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A. Etiologynavigator

  1. Unclear
  2. May be due to abnormal positioning, unusual motions
  3. Often repetative motion injuries
  4. May represent tendinitis, bursitis, abnormal nerve responses
  5. Severe cases may progress to include other syndromes
    1. Fibromyalgia
    2. Abnormal Nerve Response - RSD
    3. Ectopic calcification may occur

B. Types of Syndromesnavigator

  1. Tendinitis and Tenosynovitis
    1. Biceps tendinitis
    2. Lateral Epicondylitis - "Tennis Elbow"
    3. Medial Epicondylitis - usually associated with golf; less common than lateral form
    4. De Quervaine's Tynosynovitis
    5. Plantar Fasciitis
    6. Non-specific overuse tendinitis
  2. Bursitis
    1. Many tendons run over soft tissue sponges called bursae
    2. Inflammation or overuse of tendon may lead to inflammation of the bursa
    3. Trochanteric Bursitis
    4. Subacromial Bursitis
    5. Anserine Bursitis - often with osteoarthritis
  3. Ganglion - outpouching of synovial lining, fluid filled, painful
  4. Neuritis
    1. Carpal Tunnel Syndrome
    2. Tarsal Tunnel Syndrome
  5. Obscure Pain Syndromes
    1. Fibromyalgia
    2. Myofascial Pain Syndromes

C. Treatmentnavigator

  1. Overview
    1. Localize problem and rule out anatomic factors
    2. Some persons have abnormal anatomy which predisposes to overuse injury
    3. Pain control is critical to permit continued functioning
    4. Physical therapy, exercise, and ultrasound treatments
    5. Swimming is often effective
    6. All of these treatments require long term dedication by patients
    7. Most patients will improve in 3-12 months
  2. Physical Examination
    1. Attempt should be made to localize a specific point of maximal tenderness
    2. If one (or two) local tender points can be identified, usually in anatomic landmarks
    3. Diffuse tender areas, or specific tender points in unusual locations, may not be helpful
    4. Local injections of anesthetics may provide diagnosis and relief for specific injuries
    5. Blind injections into muscles and unusual tender points are generally not helpful
  3. Rule out anatomic abnormalities
    1. Plain radiographs may be sufficient
    2. Further evaluations should be done if trauma was involved
  4. Pain Control
    1. Non-steroidal anti-inflammatory (NSAIDs), usually in high doses, may be helpful
    2. Acetaminophen is usually less effective than NSAIDs
    3. Tramadol (Ultram®) may be effective in some patients
    4. Opiates are frequently required to provide adequate analgesia
    5. Topical capsaicin (Zostrix®) may be useful
  5. Physical Therapy
    1. Establish slow motion in the affected area
    2. Ultrasound and/or manual massage therapies are often effective
    3. Warm or cold packs on affected area may provide some relief
    4. Swimming (particularly indoor, warm water) is often well tolerated and helpful
    5. Key is to prevent atrophy in affected region
  6. Glucocorticoid Injections [1]
    1. If local anesthetic injection ameliorates pain, then steroid injection trial is warrented
    2. In general, 10-40mg of DepoMedrol (usually mixed with lidocaine) can be used
    3. Smaller joints, tendons, use less glucocorticoid; larger joints use more
    4. Avoid direct injection into tendon sheath (this can tear tendon and/or cause atrophy)
    5. These should generally NOT be repeated more than every 6-8 months
    6. Glucocorticoids should not be used in infections, fractures, osteomyelitis
    7. Relatively contraindicated in bleeding disorders (including warfarin), broken skin areas
  7. Lateral Epicondylitis [2,3]
    1. Local glucocorticoid injection or naproxen bid had similar outcomes at 6 months
    2. Glucocorticoids injections effective in 92% most effective at 4-6 weeks
    3. Physiotherapy (pulsed ultrasound massage, exercises) may also be used as treatment
    4. Observation with patient administered NSAIDs also evaluated
    5. Physiotherapy not substantially better than observation
    6. For short and long term control, injection + physiotherapy may be best
    7. Botulinum toxin injection (60 units) significantly improved pain at 3 months compared with sham with slight increase in digit paresis, weakness of finger extension [4]

References navigator

  1. Hay EM, Paterson SM, Lewis M, et al. 1999. Brit Med J. 319:964 abstract
  2. Nelson KH, Briner W, Cummins J. 1995. Am Fam Phys. 52(6):1811 abstract
  3. Smidt N, van der Windt AWM, Assendelft WJJ, et al. 2002. Lancet. 359(9307):657 abstract
  4. Wong SM, Hui ACF, Tong P, et al. 2005. Ann Intern Med. 143(11):793 abstract