dizziness x Balance problems x Balance problems x Chest pain x Chest pain x Rapid or irregular heartbeat x Rapid or irregular heartbeat Emergency Medicine Fibromyalgia x Shortness of breath x Shortness of breath x Difficulty swallowing x Difficulty swallowing x Heartburn x Heartburn x Gas x Gas x Cramping abdominal pain x Cramping abdominal pain x Alternating diarrhea & constipation xAlternating diarrhea & constipation Alternating Alternating x Frequent urination x Frequent urination Emergency Medicine Fibromyalgia x Pain in bladder area x Pain in bladder area x Urgency x Urgency x Pelvic pain x Pelvic pain x Painful menstrual periods x Painful menstrual periods x Painful sexual intercourse x Painful sexual intercourse x Depression x Depression x Anxiety x Anxiety Emergency Medicine Compare to Somatization Somatization Fibromyalgia Vomiting Abdominal pain Nausea Bloating Diarrhea Leg / arm pain Back pain Emergency Medicine Compare to Somatization Somatization Fibromyalgia Joint pain Dysuria Headaches Breathlessness Palpitations Chest pain Dizziness Emergency Medicine Compare to Somatization Somatization Fibromyalgia Amnesia Dysphagia Vision changes Weak muscles Sexual apathy Dyspareunia Impotence Emergency Medicine Compare to Somatization Somatization Fibromyalgia Dysmenorrhea Dysmenorrhea Irregular Irregular menstruation menstruation Excessive Excessive menstrual flow menstrual Emergency Medicine Fibromyalgia x Treatment x Treatment Emergency Medicine Reflex Sympathetic Dystrophy x Causalgia x Causalgia x Shoulder-hand syndrome x Shoulder-hand syndrome x Sudeck's atrophy x Sudeck's atrophy x Post-traumatic pain syndrome x Post-traumatic pain syndrome x Complex regional pain syndrome xComplex regional pain syndrome Complex Complex type II and type II ttype and type II type ype x Sympathetically maintained pain xSympathetically maintained pain Sympathetically Sympathetically Emergency Medicine Reflex Sympathetic Dystrophy x Distal extremity pain, tenderness x Distal extremity pain, tenderness x Bone demineralization, trophic skin xBone demineralization, trophic skin Bone Bone changes, vasomotor instability changes, vasomotor instability changes, changes, x Precipitating event in 2/3: injury, xPrecipitating event in 2/3: injury, Precipitating Precipitating stroke, MI, local trauma, fracture stroke, MI, local trauma, fracture stroke, stroke, x Associated with emotional liability, xAssociated with emotional liability, Associated Associated depression, anxiety depression, anxiety depression, depression, Emergency Medicine Reflex Sympathetic Dystrophy x Treatments: medication, physical xTreatments: medication, physical Treatments: Treatments: ttherapy, sympathetic nerve blocks, herapy, sympathetic nerve blocks, psychological support psychological support psychological psychological – Possible sympathectomy or dorsal –Possible sympathectomy or dorsal Possible Possible column stimulator column stimulator column column x Pain Clinic with coordinated plan xPain Clinic with coordinated plan Pain Pain may be helpful may be helpful may may Emergency Medicine Harry Lawrence: Pharmacist in Charlotte, NC Nelson “Eran Deran” Mead, retired in Oregon Joe Lex, Philadelphia Valley Forge General Hospital Phoenixville, PA 1968 Emergency Medicine ...
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This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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