Project: Ghana Emergency Medicine Collaborative
Document Title: Bursitis, Tendonitis, Fibromyalgia, and RSD
Author(s): Joe Lex, MD, 2013 (Temple University School of Medicine)
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Bursitis, Tendonitis,
Fibromyalgia, and RSD
Joe Lex, MD, FAAEM
Temple University School of Medicine
Philadelphia, PA
3
Emergency Medicine
Objectives
1. Explain how bursitis and
tendonitis are similar
2. Explain how bursitis and
tendonitis differ from from another
3. List phases in development and
healing of bursitis and tendonitis
4
Emergency Medicine
Objectives
4. List common types of bursitis and
tendonitis found at the:
 Shoulder
Hip
 Elbow
Knee
 Wrist
Ankle
5. List indications / contraindications
for injection therapy of bursitis
and tendonitis
5
Emergency Medicine
Objectives
6. Describe typical findings in a
patient with fibromyalgia
7. Describe typical findings in a
patient with reflex sympathetic
dystrophy
6
Emergency Medicine
Sports
Society more athletic
Physical activity  health benefits
Overuse syndromes increase
25% to 50% of participants will
experience tendonitis or bursitis
7
Emergency Medicine
Workplace
Musculoskeletal disorders from…
…repetitive motions
…localized contact stress
…awkward positions
…vibrations
…forceful exertions
Ergonomic design  incidence
8
Emergency Medicine
Bursae
Closed, round, flat sacs
Lined by synovium
May or may not communicate with
synovial cavity
Occur at areas of friction between
skin and underlying ligaments /
bone
9
Emergency Medicine
Bursae
Permit lubricated movement over
areas of potential impingement
Many are nameless
~78 on each side of body
New bursae may form anywhere
from frequent irritation
10
Emergency Medicine
Bursitis
Inflamed by…
…chronic friction
…trauma
…crystal
deposition
…infection
…systemic
disease:
rheumatoid
arthritis,
psoriatic
arthritis, gout
ankylosing
spondylitis
11
Emergency Medicine
Bursitis
Inflammation causes
bursal synovial cells to
thicken
Excess fluid
accumulates inside and
around affected bursae
Bemoeial (Wikipedia)
12
Emergency Medicine
Tendons
Tendon sheaths composed of
same synovial cells as bursae
Inflamed in similar manner
Tendonitis: inflammation of tendon
only
Tenosynovitis: inflammation of
tendon plus its sheath
13
Emergency Medicine
Tendons
Inflammatory changes involving
sheath well documented
Inflammatory lesions of tendon
alone not well documented
Distinction uncertain: terms
tendonitis and tenosynovitis used
interchangeably
14
Emergency Medicine
Tendons
Most overuse syndromes are NOT
inflammatory
Biopsy: no inflammatory cells
High glutamate concentrations
NSAIDs / steroids: no advantage
TendonITIS a misnomer
15
Emergency Medicine
Gray's Anatomy (Wikipedia)
16
Bursitis / Tendonitis
Most common causes:
mechanical overload and
repetitive microtrauma
Most injuries
multifactorial
17
Emergency Medicine
Bursitis / Tendonitis
Intrinsic factors: malalignment,
poor muscle flexibility, muscle
weakness or imbalance
Extrinsic factors: design of
equipment or workplace and
excessive duration, frequency, or
intensity of activity
18
Emergency Medicine
Immediate Phase
Release of chemotactic and
vasoactive chemical mediators
Vasodilation and cellular edema
PMNs perpetuate process
Lasts 48 hours to 2 weeks
Repetitive insults prolong
inflammatory stage
19
Emergency Medicine
Healing Phase
Classic inflammatory signs: pain,
warmth, erythema, swelling
Healing goes through proliferative
and maturation
6 to 12 weeks: organization and
collagen cross-linking mature to
preinjury strength
20
Emergency Medicine
History
Changes in sports activity, work
activities, or workplace
Cause not always found
Pregnancy, quinolone therapy,
connective tissue disorders,
systemic illness
21
Emergency Medicine
History
Most common complaint: PAIN
Acute or chronic
Frequently more severe after
periods of rest
May resolve quickly after initial
movement only to become
throbbing pain after exercise
22
Emergency Medicine
Articular vs. Periarticular
In joint capsule
 Joint pain / warmth /
swelling
 Worse with active &
passive movement
 All parts of joint
involved
Periarticular
 Pain not uniform
across joint
 Pain only certain
movements
 Pain character &
radiation vary
23
Emergency Medicine
Physical Exam
Careful palpation
Range of motion
Heat, warmth, redness
24
Emergency Medicine
Lab Studies
Screening tests: CBC, CRP, ESR
Chronic rheumatic disease: mild
anemia
Rheumatoid factor, antinuclear
antibody, antistreptolysin O titers,
and Lyme serologies for follow-up
Serum uric acid: not helpful
25
Emergency Medicine
Synovial Fluid
Especially crystalline, suppurative
etiology
Appearance, cell count and diff,
crystal analysis, Gram’s stain
– Positive Gram’s: diagnostic
– Negative Gram’s: cannot rule out
26
Emergency Medicine
Management
Rest
Pain relief: meds, heat, cold
No advantage to NSAIDs
Exceptions: olecranon bursitis and
prepatellar bursitis have a
moderate risk of being infected
(Staphylococcus aureus)
27
Emergency Medicine
Management
Shoulder: immobilize few days
– Risk of adhesive capsulitis
Lateral epicondylitis: forearm
brace
Olecranon bursitis: compression
dressing
28
Emergency Medicine
Management
De Quervain’s: splint wrist and
thumb in 20o dorsiflexion
Achilles tendonitis: heel lift or splint
in slight plantar flexion
29
Emergency Medicine
Local
Injection
30
Emergency Medicine
Local Injection
Lidocaine or steroid injection can
overcome refractory pain
Steroids universally given, often
with great success
No good prospective data to
support or refute therapeutic
benefit
31
Emergency Medicine
Local Injection
Short course of oral steroid may
produce statistically similar results
Primary goal of steroid injection:
relieve pain so patient can
participate in physical rehab
32
Emergency Medicine
Local Injection
Adjunct to other modalities: pain
control, PT, exercise, OT, relative
rest, immobilization
Additional pain control: NSAIDs,
acupuncture, ultrasound, ice, heat,
electrical nerve stimulation
33
Emergency Medicine
Local Injection
Analgesics + exercise: better
results than exercise alone
Eliminate provoking factors
Avoid repeat steroid injection
unless good prior response
Wait at least 6 weeks between
injections in same site
34
Emergency Medicine
Indications
Diagnosis
Obtain fluid for analysis
Eliminate referred pain
Therapy
Give pain relief
Deliver therapeutic agents
35
Emergency Medicine
Contraindication: Absolute
Bacteremia
Infectious arthritis
Periarticular cellulitis
Adjacent osteomyelitis
Significant bleeding disorder
Hypersensitivity to steroid
Osteochondral fracture
36
Emergency Medicine
Contraindication: Relative
 Violation of skin integrity
 Chronic local infection
 Anticoagulant use
 Poorly controlled diabetes
 Internal joint derangement
 Hemarthrosis
 Preexisting tendon injury
 Partial tendon rupture
37
Emergency Medicine
Preparations
Local anesthetic
Hydrocortisone / corticosteroid
Rapid anti-inflammatory effect
Categorized by solubility and
relative potency
High solubility  short duration
– Absorbed, dispersed more rapidly
38
Emergency Medicine
Preparations
Triamcinolone hexacetonide: least
soluble, longest duration
– Potential for subcutaneous atrophy
– Intra-articular injections only
Methylprednisolone acetate
(Depo-Medrol®): reasonable first
choice for most ED indications
39
Emergency Medicine
Dosage
Large bursa: subacromial,
olecranon, trochanteric: 40 – 60
mg methylprednisolone
Medium or wrist, knee, heel
ganglion: 10 – 20 mg
Tendon sheath: de Quervain,
flexor tenosynovitis: 5 – 15 mg
40
Emergency Medicine
Site Preparation
Use careful aseptic technique
Mark landmarks with skin pencil,
tincture of iodine, or thimerosal
(Merthiolate®) (sterile Q-tip)
Clean point of entry: povidoneiodine (Betadine®) and alcohol
Do not need sterile drapes
41
Emergency Medicine
Technique
Make skin wheal: 1% lidocaine or
0.25% bupivacaine OR…
…use topical vapocoolant: e.g.,
Fluori-Methane®
Use Z-tract technique: limits risk of
soft tissue fistula
Agitate syringe prior to injection:
steroid can precipitate or layer
42
Emergency Medicine
Complications: Acute
Reaction to anesthetic: rare
– Treat as in standard textbooks
Accidental IV injection
Vagal reaction: have patient flat
Nerve injury: pain, paresthesias
Post injection flare: starts in hours,
gone in days (~2%)
43
Emergency Medicine
Complications: Delayed
Localized subcutaneous or
cutaneous atrophy at injection site
Small depression in skin with
depigmentation, transparency, and
occasional telangiectasia
– Evident in 6 weeks to 3 months
– Usually resolve within 6 months
– Can be permanent
44
Emergency Medicine
Complications: Delayed
Tendon rupture: low risk (<1%)
Dose-related
Related to direct tendon injection?
Limit injections to no more than
once every 3 to 4 months
Avoid major stress-bearing
tendons: Achilles, patellar
45
Emergency Medicine
Complications: Delayed
Systemic absorption slower than
with oral steroids
Can suppress hypopituitaryadrenal axis for 2 to 7 days
Can exacerbate hyperglycemia in
diabetes
Abnormal uterine bleeding
reported
46
Emergency Medicine
Some
specific
entities…
47
Emergency Medicine
Shoulder Region
Gray's Anatomy (Wikipedia)
48
Emergency Medicine
Shoulder Region
“Bursitis of the shoulder”
•Supraspinatus tendon and subdeltoid bursa
“Bicipital tendonitis”
•Tendon of long head of biceps
49
Emergency Medicine
Bicipital Tendonitis
Risk: repeatedly flex elbow against
resistance: weightlifter, swimmer
Tendon goes through bicipital
(intertubercular) groove
Pain with elbow at 90° flexion,
arm internally / externally rotated
50
Emergency Medicine
Bicipital Tendonitis
Range of motion: normal or
restricted
Strength: normal
Tenderness: bicipital groove
Pain: elevate shoulder, reach hip
pocket, pull a back zipper
51
Emergency Medicine
Bicipital Tendonitis
Lipman test: "rolling" bicipital
tendon produces localized
tenderness
Yergason test: pain along bicipital
groove when patient attempts
supination of forearm against
resistance, holding elbow flexed at
90° against side of body
52
Emergency Medicine
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
Calcific (calcareous) tendonitis:
hydroxyapatite deposits in one or
more rotator cuff tendons
– Commonly supraspinatus
Sometimes rupture into adjacent
subacromial bursa
Acute deltoid pain, tenderness
53
Emergency Medicine
Calcific Tendonitis
54
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
Clinically similar: difficult to
differentiate
Rotator cuff: teres minor,
supraspinatus, infraspinatus,
subscapularis
– Insert as conjoined tendon into
greater tuberosity of humerus
55
Emergency Medicine
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
Jobe’s sign, AKA “empty can test”
Abduct arm to 90o in the scapular
plane, then internally rotate arms
to thumbs pointed downward
Place downward force on arms:
weakness or pain if supraspinatus
56
Emergency Medicine
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
Other tests: Neer, Hawkins
Passively abduct arm to 90°, then
passively lower arm to 0° and ask
patient to actively abduct arm to
30°
57
Emergency Medicine
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
If can abduct to 30° but no
further, suspect deltoid
If cannot get to 30°, but if placed
at 30° can actively abduct arm
further, suspect supraspinatus
If uses hip to propel arm from 0°
to beyond 30°, suspect
supraspinatus
58
Emergency Medicine
Calcific Tendonitis
Supraspinatus Tendonitis
Subacromial Bursitis
Subacromial bursa: superior and
lateral to supraspinatus tendon
Tendon and bursa in space
between acromion process and
head of humerus
Prone to impingement
59
Emergency Medicine
Calcific Tendonitis / Supraspinatus
Tendonitis / Subacromial Bursitis
Patient holds arm protectively
against chest wall
May be incapacitating
All ROM disturbed, but internal
rotation markedly limited
Diffuse perihumeral tenderness
X-ray: hazy shadow
60
Emergency Medicine
Calcific Tendonitis / Supraspinatus
Tendonitis / Subacromial Bursitis
61
Drongo (Wikipedia)
Emergency Medicine
Rotator Cuff Tear
62
Nucleus Communications (Wikimedia Commons)
Emergency Medicine
Rotator Cuff Tear
Drop arm test: arm passively
abducted at 90o, patient asked to
maintain  dropped arm
represents large rotator cuff tear
Shrug sign: attempt to abduct arm
results in shrug only
63
Emergency Medicine
Elbow and Wrist
• “Student’s elbow”
Olecranon bursa
• “Tennis Elbow”
Extendor tendons posteriorly at ischial tuberosity
• De Quervain’s tenosynovitis
Tendons of extensor pollicis brevis and abductor pollicis longus
• “Acute tendonitis of the wrist”
Flexor carpi ulnaris and other wrist flexor tendons
64
Emergency Medicine
Elbow and Wrist
Pngbot (Wikipedia)
65
Emergency Medicine
Lateral Epicondylitis
Pain at insertion of extensor carpi
radialis and extensor digitorum
muscles
Radiohumeral bursitis: tender over
radiohumeral groove
Tennis elbow: tender over lateral
epicondyle
66
Emergency Medicine
Lateral Epicondylitis
67
Gray's Anatomy (Wikipedia)
Emergency Medicine
Lateral Epicondylitis
History repetitive overhead motion:
golfing, gardening, using tools
Worse when middle finger
extended against resistance with
wrist and the elbow in extension
Worse when wrist extended
against resistance
68
Emergency Medicine
Radial Tunnel Syndrome
69
Gray's Anatomy (Wikipedia)
Emergency Medicine
Medial Epicondylitis
“Golfer's elbow” or “pitcher’s
elbow” similar
Much less common
Worse when wrist flexed against
resistance
Tender medial epicondyle
70
Emergency Medicine
Cubital Tunnel Syndrome
Ulnar nerve passes through cubital
tunnel just behind ulnar elbow
Numbness and pain small and ring
fingers
Initial treatment: rest, splint
71
Emergency Medicine
Cubital Tunnel Syndrome
Area of Pain
Schplook (Open Clipart)
Area of Numbness
Schplook (Open Clipart)
Emergency Medicine
72
Olecranon Bursitis
“Student's” or “barfly elbow”
Most frequent site of septic bursitis
Aseptic: motion at elbow joint
complete and painless
Septic: all motion usually painful
73
Emergency Medicine
Olecranon Bursitis
Aseptic olecranon bursitis
Cosmetically bothersome, usually
resolves spontaneously
If bothersome, aspiration and
steroid injection speed resolution
Oral NSAID after steroid injection
does not affect outcome
74
Emergency Medicine
Olecranon Bursitis
Source Undetermined
75
Emergency Medicine
Septic Olecranon Bursitis
Most common septic bursitis:
olecranon and prepatellar
2o to acute trauma / skin breakage
Impossible to differentiate acute
gouty olecranon bursitis from
septic bursitis without laboratory
analysis
76
Emergency Medicine
77
Arcadian (Wikimedia Commons)
Ganglion Cysts
Swelling on dorsal wrist
~60% of wrist and hand soft tissue
tumors
Etiology obscure
Lined with mesothelium or
synovium
Arise from tendon sheaths or near
joint capsule
78
Emergency Medicine
Ganglion Cysts
79
Source Undetermined
Emergency Medicine
Ganglion Cysts
Cieslaw (Wikipedia)
80
Emergency Medicine
Source Undetermined
Source Undetermined
81
Source Undetermined
Carpal Tunnel Syndrome
Median nerve compression in
fibro-osseous tunnel of wrist
Pain at wrist that sometimes
radiates upward into forearm
Associated with tingling and
paresthesias of palmar side of
index and middle fingers and radial
half of the ring finger
82
Emergency Medicine
Carpal Tunnel Syndrome
83
BruceBlaus (Wikipedia)
Emergency Medicine
Carpal Tunnel Syndrome
Numbness
Schplook (Open Clipart)
Pain
Schplook (Open Clipart)
Emergency Medicine
84
Carpal Tunnel Syndrome
Patient wakes during night with
burning or aching pain, numbness,
and tingling
Positive Tinel sign: reproduce
tingling and paresthesias by
tapping over median nerve at volar
crease of wrist
85
Emergency Medicine
Carpal Tunnel Syndrome
www.hulc.co.uk (Wikimedia Commons)
86
Emergency Medicine
Carpal Tunnel Syndrome
Positive Phalen test: flexed wrists
held against each other for several
minutes in effort to provoke
symptoms in median nerve
distribution
87
Emergency Medicine
Carpal Tunnel Syndrome
Source Undetermined
88
Emergency Medicine
Carpal Tunnel Syndrome
May be idiopathic
Known causes: rheumatoid
arthritis pregnancy, diabetes,
hypothyroidism, acromegaly
89
Emergency Medicine
Carpal Tunnel Syndrome
Insert needle just radial or ulnar to
palmaris longus and proximal to
distal wrist crease
Ulnar preferred: avoids nerve
Direct needle at 60° to skin
surface, point toward tip of middle
finger
90
Emergency Medicine
de Quervain’s Disease
Chronic tenosynovitis due to
narrowed tendon
sheaths around
abductor policis
longus and
extensor pollicis
brevis muscles
Gray’s Anatomy (Wikipedia)
91
Emergency Medicine
de Quervain’s Disease
1st dorsal compartment
Radial border of anatomic snuffbox
1st compartment may cross over
2nd compartment (ECRL/B)
proximal to extensor retinaculum
Steroid injections relieve most
symptoms
92
Emergency Medicine
de Quervain’s Disease
Source Undetermined
Finkelstein’s Test
93
Emergency Medicine
Trigger Finger
Digital flexor tenosynovitis
Stenosed tendon sheath
– Palmar surface over MC head
Intermittent tendon “catch”
“Locks” on awakening
Most frequent: ring and middle
94
Emergency Medicine
Trigger Finger
www.med.und.edu
95
Emergency Medicine
Trigger Finger
Tendon sheath walls lined with
synovial cells
Tendon unable to glide within
sheath
Initial treatment: splint, moist heat,
NSAID
Steroid for recalcitrant cases
96
Emergency Medicine
Hip and Groin
• “ischial bursitis”
Located medial to the sciatic nerve
• “trochanteric bursitis”
Gluteus medius and minimus tendons
• “iliopectineal bursitis”
Located lateral to femoral vessels
97
Emergency Medicine
Hip and Groin
98
Beth Ohara (Wikipedia)
Emergency Medicine
Anterior View
Hip and Groin
Posterior View
99
Gray's Anatomy (Wikipedia)
Gray's Anatomy (Wikipedia)
Emergency Medicine
Trochanteric Bursitis
Second leading cause of lateral
hip pain after osteoarthritis
Discrete tenderness to deep
palpation
Principal bursa between gluteus
maximus and posterolateral
prominence of greater trochanter
100
Emergency Medicine
Trochanteric Bursitis
Pain usually chronic
Pathology in hip abductors
May radiate down thigh, lateral or
posterior
Worse with lying on side, stepping
from curb, descending steps
101
Emergency Medicine
Trochanteric Bursitis
Patrick fabere sign (flexion,
abduction, external rotation, and
extension) may be negative
Passive ROM relatively painless
Active abduction when lying on
opposite side  pain
Sharp external rotation  pain
102
Emergency Medicine
Ischiogluteal Bursitis
Weaver's bottom / tailor’s seat:
pain center of buttock radiating
down back of leg
Often mistaken for back strain,
herniated disk
Pain worse with sitting on hard
surface, bending forward, standing
on tiptoe
103
Emergency Medicine
Ischiogluteal Bursitis
Tenderness over ischial tuberosity
Ischiogluteal bursa adjacent to
ischial tuberosity, overlies sciatic /
posterior femoral cutaneous
nerves
104
Emergency Medicine
Some Other Back Pains
Low back pain: Spasm and
tenderness of lumbosacral
musculature and straightening
of normal lumbar lordosis
Trochanteric bursitis: localized pain
over greater trochanter
Coccygodynia: Pain localized
to the coccyx
Sciatica: localized tenderness
at the sciatic notch
Ischial bursitis: localized tenderness
105
medial to the sciatic nerve
Gray's Anatomy (Wikipedia)
Emergency Medicine 120
Legs and Feet
“Housemaid’s knee”
prepatellar bursa
“Infrapatellar bursitis”
infrapatellar bursa
“Anserine bursitis”
anserine bursa
“Bursitis of the heel”
Achilles tendon
Gray's Anatomy (Wikipedia)
106
Gray's Anatomy (Wikipedia)
Emergency Medicine
Knee
BruceBlaus (Wikipedia)
107
Emergency Medicine
Prepatellar Bursitis
Housemaid’s knee / nun’s knee:
swelling with effusion of superficial
bursa over lower pole of patella
Passive motion fully preserved
Pain mild except during extreme
knee flexion or direct pressure
108
Emergency Medicine
Prepatellar Bursitis
Pressure from repetitive kneeling
on a firm surface: rug cutter's knee
Rarely direct trauma
Second most common site for
septic bursitis
109
Emergency Medicine
Prepatellar Bursitis
110
Source Undetermined
Emergency Medicine
Prepatellar Bursitis
111
Source Undetermined
Emergency Medicine
Baker’s Cyst
Pseudothrombophlebitis syndrome
Herniated fluid-filled sacs of
articular synovial membrane that
extend into popliteal fossa
Causes: trauma, rheumatoid
arthritis, gout, osteoarthritis
Pain worse with active knee flexion
112
Emergency Medicine
Baker’s Cyst
Can mimic deep venous
thrombosis
Ultrasound eseential
Many resolve over weeks
May require surgery
Steroid injections not performed:
risk of neurovascular injury
113
Emergency Medicine
Baker’s Cyst
114
Source Undetermined
Emergency Medicine
Baker’s Cyst
Source Undetermined
115
Emergency Medicine
Anserine Bursitis
Cavalryman's disease / pes
bursitis / goosefoot bursitis: obese
women with large thighs, athletes
who run
Anteromedial knee, inferior to joint
line at insertion of sartorius,
semitendinous, and gracilis tendon
116
Emergency Medicine
Anserine Bursitis
Abrupt knee pain, local tenderness
4 to 5 cm below medial aspect of
tibial plateau
Knee flexion exacerbates
117
Emergency Medicine
Iliotibial Band Syndrome
Lateral knee pain
Cyclists, dancers, distance
runners, football players
Pain worse climbing stairs
Tenderness when patient supine,
knee flexed to 90o
118
Emergency Medicine
Ankle and Foot
119
Gray's Anatomy (Wikimedia Commons)
Emergency Medicine
Peroneal Tendonitis
Peroneal tendons cross behind
lateral malleolus
Running, jumping, sprain
Holding foot up and out against
downward pressure causes pain
120
Emergency Medicine
Peroneal Tendon Rupture
Torn retinaculum
Have patient dorsiflex and plantar
flex with foot in inversion
Feel for “snapping” behind lateral
malleolus
121
Emergency Medicine
Foot
Gray's Anatomy (Wikipedia)
Gray's Anatomy (Wikipedia)
122
Emergency Medicine
Retrocalcaneal Bursitis
Ankle overuse: excessive walking,
running, or jumping
Heel pain: especially with walking,
running, palpation
Haglund disease: bony ridge on
posterosuperior calcaneus
Treatment: open heels (clogs),
bare feet, sandals, or heel lift
123
Emergency Medicine
Plantar Fasciitis
Policeman's heel / soldier's heel:
associated with heel spurs
Degenerated plantar fascial band
at origin on medial calcaneous
Heel pain worse in morning and
after long periods of rest
May be relieved with activity
124
Emergency Medicine
Plantar Fasciitis
125
Davius (Wikipedia)
Emergency Medicine
Plantar Fasciitis
Microtears in fascia from overuse?
Eliminate precipitators, rest,
strength and stretching exercises,
arch supports, and night splints
Sometimes need steroid injection
Risk of plantar fascia rupture and
fat pad atrophy
126
Emergency Medicine
Tarsal Tunnel Syndrome
Between medial malleolus and
flexor retinaculum
Vague pain in sole of foot: burning
or tingling
Worse with activity, especially
standing, walking for long periods
Tender along course of nerve
127
Emergency Medicine
Tarsal Tunnel Syndrome
Between medial malleolus and
flexor retinaculum
Vague pain in sole of foot: burning
or tingling
Worse with activity, especially
standing, walking for long periods
Tender along course of nerve
128
Emergency Medicine
Achilles Tendonitis
Grook Da Oger (Wikipedia)
129
Emergency Medicine
Fibromyalgia
Sav vas (Wikimedia Commons)
130
Emergency Medicine
Fibromyalgia
mitopencourseware (Flickr)
131
Emergency Medicine
132
Google
133
Amazon
Emergency Medicine
Fibromyalgia
Pain in muscles, joints, ligaments
and tendons
“Tender points“
– Knees, elbows, hips, neck
5% of population, including kids
Main symptom: sensitivity to pain
134
Emergency Medicine
Fibromyalgia
Pain: chronic, deep or burning,
migratory, intermittent
Fatigue, poor sleep
Numbness or tingling
“Poor blood flow”
Sensitivity to odors, bright lights,
loud noises, medicines
135
Emergency Medicine
Fibromyalgia
Jaw pain
Dry eyes
Difficulty focusing
Dizziness
Balance problems
Chest pain
Rapid or irregular heartbeat
136
Emergency Medicine
Fibromyalgia
Shortness of breath
Difficulty swallowing
Heartburn
Gas
Cramping abdominal pain
Alternating diarrhea & constipation
Frequent urination
137
Emergency Medicine
Fibromyalgia
Pain in bladder area
Urgency
Pelvic pain
Painful menstrual periods
Painful sexual intercourse
Depression
Anxiety
138
Emergency Medicine
Compare to Somatization
Somatization Fibromyalgia
Vomiting
Abdominal pain
Nausea
Bloating
Diarrhea
Leg / arm pain
Back pain














139
Emergency Medicine
Compare to Somatization
Somatization Fibromyalgia
Joint pain
Dysuria
Headaches
Breathlessness
Palpitations
Chest pain
Dizziness














140
Emergency Medicine
Compare to Somatization
Somatization Fibromyalgia
Amnesia
Dysphagia
Vision changes
Weak muscles
Sexual apathy
Dyspareunia
Impotence












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141
Emergency Medicine
Compare to Somatization
Somatization Fibromyalgia
Dysmenorrhea


Irregular
menstruation
Excessive
menstrual flow




142
Emergency Medicine
Fibromyalgia
Treatment
143
Emergency Medicine
Reflex Sympathetic Dystrophy
Causalgia
Shoulder-hand syndrome
Sudeck's atrophy
Post-traumatic pain syndrome
Complex regional pain syndrome
type I and type II
Sympathetically maintained pain
144
Emergency Medicine
Reflex Sympathetic Dystrophy
Distal extremity pain, tenderness
Bone demineralization, trophic skin
changes, vasomotor instability
Precipitating event in 2/3: injury,
stroke, MI, local trauma, fracture
Associated with emotional liability,
depression, anxiety
145
Emergency Medicine
Reflex Sympathetic Dystrophy
Treatments: medication, physical
therapy, sympathetic nerve blocks,
psychological support
– Possible sympathectomy or dorsal
column stimulator
Pain Clinic with coordinated plan
may be helpful
146
Emergency Medicine