Tendinopathy Diagnosis
Diagnosis
Common Types of Tendinitis
Achilles Tendinopathy
Achilles Tendinopathy
- Common in runners, football, tennis & basketball players; incidence increases w/ age
- Caused by tight or weak calf muscles, anatomic misalignment, improper technique, uneven training surfaces & improperly fitted shoes
- Pain is experienced at the posterior heel proximal to the tendon insertion
- Physical exam may show thickened, tender & palpable nodules
- Observe for anatomic deformities (eg heel varus, forefoot, excessive pes planus or foot pronation)
- Magnetic resonace imaging (MRI) is useful for showing partial tendon tears, tendon thickening & chronic degenerative changes
- Ultrasonography shows tendon thickening & heterogeneous echogenicity
- Plain film radiography may show calcific tendinopathy, calcaneal avulsion fracture & soft-tissue swelling
- Causes pain in the anterior shoulder & radiates to the elbow & forearm
- There is worsening of pain when flexing the shoulder or supinating the forearm
- Yergason’s test
- Done w/ patient’s arm fully pronated & elbow flexed to 90°. Patient is asked to supinate his arm against resistance applied by the examiner
- Considered positive test if pain localized to the long biceps tendon is elicited
- Speed’s test
- Patient forward flexes the shoulder about 30° against resistance applied by the examiner, while keeping the elbow fully extended & the arm fully supinated
- Considered positive if pain is elicited in the anterior shoulder
- Deposition of Ca hydroxyapatite crystals in or around the tendons of the rotator cuff
- Affects any of the rotator cuff tendons but has a predilection for the supraspinatus
- Has been postulated to be related to continuous microtrauma
- Symptoms are similar to those of an impingement syndrome
- Physical exam reveals point tenderness over the greater tuberosity
- Plain film radiography confirms evidence of calcification in or around the rotator cuff tendons
- Equally affects men & women; most common in patients >40 years of age
- Lateral epicondylitis or tennis elbow
- More common than medial epicondylitis
- Common in persons who play racquet sports or manual laborers whose activities involve repetitive wrist extension
- Patient experiences insidious lateral or outer elbow pain aggravated by wrist supination or extension activities (eg grasping & twisting)
- Physical exam reveals tenderness over or just distal to the lateral epicondyle where the extensor tendons insert
- Cozen test
- Patient is asked to keep his fist clenched while extending the wrist. The examiner grasps the forearm w/ the left hand while the right hand pulls the patients hand toward flexion against the patient’s resistance
- Positive test if pain is elicited at the lateral epicondyle
- Medial epicondylitis or golfer’s elbow
- Common in golfers, bowlers, carpenters & other manual laborers whose activities involve repetitive wrist flexion
- Can result from microtrauma at the site of the insertion of the flexor carpi radialis on the medial epicondyle
- There is medial or inner elbow pain exacerbated w/ wrist flexion & pronation
- Physical exam reveals tenderness over the medial epicondyle near the insertion of the wrist flexor tendons
- Imaging modalities:
- MRI shows degenerative thickening of the tendons, fibrovascular proliferation & mucoid degeneration
- Ultrasonography shows tendon thickening & heterogeneous echogenicity, which are common findings in elbow tendinopathy
- Common in cyclists, dancers, long-distance runners, football players, military recruits
- Pain is observed after completion of a run or several minutes into a run
- Pain is exacerbated by running down hills, lengthening stride or sitting for long periods w/ knee flexed
- Positive Renne test
- Knee is flexed while standing w/ weight on affected knee resulting in pain at approx 30° of flexion
- Ober test
- Patient lies down w/ unaffected side down & unaffected hip & knee at a 90° angle
- If iliotibial band is tight, patient will experience difficulty in adducting the leg beyond midline & may experience pain at the lateral aspect of the knee
- Common in those who engage in jumping sports (eg basketball, high jumping, volleyball) & running
- Characterized by insidious onset of localized anterior knee pain
- Pain is exacerbated when changing position (eg going up & down the stairs, sitting to standing)
- Physical exam reveals pain at the inferior pole of the patella w/ the leg fully extended using resisted leg extension
- Decline squat test
- Pain is reproduced when placing greater load on the patellar tendon than a squat performed on level ground
- MRI is useful for showing changes consistent w/ chronic degenerative changes of the tendon as well as other detailed anatomic information of the knee joint
- Has a 78% sensitivity & 86% specificity
- Ultrasonography shows tendon thickening, decreased echogenicity & tendon calcification
- More specific (94%) than sensitive (58%)
- Common in athletes who throw repetitively & in persons w/ history of participating in overhead activities (eg painting, swimming)
- Pain on top of the shoulder & upper arm; usually worsened when reaching, pushing, pulling or lifting the arm above the shoulder & when lying on the affected side
- May elicit point tenderness over the greater tuberosity
- Jobe’s test
- A resistance test to assess the supraspinatus function
- W/ both arms abducted to 90°, held slightly in front of the body & arms fully pronated, comparative resistance is placed on both arms to compare strength & presence of pain
- Weakness or presence of pain is suggestive of supraspinatus tendinopathy
- Hawkin’s Test
- Test for rotator cuff tendinopathy or subacromial impingement
- Elicits pain w/ forcible internal rotation w/ the patient’s arm passively flexed forward at 90°
- Neer’s Test
- Test for impingement of the rotator cuff tendons under the coracoacromial arch
- Elicits pain w/ full forward flexion between 70° & 120°
- MRI is 95% sensitive & specific for the detection of chronic tendinopathy, cuff tears & degeneration
- Ultrasonography is useful for detecting moderate to full thickness tears
- Has limited ability to detect small tears but may show tendon changes of chronic tendinopathy
History
- Diagnosis is based on medical history & careful physical exam
- Elicit the following in the history:
- History of repetitive stress (eg changes in sports or other recreational activities, work activities, changes in workplace) either recent or over several weeks/months; determine the type of activity or training
- History of infectious disease, fluoroquinolone therapy or other systemic illness
- Pain is the most common symptom
- May be described as sharp, stabbing, insidious, localized pain aggravated by activity, or as a dull ache after activity & during rest period
- Initially, pain is present during activity but subsides after a period of warm-up. Later, there is gradual increase in pain intensity & duration, & may be present at rest
Physical Examination
- Inspection of muscle for atrophy, asymmetry, erythema, swelling, & joint effusions
- Atrophy is usually observed in chronic conditions & gives information on the duration of the tendinopathy
- Asymmetry, erythema & swelling are common in abnormal tendons
- Joint effusions are infrequent w/ tendinopathy & more suggestive of intra-articular problems
- Search for signs of deformity, trauma
- Palpation
- Localized tenderness along the involved tendon or its sheath
- Motor evaluation such as active & passive range of motion, strength
- Physical maneuvers
- Support the diagnosis by simulating tendon loading & reproducing patient’s pain
- Important to determine the source of pain, whether articular (w/in the joint capsule) or periarticular (around the joint capsule), to narrow down the diagnosis
Imaging
- Plain film radiography
- Indicated if a history of trauma is present
- Not useful in showing tendons & other soft tissue changes but helpful in excluding other joint or bone abnormalities (eg osteoarthritis)
- Magnetic resonance imaging (MRI) & Ultrasound
- Can show damage to bones & soft tissues (eg tendon tears, tendon thickening, degenerative changes)
- Reserved for when the diagnosis is uncertain, in cases of recalcitrant pain despite adequate conservative management, & for preoperative evaluation
- Changes seen do not necessarily correlate w/ clinical symptoms