Tendinitis and Tenosynovitis

The cause of tendinitis is often unknown. It usually occurs in people who are middle-aged or older as the vascularity of tendons decreases; repetitive microtrauma may contribute. Repeated or extreme trauma (short of rupture), strain, and excessive or unaccustomed exercise probably also contribute. Some fluoroquinolone antibiotics may increase the risk of tendinopathy and tendon rupture.

Risk of tendinitis may be increased by certain systemic disorders—most commonly rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more , systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more , gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more , reactive arthritis Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more , and diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more or, very rarely, amyloidosis Amyloidosis Amyloidosis is any of a group of disparate conditions characterized by extracellular deposition of insoluble fibrils composed of misaggregated proteins. These proteins may accumulate locally... read more or markedly elevated blood cholesterol levels. In younger adults, particularly women, disseminated gonococcal infection Gonorrhea Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more may cause acute migratory tenosynovitis.

Affected tendons are usually painful when actively moved or when natural motion is resisted. For example, because the posterior tibial tendon helps invert the foot, passive eversion plus active, resisted inversion causes pain in patients with posterior tibial tendinitis. Occasionally, tendon sheaths become swollen and fluid accumulates, usually when patients have infection, rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more , or gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more . Swelling may be visible or only palpable. Along the tendon, palpation elicits localized tenderness of varying severity.

In systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more , the tendon sheath may remain dry, but movement of the tendon in its sheath may cause friction, which can be felt or heard with a stethoscope.

Usually, the diagnosis can be based on symptoms and physical examination, including palpation or specific maneuvers to assess pain. MRI or ultrasonography may be done to confirm the diagnosis, rule out other disorders, and detect tendon tears and inflammation.

Symptoms are relieved by rest or immobilization (eg, splint or sling) of the tendon, application of heat (usually for chronic inflammation) or cold (usually for acute inflammation), and high-dose NSAIDs (see table ) for 7 to 10 days. Indomethacin or colchicine may be helpful if gout Treatment Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more is the cause. After inflammation is controlled, exercises that gradually increase range of motion should be done several times a day, especially for the shoulder, which can develop contractures rapidly.

Injecting a sustained-release corticosteroid (eg, betamethasone 6 mg/mL, triamcinolone 40 mg/mL, methylprednisolone 20 to 40 mg/mL) in the tendon sheath may help; injection is usually indicated if pain is severe or if the problem has been chronic. Injection volume may range from 0.3 mL to 1 mL, depending on the site. An injection through the same needle of an equal or double volume of local anesthetic (eg, 1 to 2% lidocaine) confirms the diagnosis if pain is relieved immediately. Clinicians should be careful not to inject the tendon (which can be recognized by marked resistance to injection); doing so may weaken it, increasing risk of rupture. Patients are advised to rest the adjacent joint to reduce the slight risk of tendon rupture. Infrequently, symptoms can worsen for up to 24 hours after the injection.

Repeat injections and symptomatic treatment may be required. Rarely, for persistent cases, particularly rotator cuff tendinitis, surgical exploration with removal of calcium deposits or tendon repair, followed by graded physical therapy, is needed. Occasionally, patients require surgery to release scars that limit function, remove part of a bone causing repetitive friction, or do tenosynovectomy to relieve chronic inflammation.