ARTHRITIS
Arthritis is a process of irritation or inflammation of the joints. The articular cartilage is primarily affected, at first becoming rough and irregular and eventually being destroyed completely. This results in pain, swelling and loss of motion. Degenerative arthritis occurs from wear and tear of the cartilage. This is associated with ageing, joint injury or following a joint infection. Inflammatory or rheumatoid arthritis is secondary to an immune reaction that destroys the articular cartilage. It usually involves multiple joints and leads to progressive joint deformities.

Evaluation and diagnosis

Degenerative arthritis

Degenerative arthritis is characterized by:

Rheumatoid arthritis

Rheumatoid arthritis is characterized by:

Treatment

Rest

Decrease activities to protect the joint from further injury. During acute episodes of rheumatoid arthritis, splint the joint with a removable plaster dressing. Begin a range of motion as soon as pain allows.

Medication

Give oral anti-inflammatory medication, such as aspirin or ibuprofen. Patients with rheumatoid arthritis may benefit from oral corticosteroid medication or other special drugs.

Injections

For degenerative arthritis, use intra-articular injections of cortisone with caution, as it often speeds up the cartilage deterioration.

In patients with rheumatoid arthritis, cortisone helps to control the inflammation and periodic injections may be helpful.

Muscle strengthening

For both types of arthritis, try to preserve joint motion and extremity muscle strength. Strong muscles will protect the joint and delay deterioration.

Surgery

Surgery may be needed for end stage joint destruction or for lack of response to medical treatment in patients with rheumatoid arthritis.

BURSITIS AND TENDINITIS

Bursa are sacs lined by synovial tissue containing a small amount of fluid. They are positioned between structures that move over each other and act to reduce friction. When subjected to increased pressure or excessive motion, they become inflamed, fill with fluid and are painful.

Tendons are most vulnerable to inflammatory overuse symptoms in places where they attach to bone (the lateral epicondyle of the humerus) or travel within a surrounding sheath (the flexor tendons of the digits or the Achilles tendon at the ankle).

Evaluation and diagnosis
Make the diagnosis based on a history of overuse and the physical findings of tenderness, swelling and pain with use.

Common sites of bursitis and tendinitis

Bursitis

::	Subcromial bursa (Figure 19.10) Located between the acromion process and the rotator cuff tendon. Causes painful abduction or flexion of the shoulder joint (impingement syndrome).
Figure 19.2
::	Olecranon bursa (Figure 19.11) A common problem caused by resting the elbow on hard surfaces. Infectious bursitis is common at this location, so aspirate the bursa fluid and examine it for infection before treating as an inflammatory bursitis. Infected fluid will be cloudy and will contain bacteria on Gram stain. Treat the infection with surgical drainage and antibiotics.
Figure 19.11
::	Trochanteric bursa (Figure 19.12) A common cause of lateral hip pain. Diagnose by history of pain with walking, pain while lying on the affected side and tenderness to palpation directly over and slightly posterior to the greater trochanter of the femur.
Figure 19.12
::	Prepatella bursa (Figure 19.13) Each of the four bursa about the knee may, at times, become inflamed and painful. Prepatella bursitis is the most common of these conditions. It is caused by direct pressure on the anterior aspect of the knee from activities such as kneeling. The other bursa (pes anserine, infrapatella, fibular collateral) are irritated by excessive use associated with walking or climbing.
Figure 19.13

Tendinitis

::	Lateral epicondylitis (tennis elbow) (Figure 19.14) There is pain with use of the hand for gripping activities and tenderness at the insertion of the extensor muscles of the forearm into the lateral epicondyle of the humerus.
Figure 19.14
::	De Quervain’s tenosynovitis (Figure 19.15) Occurs from motion of the abductor pollicis longus and extensor pollicis brevis tendons within their tendon sheaths on the radial side of the wrist joint.
Figure 19.15
::	Trigger finger (Figure 19.16) Tenosynovitis of the flexor tendons within the tendon sheaths leads to nodule formation on the tendons at the level of the distal palm. As the tendons move in and out of the sheath, the nodule catches at the edge, causing the finger to “trigger” (snap into flexion or extension).
Figure 19.16
::	Achilles tendinitis (Figure 19.17) There is pain in the tendinous portion of the gastrosoleus muscle complex, at or above the insertion into the posterior calcaneus. The tendon is contained within a sheath and nodule formation or calcification of the tendon is common.
Figure 19.17
::	Plantar fasciitis (Figure 19.18) Causes pain with weight bearing at the insertion of the plantar fascia into the calcaneus.
Figure 19.18

Treatment

Rest

The patient should decrease activities or use a plaster splint for a short time and gradually resume activities when they do not cause pain. Heat or cold treatments may help to decrease the inflammation.

Medication

Give oral anti-inflammatory drugs (aspirin or ibuprofen). Corticosteroid injections into bursa and tendon sheaths may help if other methods fail.

Do not inject steroids directly into tendons. They decrease tendon strength and lead to ruptures.

Surgery

Occasionally, surgical release of the tendon sheath is necessary to prevent continuing irritation of the tendon. This is especially helpful for trigger fingers and De Quervain’s tenosynovitis.