Post by Joey Smith on Jul 30, 2006 23:14:16 GMT -5
INTRODUCTION — Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure a tendon and lead to inflammation, pain, and impaired function. This is called tendinitis. Although the most common cause of tendinitis is overuse, it can also be caused by other conditions including inflammatory rheumatic diseases.
Tendinitis is a common problem. The risk of getting tendinitis increases with age and is higher in persons who routinely perform activities that require repetitive motions and that place stress on susceptible tendons. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and promoting muscle strength. In most patients, tendinitis readily resolves with treatment. In some cases, it goes away on its own.
Tendinitis can affect many different tendons in the body. Some of the more common forms of tendinitis are reviewed below.
EPICONDYLITIS OR TENNIS ELBOW — The muscles of the lower arm extend along the forearm and are connected to tendons, attach to the humerus (or upper arm bone) at two points just above the elbow. These points, called the medial and lateral epicondyles, are where tendons attached to the muscles insert into the bone.
Epicondylitis refers to injury and inflammation at the point of tendon insertion. Epicondylitis affecting the medial epicondyle (or the epicondyle located on the side nearest the body) is often referred to as "golfer's elbow", while epicondylitis affecting the lateral epicondyle is sometimes called "tennis elbow". These terms can be misleading, however, since any activity that involves repetitive wrist turning or hand gripping, tool use, hand shaking, or twisting movements can lead to the condition. Carpenters, gardeners, dentists, musicians, and others that routinely employ these movements are at increased risk for developing epicondylitis.
Symptoms — Epicondylitis most often affects the dominant arm. Patients experience localized elbow pain that may radiate into the upper arm or down to the forearm. Pain may cause weakness of the forearm. Symptoms of epicondylitis may occur acutely or can develop gradually over time. Once they appear, symptoms are often persistent, but in some patients will subside and reappear intermittently.
Diagnosis — The diagnosis of epicondylitis is usually based on the physical exam and a history of pain over the affected epicondyle. Sometimes, an anesthetic-injection test is performed to confirm the diagnosis. In this test, an anesthetic is injected into the affected area. Epicondylitis is confirmed if the pain is temporarily relieved.
Treatment — Treatment of epicondylitis focuses on healing the injured tendon, decreasing inflammation, and restoring forearm strength. During the acute period, treatment includes:
Activity restriction — Activity involving the affected elbow is restricted to encourage healing and prevent further injury. Elbow bands that provide some compression over the forearm muscle are available and can provide some pain relief.
Pain relief — Patients are typically instructed to apply ice to the affected area for 15 to 20 minutes every four to six hours. Topical linaments may also be used to provide temporary relief of pain and swelling, and a nonsteroidal anti-inflammatory drug (such as ibuprofen) may be prescribed for three to four weeks.
Immobilization — Wrist and hand motions tend to aggravate symptoms, and some patients find that immobilization with a wrist splint that has a metal stay extending up the forearm reduces symptoms. Immobilization is generally required for three to four weeks but may be necessary for a longer time in patients with severe symptoms.
If symptoms persist, non-steroidal anti-inflammatory medications may be discontinued and other measures considered. For example, a corticosteroid may be injected into the affected area. (See "Patient information: Aftercare instruction for elbow tendinitis injection"). Following injection, patients are prescribed a regimen of rest, ice, acetaminophen for soreness, and immobilization, followed by physical therapy exercises. Reinjection may be necessary if symptoms are not significantly reduced, or if they recur. A topical cortisone gel also may be directed into the affected tissue with ultrasound by a physical therapist.
Recovery and rehabilitation — Patients are often prescribed isometric exercises to restore the strength and tone of the affected muscles and prevent recurrences. Exercises are usually begun between three and four weeks after elbow pain has resolved. The exercises are continued for up to 6 to 12 months in patients with recurrent disease. (See "Patient information: Physical therapy for elbow tendinitis").
Most patients respond well to treatment. Pain at rest is often relieved after a few days of treatment, although patients may experience pain with arm use for up to 6 to 12 weeks. A small number of patients may need long-term physical therapy toning exercises with severe restrictions of forearm use. In patients with persistent symptoms, a diagnostic work-up to rule out other conditions may be considered. Surgery is rarely indicated, unless symptoms have persisted for one year or longer.
BICEPS TENDINITIS — The biceps muscle is located in the front of the upper arm and is used when lifting, bending the elbow, and reaching up over the head. The upper portion of the biceps muscle attaches to the shoulder in two places, and the lower portion attaches to a bone in the forearm. Repetitious lifting and overhead reaching can lead to biceps tendinitis, a condition characterized by inflammation and partial tears of the upper biceps tendon.
Symptoms — Patients with biceps tendinitis typically complain of pain localized to the front of the shoulder that is aggravated by lifting, overhead reaching, or both. The chronic inflammation increases the risk of spontaneous rupture of a biceps tendon. This may occur in up to 10 percent of patients with biceps tendinitis. A lump typically appears in the area of the lower biceps muscle signaling that rupture has occurred. Because of the dual attachments of the upper portion of the biceps muscle, a rupture usually results in only a slight decrease in muscle strength, and usually is not surgically repaired. Shoulder pain due to bicipital tendinitis is sometimes completely relieved after the rupture occurs.
Diagnosis — Biceps tendinitis is usually diagnosed based on the patient's history and description of pain and on the results of a physical examination. In the physical exam, the doctor assesses the patient's pain while moving the affected arm through a series of motions. This assessment helps the doctor confirm the diagnosis and evaluate the severity of the condition. In some patients, an anesthetic injection test may be performed to rule out other conditions. Patients with biceps tendinitis will experience temporary pain relief upon injection of the anesthetic.
Treatment — Treatment of biceps tendinitis focuses on reducing tendon inflammation and swelling, strengthening the biceps muscle and tendon, and preventing rupture. Acute treatment includes:
Applying ice for 15 to 20 minutes each day to reduce inflammation. A nonsteroidal anti-inflammatory drug such as ibuprofen may also be prescribed for three to four weeks.
Eliminating lifting and restricting over-the-shoulder positions and reaching. There is a 5 to 10 percent risk of rupture if these precautions are not followed.
Specific stretching exercises are prescribed to reduce the chance of recurrent tendinitis. In addition, isometric toning exercises are usually prescribed three to four weeks after the acute pain has resolved.
If symptoms persist for more than four weeks despite treatment, a corticosteroid may be injected into the affected area to reduce inflammation. (See "Patient information: Aftercare instructions for biceps tendonitis injection"). Following injection, patients are generally prescribed a regimen of rest, ice, acetaminophen for soreness, followed by physical therapy exercises. (See "Patient information: Physical therapy for biceps tendonitis"). Reinjection may be necessary if symptoms are not significantly reduced.
Sometimes pressure on the tendons due to arthritis of the shoulder joints contributes to tendinitis. This condition, call the impingement syndrome, can be diagnosed from the history and physical examination, plain Xrays, or magnetic resonance imaging (MRI). If the impingement syndrome does not respond to the treatments above, surgery may be necessary.
ROTATOR CUFF TENDINITIS — The rotator cuff is composed of four tendons that form a cuff around the head (or shoulder end) of the humerus. The tendons extend from muscles that arise from the shoulder blade, and attach to the humerus just beyond the head. The main portion of the shallow shoulder socket, the glenoid, is a cartilage covered portion of the shoulder blade into which the head of the humerus fits; the roof of the socket is formed by an extension of the shoulder blade called the acromion. A cushion-like, fluid lubricated sac, called a "bursa," is between the acromion and the top of the rotator cuff. The bursa helps to protect the tendons from "impingement," or becoming compressed and damaged between the arm bone and the shoulder blade.
The rotator cuff helps to stabilize the shoulder joint while allowing the largest range of motion of any joint in the human body. Repetitive overhead reaching, pushing, pulling, and lifting with outstretched arms can lead to rotator cuff tendinitis, a condition characterized by compression and inflammation of the rotator cuff tendons. Rotator cuff tendinitis is the most common cause of shoulder complaints, particularly in people over age 30.
Symptoms — Patients with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. The pain often awakens a patient from sleep, particularly if the patient rolls onto the shoulder.
Diagnosis — The diagnosis is usually based on a description of the pain and the results of a physical examination. During the exam, the doctor assesses the shoulder for points of localized tenderness and carefully assesses the impact of shoulder and arm movement on the patient's pain and arm strength. An anesthetic injection test may be performed to rule out other conditions. With injection, patients with rotator cuff tendinitis will experience temporary pain relief and will demonstrate normal arm strength. Those with muscle or tendon tears may have pain relief, but still have decreased strength in the affected muscle.
If the diagnosis is still uncertain after an anesthetic injection test, other studies may be necessary, or treatment may be started, and further testing postponed until the results of treatment are apparent.
Treatment — Treatment focuses on decreasing inflammation and swelling of the tendon, and reducing the degree of impingement. During the acute period, treatment includes:
Applying ice to the area to reduce inflammation. A nonsteroidal anti-inflammatory drug such as ibuprofen may be also be used.
Avoiding overhead reaching, lifting, or placing the arm in an overhead position
Discouraging the use of an arm sling as it may lead to a frozen shoulder or a marked reduction in shoulder range of motion
Specific stretching exercises. Toning exercises and exercises to recover any lost strength of the shoulder muscles may be prescribed two to three weeks later.
Tendinitis is a common problem. The risk of getting tendinitis increases with age and is higher in persons who routinely perform activities that require repetitive motions and that place stress on susceptible tendons. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and promoting muscle strength. In most patients, tendinitis readily resolves with treatment. In some cases, it goes away on its own.
Tendinitis can affect many different tendons in the body. Some of the more common forms of tendinitis are reviewed below.
EPICONDYLITIS OR TENNIS ELBOW — The muscles of the lower arm extend along the forearm and are connected to tendons, attach to the humerus (or upper arm bone) at two points just above the elbow. These points, called the medial and lateral epicondyles, are where tendons attached to the muscles insert into the bone.
Epicondylitis refers to injury and inflammation at the point of tendon insertion. Epicondylitis affecting the medial epicondyle (or the epicondyle located on the side nearest the body) is often referred to as "golfer's elbow", while epicondylitis affecting the lateral epicondyle is sometimes called "tennis elbow". These terms can be misleading, however, since any activity that involves repetitive wrist turning or hand gripping, tool use, hand shaking, or twisting movements can lead to the condition. Carpenters, gardeners, dentists, musicians, and others that routinely employ these movements are at increased risk for developing epicondylitis.
Symptoms — Epicondylitis most often affects the dominant arm. Patients experience localized elbow pain that may radiate into the upper arm or down to the forearm. Pain may cause weakness of the forearm. Symptoms of epicondylitis may occur acutely or can develop gradually over time. Once they appear, symptoms are often persistent, but in some patients will subside and reappear intermittently.
Diagnosis — The diagnosis of epicondylitis is usually based on the physical exam and a history of pain over the affected epicondyle. Sometimes, an anesthetic-injection test is performed to confirm the diagnosis. In this test, an anesthetic is injected into the affected area. Epicondylitis is confirmed if the pain is temporarily relieved.
Treatment — Treatment of epicondylitis focuses on healing the injured tendon, decreasing inflammation, and restoring forearm strength. During the acute period, treatment includes:
Activity restriction — Activity involving the affected elbow is restricted to encourage healing and prevent further injury. Elbow bands that provide some compression over the forearm muscle are available and can provide some pain relief.
Pain relief — Patients are typically instructed to apply ice to the affected area for 15 to 20 minutes every four to six hours. Topical linaments may also be used to provide temporary relief of pain and swelling, and a nonsteroidal anti-inflammatory drug (such as ibuprofen) may be prescribed for three to four weeks.
Immobilization — Wrist and hand motions tend to aggravate symptoms, and some patients find that immobilization with a wrist splint that has a metal stay extending up the forearm reduces symptoms. Immobilization is generally required for three to four weeks but may be necessary for a longer time in patients with severe symptoms.
If symptoms persist, non-steroidal anti-inflammatory medications may be discontinued and other measures considered. For example, a corticosteroid may be injected into the affected area. (See "Patient information: Aftercare instruction for elbow tendinitis injection"). Following injection, patients are prescribed a regimen of rest, ice, acetaminophen for soreness, and immobilization, followed by physical therapy exercises. Reinjection may be necessary if symptoms are not significantly reduced, or if they recur. A topical cortisone gel also may be directed into the affected tissue with ultrasound by a physical therapist.
Recovery and rehabilitation — Patients are often prescribed isometric exercises to restore the strength and tone of the affected muscles and prevent recurrences. Exercises are usually begun between three and four weeks after elbow pain has resolved. The exercises are continued for up to 6 to 12 months in patients with recurrent disease. (See "Patient information: Physical therapy for elbow tendinitis").
Most patients respond well to treatment. Pain at rest is often relieved after a few days of treatment, although patients may experience pain with arm use for up to 6 to 12 weeks. A small number of patients may need long-term physical therapy toning exercises with severe restrictions of forearm use. In patients with persistent symptoms, a diagnostic work-up to rule out other conditions may be considered. Surgery is rarely indicated, unless symptoms have persisted for one year or longer.
BICEPS TENDINITIS — The biceps muscle is located in the front of the upper arm and is used when lifting, bending the elbow, and reaching up over the head. The upper portion of the biceps muscle attaches to the shoulder in two places, and the lower portion attaches to a bone in the forearm. Repetitious lifting and overhead reaching can lead to biceps tendinitis, a condition characterized by inflammation and partial tears of the upper biceps tendon.
Symptoms — Patients with biceps tendinitis typically complain of pain localized to the front of the shoulder that is aggravated by lifting, overhead reaching, or both. The chronic inflammation increases the risk of spontaneous rupture of a biceps tendon. This may occur in up to 10 percent of patients with biceps tendinitis. A lump typically appears in the area of the lower biceps muscle signaling that rupture has occurred. Because of the dual attachments of the upper portion of the biceps muscle, a rupture usually results in only a slight decrease in muscle strength, and usually is not surgically repaired. Shoulder pain due to bicipital tendinitis is sometimes completely relieved after the rupture occurs.
Diagnosis — Biceps tendinitis is usually diagnosed based on the patient's history and description of pain and on the results of a physical examination. In the physical exam, the doctor assesses the patient's pain while moving the affected arm through a series of motions. This assessment helps the doctor confirm the diagnosis and evaluate the severity of the condition. In some patients, an anesthetic injection test may be performed to rule out other conditions. Patients with biceps tendinitis will experience temporary pain relief upon injection of the anesthetic.
Treatment — Treatment of biceps tendinitis focuses on reducing tendon inflammation and swelling, strengthening the biceps muscle and tendon, and preventing rupture. Acute treatment includes:
Applying ice for 15 to 20 minutes each day to reduce inflammation. A nonsteroidal anti-inflammatory drug such as ibuprofen may also be prescribed for three to four weeks.
Eliminating lifting and restricting over-the-shoulder positions and reaching. There is a 5 to 10 percent risk of rupture if these precautions are not followed.
Specific stretching exercises are prescribed to reduce the chance of recurrent tendinitis. In addition, isometric toning exercises are usually prescribed three to four weeks after the acute pain has resolved.
If symptoms persist for more than four weeks despite treatment, a corticosteroid may be injected into the affected area to reduce inflammation. (See "Patient information: Aftercare instructions for biceps tendonitis injection"). Following injection, patients are generally prescribed a regimen of rest, ice, acetaminophen for soreness, followed by physical therapy exercises. (See "Patient information: Physical therapy for biceps tendonitis"). Reinjection may be necessary if symptoms are not significantly reduced.
Sometimes pressure on the tendons due to arthritis of the shoulder joints contributes to tendinitis. This condition, call the impingement syndrome, can be diagnosed from the history and physical examination, plain Xrays, or magnetic resonance imaging (MRI). If the impingement syndrome does not respond to the treatments above, surgery may be necessary.
ROTATOR CUFF TENDINITIS — The rotator cuff is composed of four tendons that form a cuff around the head (or shoulder end) of the humerus. The tendons extend from muscles that arise from the shoulder blade, and attach to the humerus just beyond the head. The main portion of the shallow shoulder socket, the glenoid, is a cartilage covered portion of the shoulder blade into which the head of the humerus fits; the roof of the socket is formed by an extension of the shoulder blade called the acromion. A cushion-like, fluid lubricated sac, called a "bursa," is between the acromion and the top of the rotator cuff. The bursa helps to protect the tendons from "impingement," or becoming compressed and damaged between the arm bone and the shoulder blade.
The rotator cuff helps to stabilize the shoulder joint while allowing the largest range of motion of any joint in the human body. Repetitive overhead reaching, pushing, pulling, and lifting with outstretched arms can lead to rotator cuff tendinitis, a condition characterized by compression and inflammation of the rotator cuff tendons. Rotator cuff tendinitis is the most common cause of shoulder complaints, particularly in people over age 30.
Symptoms — Patients with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. The pain often awakens a patient from sleep, particularly if the patient rolls onto the shoulder.
Diagnosis — The diagnosis is usually based on a description of the pain and the results of a physical examination. During the exam, the doctor assesses the shoulder for points of localized tenderness and carefully assesses the impact of shoulder and arm movement on the patient's pain and arm strength. An anesthetic injection test may be performed to rule out other conditions. With injection, patients with rotator cuff tendinitis will experience temporary pain relief and will demonstrate normal arm strength. Those with muscle or tendon tears may have pain relief, but still have decreased strength in the affected muscle.
If the diagnosis is still uncertain after an anesthetic injection test, other studies may be necessary, or treatment may be started, and further testing postponed until the results of treatment are apparent.
Treatment — Treatment focuses on decreasing inflammation and swelling of the tendon, and reducing the degree of impingement. During the acute period, treatment includes:
Applying ice to the area to reduce inflammation. A nonsteroidal anti-inflammatory drug such as ibuprofen may be also be used.
Avoiding overhead reaching, lifting, or placing the arm in an overhead position
Discouraging the use of an arm sling as it may lead to a frozen shoulder or a marked reduction in shoulder range of motion
Specific stretching exercises. Toning exercises and exercises to recover any lost strength of the shoulder muscles may be prescribed two to three weeks later.