Muscles & Tendons. AFFLICTION OF TENDONS AND BURSAE Injury occurs when the normal physical limits of human tissues are exceeded.

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1 Muscles & Tendons AFFLICTION OF TENDONS AND BURSAE Injury occurs when the normal physical limits of human tissues are exceeded. CLASSIFICATION Single traumatic incident Overuse / repetitive stress ABNORMAL WEAKENING OF TISSUES Diabetes Rheumatoid Arthritis Chronic Renal Disease INJURIES Strain: Stretching of muscle and its tendinous attachment to bone Sprain: Ligament injury (Connective tissue attaching bone to bone) First, Second and Third Degree Fractures, (Break or discontinuity of a bone) Stress / Avulsion Bursa (Fluid filled endothelium lined sac which decreases frictional forces Shoulder Rupture Biceps brachii, Pectrolismajor Capsular tear Bicipital tindinitis Supraspinatus syndrome Bursae Subdeltoid Subacromial Subscbscapularis Dislocations UPPER LIMB

2 Adhesive Capsulitis (Frozen shoulder) Frozen shoulder be reserved for a well defined disorder characteristic & by progressive pain & stiffness which usually resolve spontaneously after about 18 months. Clinical feature year of age May give history of trauma Pain gradually increases in severity & often presents on sleeping on affected side. After several months it begins to subside (Conservative treatment) Analgesic / anti-inflammatory drugs Local heat Exercises aims to relieve pain and to prevent further stiffness Injection of corticosteroid & local anesthetic sometimes help Manipulation under anaesthesia often help to recovery Operative treatment Arthroscopic division of interval between supraspinatus & infraspinatus Rotator Cuff Tear Common in > 40 years Youngers have history of trauma Lead to muscular atrophy difficulty in diagnosis surgical repair in young and selected older patients Repair should be done within 03 weeks of injury Impingement syndrome Near described as series of pathological changes in supra spinus tendon Pain usually occurs over anterolateral aspect of shoulder Pain aggravated by overhead activity Worst at night clicking or popping sensation Conservative, heat massage, NSAIDS, local steroids, surgical BICEPS TENDINITUS Inflammation of sheath around the long head of biceps

3 Causes discrete pain and tenderness in biceptal groove Rest, icing, NSAIDS, local steroids Surgical Transfer of tendons DELTOID CONTRACTURE Fibrosis of deltoid muscle result in grotesque looking shoulder with severe impairment of function Causes infection, pressure ischemeia surgical release of fibrotic band

4 ELBOW Avulsion of Biceps, Rupture of Triceps Tennis Elbow Golfer Elbow Javelins Elbow Olecranon bursa Tennis elbow The cause of this condition is unknown but most cases follow minor trauma or repetative strain on the tendon aponeurosis attached to either the lateral or medial humeral epicondyle Clinical feature Pain Felt over the outer side of elbow, aggravated by movements such as pouring out tea, turning a stiff door handle, shaking hands or lifting with the forearm pronated Tenderness is localized to spot just below the lateral epicondyle

5 Test Simply by flexing the wrist so as to stretch the common extensors GOLFERS ELBOW Similar symptoms occurs around the medial epicondyle, because of involvement of common tendon of origin of wrist flexors. How to test Pain is respond by passive extension of wrist (conservative) Rest or avoiding the participating activity If pain is severe, the area of maximum tenderness is injected by mixture of corticosteroid & local anesthesia Operative. The affected common tendon on the lateral or medial side of elbow is detached from its origin at humeral epicondyle OLECRANON BURSITIS Chronic inflammation of olecranon bursae Result from minor trauma repeatedly Usually swelling over tip of olecranon NSAIDS, local steroids, excision of bursae

6 WRIST Ganglion Dequervain s disease Carpal tunnel syndrome De Quervain s disease Tenovaginitis of the first dorsal compartment Usually years of age group Common in women

7 May be history of unaccustomed activity such as pouring roses, cutting with scissors, or wringing out clothes Clinical feature Pain & swelling (sometime to radial side of wrist) Tenderness (most acute at tip of radial styloid Sign Pathognomonic sign is elicited by Finkelstein s test Early treatment with ultrasound therapy Corticosteroid injection in tendon sheath Splintage of wrist Resistant cases Need operation which consists splitting the thickened tendon sheath GANGLION Most common on back of wrist It is cystic degeneration of joint capsule or tendon sheath Cyst contain glairy fluid Painless lump on back of wrist TREATMENT Often disappear after some months If causing problems then Aspiration can be done Excision of ganglion can be done 30% chances of recurrences CARPAL TUNNEL SYNDROME The syndrome is common in women at menopause, in Rheumatoid arthritis in pregnancy, and in myxodema, usual age group is 40 50years Clinical feature Pain & Paraestheisia (occur in the disturbance of median nerve in hand) Night pain, tingling & numbness, patient tends to seek relief by hanging the arm over the side of bed or shaking the arm. How to test: Tinel s sign (percusion over the median nerve can reproduce the sensory symptoms) Phalen s test (holding the wrist fully flexed) In late cases Wasting of thenar muscles Investigations Nerve Conduction velocity Light Splints initially (to prevent wrist flexion)

8 Steroid injection into carpal tunnel Open Surgical division of transverse carpel ligament HAND Mallet Finger (Base ball finger) This results from injury to the extensor tendon of terminal phalanx Patient cannot actively straigten terminal joint but passive movement is normal. Dip joint splinted for 08 weeks TRIGGER FINGER Patient will complain that when the hand is clenched and then opened, the finger or thumb gets stuck in flexion, with little more efforts, it suddenly shape into full extension. It is due to thickening of fibrous tendon sheath, on examination, a tender nodule or thickened tendon usually felt at distal palmer crease. : Injection of the corticosteroid at entrance of tendon sheath Re fractory cases need operation, the fibrous sheath is incised, allowing the tendon

9 to move freely LOWER LIMB Bursae Prepatellar Infrapatellar Suprapatellar Tibial / Fibular collateral ligament Semimembranous Anserine Baker s cyst (popliteal cyst) HIP Muscular Injury Hamstrings Rectus femoris Ad longus

10 Bursae Sub gluteal Trochamteric Ischiogluteal KNEE Rupture of extensor mechanism Quadriceps tendon Patellar Fracture Ligamentum patellae Jumpers Knee (Tendinitis of extensor mechanism) Ligament and meniscus ANKLE Tendoachilles rupture Peroneal tendous (Tendinitis, rupture, Subluxation or dislocation) Bursae Retrocalcaneal Bunion Ankle March Fracture Tenosynovitis of Achilles tendon of heel due to wearing of shoes causes pain beating out the lateral half of counter of the shoes at the back of heel Surgical Removal of posterior prominent of heel HAYELAND'S DISEASE OR WINTER HEEL PLANTER FASCIATIS Pain in the planter surface of heel More pain in morning gradually subsides after walking few steps On examination tenderness positive on medial aspect of posterior heel. Passive stretching of toes causes more pain in heel

11 Surgical conservative heel cushions, NSAIDS, local steroids Partial planter release HALLUX VALGUS Derivation of giant great toe at metatarsophalangeal joint away form the mid line Causes Wearing tight shoes and foot wears, gout, R.A. congenital Pain, deformed toe swelling medial side bunion Mild cases physiotherapy, passive stretching, active exercises Surgery in severe cases HAMMER TOE Deformity at PIP joint flexion Pain, swelling PIP joint stretching dorsal extrinsic in a position of planter flexion & MTP extension Extra depth shoes CLAW TOES Extension deformity of MTP joint with simultaneous flexing & clawing of toes both proximal and distal I.P. joint Causes Due to muscle imbalance in which active extrinsic are strong than intrinsic Similar to hammer toe

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