Bursitis, Tendonitis,
Fibromyalgia, and RSD
Joe Lex, MD, FAAEM
Temple University School of Medicine
Philadelphia, PA
joe@joelex.net
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
Objectives
4. List common types of bursitis and
tendonitis found at the:
 Shoulder
 Elbow
 Wrist
Hip
Knee
Ankle
5. List indications / contraindications
for injection therapy of bursitis
and tendonitis
Objectives
6. Describe typical findings in a
patient with fibromyalgia
7. Describe typical findings in a
patient with reflex sympathetic
dystrophy
Sports
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Society more athletic
Physical activity  health benefits
Overuse syndromes increase
25% to 50% of participants will
experience tendonitis or bursitis
Workplace
Musculoskeletal disorders from…
…repetitive motions
…localized contact stress
…awkward positions
…vibrations
…forceful exertions
• Ergonomic design  incidence
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
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
Bursitis
Inflamed by…
…chronic friction
…trauma
…crystal
deposition
…infection
…systemic
disease:
rheumatoid
arthritis,
psoriatic
arthritis, gout
ankylosing
spondylitis
Bursitis
• Inflammation causes bursal
synovial cells to thicken
• Excess fluid accumulates inside
and around affected bursae
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
Tendons
• Inflammatory changes involving
sheath well documented
• Inflammatory lesions of tendon
alone not well documented
• Distinction uncertain: terms
tendonitis and tenosynovitis used
interchangeably
Tendons
• Most overuse syndromes are NOT
inflammatory
• Biopsy: no inflammatory cells
• High glutamate concentrations
• NSAIDs / steroids: no advantage
• TendonITIS a misnomer
Bursitis / Tendonitis
• Most common causes: mechanical
overload and repetitive
microtrauma
• Most injuries multifactorial
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
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
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
History
• Changes in sports activity, work
activities, or workplace
• Cause not always found
• Pregnancy, quinolone therapy,
connective tissue disorders,
systemic illness
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
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
Physical Exam
• Careful palpation
• Range of motion
• Heat, warmth, redness
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
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
Management
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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)
Management
• Shoulder: immobilize few days
• Risk of adhesive capsulitis
• Lateral epicondylitis: forearm brace
• Olecranon bursitis: compression
dressing
Management
• De Quervain’s: splint wrist and
thumb in 20o dorsiflexion
• Achilles tendonitis: heel lift or splint
in slight plantar flexion
Local
Injection
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
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
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
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
Indications
Diagnosis
• Obtain fluid for analysis
• Eliminate referred pain
Therapy
• Give pain relief
• Deliver therapeutic agents
Contraindication: Absolute
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Bacteremia
Infectious arthritis
Periarticular cellulitis
Adjacent osteomyelitis
Significant bleeding disorder
Hypersensitivity to steroid
Osteochondral fracture
Contraindication: Relative
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Violation of skin integrity
Chronic local infection
Anticoagulant use
Poorly controlled diabetes
Internal joint derangement
Hemarthrosis
Preexisting tendon injury
Partial tendon rupture
Preparations
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Local anesthetic
Hydrocortisone / corticosteroid
Rapid anti-inflammatory effect
Categorized by solubility and
relative potency
• High solubility  short duration
• Absorbed, dispersed more rapidly
Preparations
• Triamcinolone hexacetonide: least
soluble, longest duration
• Potential for subcutaneous atrophy
• Intra-articular injections only
• Methylprednisolone acetate (DepoMedrol®): reasonable first choice
for most ED indications
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
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
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
Complications: Acute
• Reaction to anesthetic: rare
• Treat as in standard textbooks
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Accidental IV injection
Vagal reaction: have patient flat
Nerve injury: pain, paresthesias
Post injection flare: starts in hours,
gone in days (~2%)
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
Complications: Delayed
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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
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
Some
specific
entities…
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
Bicipital Tendonitis
• Range of motion: normal or
restricted
• Strength: normal
• Tenderness: bicipital groove
• Pain: elevate shoulder, reach hip
pocket, pull a back zipper
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
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
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
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
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°
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
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
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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
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
Elbow and Wrist
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
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
Medial Epicondylitis
• “Golfer's elbow” or “pitcher’s
elbow” similar
• Much less common
• Worse when wrist flexed against
resistance
• Tender medial epicondyle
Cubital Tunnel Syndrome
• Ulnar nerve passes through cubital
tunnel just behind ulnar elbow
• Numbness and pain small and ring
fingers
• Initial treatment: rest, splint
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
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
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
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
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
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
Carpal Tunnel Syndrome
• Positive Phalen test: flexed wrists
held against each other for several
minutes in effort to provoke
symptoms in median nerve
distribution
Carpal Tunnel Syndrome
• May be idiopathic
• Known causes: rheumatoid
arthritis pregnancy, diabetes,
hypothyroidism, acromegaly
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
de Quervain’s Disease
• Chronic teno-synovitis due to
narrowed tendon sheaths around
abductor policis longus and
extensor pollicis brevis muscles
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
Trigger Finger
• Digital flexor tenosynovitis
• Stenosed tendon sheath
• Palmar surface over MC head
• Intermittent tendon “catch”
• “Locks” on awakening
• Most frequent: ring and middle
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
Hip and Groin
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
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
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
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
Ischiogluteal Bursitis
• Tenderness over ischial tuberosity
• Ischiogluteal bursa adjacent to
ischial tuberosity, overlies sciatic /
posterior femoral cutaneous
nerves
Legs and Feet
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
Prepatellar Bursitis
• Pressure from repetitive kneeling
on a firm surface: rug cutter's knee
• Rarely direct trauma
• Second most common site for
septic bursitis
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
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
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
Anserine Bursitis
• Abrupt knee pain, local tenderness
4 to 5 cm below medial aspect of
tibial plateau
• Knee flexion exacerbates
Iliotibial Band Syndrome
• Lateral knee pain
• Cyclists, dancers, distance
runners, football players
• Pain worse climbing stairs
• Tenderness when patient supine,
knee flexed to 90o
Ankle and Foot
Peroneal Tendonitis
• Peroneal tendons cross behind
lateral malleolus
• Running, jumping, sprain
• Holding foot up and out against
downward pressure causes pain
Peroneal Tendon Rupture
• Torn retinaculum
• Have patient dorsiflex and plantar
flex with foot in inversion
• Feel for “snapping” behind lateral
malleolus
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
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
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
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
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
Fibromyalgia
Fibromyalgia
• Pain in muscles, joints, ligaments
and tendons
• “Tender points“
• Knees, elbows, hips, neck
• 5% of population, including kids
• Main symptom: sensitivity to pain
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
Fibromyalgia
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Jaw pain
Dry eyes
Difficulty focusing
Dizziness
Balance problems
Chest pain
Rapid or irregular heartbeat
Fibromyalgia
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Shortness of breath
Difficulty swallowing
Heartburn
Gas
Cramping abdominal pain
Alternating diarrhea & constipation
Frequent urination
Fibromyalgia
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Pain in bladder area
Urgency
Pelvic pain
Painful menstrual periods
Painful sexual intercourse
Depression
Anxiety
Compare to Somatization
Somatization Fibromyalgia
Vomiting
Abdominal pain
Nausea
Bloating
Diarrhea
Leg / arm pain
Back pain
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Compare to Somatization
Somatization Fibromyalgia
Joint pain
Dysuria
Headaches
Breathlessness
Palpitations
Chest pain
Dizziness
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Compare to Somatization
Somatization Fibromyalgia
Amnesia
Dysphagia
Vision changes
Weak muscles
Sexual apathy
Dyspareunia
Impotence
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Compare to Somatization
Somatization Fibromyalgia
Dysmenorrhea
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Irregular
menstruation
Excessive
menstrual flow
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Fibromyalgia
• Treatment
Reflex Sympathetic Dystrophy
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Causalgia
Shoulder-hand syndrome
Sudeck's atrophy
Post-traumatic pain syndrome
Complex regional pain syndrome
type I and type II
• Sympathetically maintained pain
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
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