Kuliah Kelainan Periartikuler

Periarticular Disorders of
the Extremities
Dr Budi Enoch
A number of periarticular disorders have become
increasingly common over the past two to three
decades, due in part to greater participation in
recreational sports by individuals of a wide range of
ages.
Periarticular disorders most commonly affect the knee
or shoulder. With the exception of bursitis, hip pain is
most often articular or is being referred from disease
affecting another structure
Bursitis
Bursitis is inflammation of a bursa, which is a thin-walled sac lined
with synovial tissue. The function of the bursa is to facilitate
movement of tendons and muscles over bony prominences.
Excessive frictional forces from overuse, trauma, systemic disease
(e.g., rheumatoid arthritis, gout), or infection may cause bursitis.
Subacromial bursitis (subdeltoid bursitis) is the most common
form of bursitis.
The subacromial bursa, which is contiguous with the subdeltoid
bursa, is located between the undersurface of the acromion and the
humeral head and is covered by the deltoid muscle.
Bursitis is caused by repetitive overhead motion and often
accompanies rotator cuff tendinitis.
Another frequently encountered form is trochanteric bursitis,
which involves the bursa around the insertion of the gluteus
medius onto the greater trochanter of the femur
Olecranon bursitis occurs over the posterior elbow, and when the area is
acutely inflamed, infection or gout should be excluded by aspirating the
bursa and performing a Gram stain and culture on the fluid as well as
examining the fluid for urate crystals.
Achilles bursitis involves the bursa located above the insertion of the
tendon to the calcaneus and results from overuse and wearing tight
shoes.
Retrocalcaneal bursitis involves the bursa that is located between the
calcaneus and posterior surface of the Achilles tendon. The pain is
experienced at the back of the heel, and swelling appears on the medial
and/or lateral side of the tendon. It occurs in association with
spondyloarthropathies, rheumatoid arthritis, gout, or trauma.
Ischial bursitis (weaver's bottom) affects the bursa separating the
gluteus medius from the ischial tuberosity and develops from prolonged
sitting and pivoting on hard surfaces.
Iliopsoas bursitis affects the bursa that lies between the iliopsoas muscle
and hip joint and is lateral to the femoral vessels. Pain is experienced
over this area and is made worse by hip extension and flexion
Anserine bursitis is an inflammation of the sartorius
bursa located over the medial side of the tibia just
below the knee and under the conjoint tendon and is
manifested by pain on climbing stairs. Tenderness is
present over the insertion of the conjoint tendon of the
sartorius, gracilis, and semitendinosus. Prepatellar
bursitis (housemaid's knee) occurs in the bursa
situated between the patella and overlying skin and is
caused by kneeling on hard surfaces. Gout or infection
may also occur at this site. Treatment of bursitis
consists of prevention of the aggravating situation, rest
of the involved part, administration of a nonsteroidal
anti-inflammatory drug (NSAID) where appropriate for
an individual patient, or local glucocorticoid injection.
Rotator Cuff Tendinitis and
Impingement Syndrome
Tendinitis of the rotator cuff is the major cause of a
painful shoulder and is currently thought to be caused by
inflammation of the tendon(s).
The rotator cuff consists of the tendons of the
supraspinatus, infraspinatus, subscapularis, and teres
minor muscles, and inserts on the humeral tuberosities.
Of the tendons forming the rotator cuff, the
supraspinatus tendon is the most often affected, probably
because of its repeated impingement (impingement
syndrome) between the humeral head and the
undersurface of the anterior third of the acromion and
coracoacromial ligament above as well as the reduction in
its blood supply that occurs with abduction of the arm
The tendon of the infraspinatus and that of the long head of the biceps are
less commonly involved. The process begins with edema and hemorrhage
of the rotator cuff, which evolves to fibrotic thickening and eventually to
rotator cuff degeneration with tendon tears and bone spurs.
Subacromial bursitis also accompanies this syndrome.
Symptoms usually appear after injury or overuse, especially with activities
involving elevation of the arm with some degree of forward flexion.
Impingement syndrome occurs in persons participating in baseball, tennis,
swimming, or occupations that require repeated elevation of the arm.
Those over age 40 are particularly susceptible.
Patients complain of a dull aching in the shoulder, which may interfere
with sleep. Severe pain is experienced when the arm is actively abducted
into an overhead position. The arc between 60° and 120° is especially
painful. Tenderness is present over the lateral aspect of the humeral head
just below the acromion. NSAIDs, local glucocorticoid injection, and
physical therapy may relieve symptoms. Surgical decompression of the
subacromial space may be necessary in patients refractory to conservative
treatment.
Patients may tear the supraspinatus tendon acutely by falling on an outstretched arm or
lifting a heavy object. Symptoms are pain along with weakness of abduction and external
rotation of the shoulder. Atrophy of the supraspinatus muscles develops. The diagnosis is
established by arthrogram, ultrasound, or MRI. Surgical repair may be necessary in patients
who fail to respond to conservative measures. In patients with moderate-to-severe tears
and functional loss, surgery is indicated.
Calcific Tendinitis
This condition is characterized by deposition of calcium
salts, primarily hydroxyapatite, within a tendon.
The exact mechanism of calcification is not known but
may be initiated by ischemia or degeneration of the
tendon. The supraspinatus tendon is most often affected
because it is frequently impinged on and has a reduced
blood supply when the arm is abducted.
The condition usually develops after age 40. Calcification
within the tendon may evoke acute inflammation,
producing sudden and severe pain in the shoulder.
However, it may be asymptomatic or not related to the
patient's symptoms
Bicipital Tendinitis and Rupture
Bicipital tendinitis, or tenosynovitis, is produced by friction on the
tendon of the long head of the biceps as it passes through the
bicipital groove.
When the inflammation is acute, patients experience anterior
shoulder pain that radiates down the biceps into the forearm.
Abduction and external rotation of the arm are painful and limited.
The bicipital groove is very tender to palpation. Pain may be elicited
along the course of the tendon by resisting supination of the forearm
with the elbow at 90° (Yergason's supination sign).
Acute rupture of the tendon may occur with vigorous exercise of the
arm and is often painful. In a young patient, it should be repaired
surgically. Rupture of the tendon in an older person may be
associated with little or no pain and is recognized by the presence of
persistent swelling of the biceps ("Popeye" muscle) produced by the
retraction of the long head of the biceps. Surgery is usually not
necessary in this setting.
De Quervain's Tenosynovitis
In this condition, inflammation involves the abductor pollicis longus and
the extensor pollicis brevis as these tendons pass through a fibrous
sheath at the radial styloid process. The usual cause is repetitive twisting
of the wrist.
It may occur in pregnancy, and it also occurs in mothers who hold their
babies with the thumb outstretched.
Patients experience pain on grasping with their thumb, such as with
pinching. Swelling and tenderness are often present over the radial
styloid process. The Finkelstein sign is positive, which is elicited by
having the patient place the thumb in the palm and close the fingers over
it. The wrist is then ulnarly deviated, resulting in pain over the involved
tendon sheath in the area of the radial styloid. Treatment consists
initially of splinting the wrist and an NSAID. When severe or refractory
to conservative treatment, glucocorticoid injections can be very effective.
Patellar Tendinitis (Jumper's Knee)
Tendinitis involves the patellar tendon at its

attachment to the lower pole of the patella.
Patients may experience pain when jumping during
basketball or volleyball, going up stairs, or doing deep
knee squats.
Tenderness is noted on examination over the lower
pole of the patella. Treatment consists of rest, icing,
and NSAIDs, followed by strengthening and
increasing flexibility.
Iliotibial Band Syndrome
The iliotibial band is a thick connective tissue that runs from the
ilium to the fibula.
Patients with iliotibial band syndrome most commonly present
with aching or burning pain at the site where the band courses
over the lateral femoral condyle of the knee; pain may also radiate
up the thigh, toward the hip.
Predisposing factors for iliotibial band syndrome include a varus
alignment of the knee, excessive running distance, poorly fitted
shoes, or continuous running on uneven terrain.
Treatment consists of rest, NSAIDs, physical therapy, and
addressing risk factors such as shoes and running surface.
Glucocorticoid injection into the area of tenderness can provide
relief, but running must be avoided for at least two weeks after the
injection. Surgical release of the iliotibial band has been helpful in
rare patients for whom conservative treatment has failed.
Adhesive Capsulitis
Often referred to as "frozen shoulder," adhesive capsulitis is characterized by pain
and restricted movement of the shoulder, usually in the absence of intrinsic
shoulder disease.
Adhesive capsulitis may follow bursitis or tendinitis of the shoulder or be
associated with systemic disorders such as chronic pulmonary disease, myocardial
infarction, and diabetes mellitus.
Prolonged immobility of the arm contributes to the development of adhesive
capsulitis. Pathologically, the capsule of the shoulder is thickened, and a mild
chronic inflammatory infiltrate and fibrosis may be present.
Adhesive capsulitis occurs more commonly in women after age 50.
Pain and stiffness usually develop gradually but progress rapidly in some patients.
Night pain is often present in the affected shoulder and pain may interfere with
sleep. The shoulder is tender to palpation, and both active and passive movement
are restricted. Radiographs of the shoulder show osteopenia. The diagnosis is
typically made by physical examination but can be confirmed if necessary by
arthrography, in that only a limited amount of contrast material, usually <15 mL,
can be injected under pressure into the shoulder joint.
Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, or tennis elbow, is a painful condition
involving the soft tissue over the lateral aspect of the elbow.
The pain originates at or near the site of attachment of the
common extensors to the lateral epicondyle and may radiate
into the forearm and dorsum of the wrist. The pain usually
appears after work or recreational activities involving repeated
motions of wrist extension and supination against resistance.
Most patients with this disorder injure themselves in activities
other than tennis, such as pulling weeds, carrying suitcases or
briefcases, or using a screwdriver. The injury in tennis usually
occurs when hitting a backhand with the elbow flexed.
Shaking hands and opening doors can reproduce the pain.
Striking the lateral elbow against a solid object may also
induce pain.
Medial Epicondylitis
Medial epicondylitis is an overuse syndrome resulting in pain over the
medial side of the elbow with radiation into the forearm.
The cause of this syndrome is considered to be repetitive resisted motions
of wrist flexion and pronation, which lead to microtears and granulation
tissue at the origin of the pronator teres and forearm flexors, particularly
the flexor carpi radialis.
This overuse syndrome is usually seen in patients >35 years and is much
less common than lateral epicondylitis. It occurs most often in work-
related repetitive activities but also occurs with recreational activities
such as swinging a golf club (golfer's elbow) or throwing a baseball.
On physical examination, there is tenderness just distal to the medial
epicondyle over the origin of the forearm flexors. Pain can be reproduced
by resisting wrist flexion and pronation with the elbow extended.
Radiographs are usually normal. The differential diagnosis of patients
with medial elbow symptoms include tears of the pronator teres, acute
medial collateral ligament tear, and medial collateral ligament instability
Plantar
Plantar Fasciitis fasciitis
is a common cause of foot pain in adults,
with the peak incidence occurring in people between the
ages of 40 and 60 years.
It is also seen more frequently in a younger population
consisting of runners, aerobic exercise dancers, and ballet
dancers.
The pain originates at or near the site of the plantar fascia
attachment to the medial tuberosity of the calcaneus.
Several factors that increase the risk of developing plantar
fasciitis include obesity, pes planus (flat foot or absence of
the foot arch when standing), pes cavus (high-arched
foot), limited dorsiflexion of the ankle, prolonged
standing, walking on hard surfaces, and faulty shoes. In
runners, excessive running and a change to a harder
running surface may precipitate plantar fasciitis.
The diagnosis of plantar fasciitis can usually be made on the basis
of history and physical examination alone.
Patients experience severe pain with the first steps on arising in the
morning or following inactivity during the day.
The pain usually lessens with weight-bearing activity during the
day, only to worsen with continued activity. Pain is made worse on
walking barefoot or up stairs.
On examination, maximal tenderness is elicited on palpation over
the inferior heel corresponding to the site of attachment of the
plantar fascia.
Imaging studies may be indicated when the diagnosis is not clear.
Plain radiographs may show heel spurs, which are of little
diagnostic significance. Ultrasonography in plantar fasciitis can
demonstrate thickening of the fascia and diffuse hypoechogenicity,
indicating edema at the attachment of the plantar fascia to the
calcaneus. MRI is a sensitive method for detecting plantar fasciitis,
but it is usually not required for establishing the diagnosis
The differential diagnosis of inferior heel pain includes calcaneal stress
fractures, the spondyloarthritides, rheumatoid arthritis, gout,
neoplastic or infiltrative bone processes, and nerve
compression/entrapment syndromes.
Resolution of symptoms occurs within 12 months in more than 80% of
patients with plantar fasciitis. The patient is advised to reduce or
discontinue activities that can exacerbate plantar fasciitis.
Initial treatment consists of ice, heat, massage, and stretching.
Stretching of the plantar fascia and calf muscles are commonly
employed and can be beneficial. Orthotics provide medial arch support
and can be effective. Foot strapping or taping are commonly performed,
and some patients may benefit by wearing a night splint designed to
keep the ankle in a neutral position. A short course of NSAIDs can be
given to patients when the benefits outweigh the risks. Local
glucocorticoid injections have also been shown to be efficacious but
may carry an increased risk for plantar fascia rupture.
Plantar fasciotomy is reserved for those patients who have failed to
improve after at least 6–12 months of conservative treatment.
Thanks for your attention

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Periarticular Disorders of

Tendinitis involves the patellar tendon at its

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