Entesopathy Z. Rozkydal Entesopathy Pathological changes of insertions of tendons, ligaments and joint capsules into the bone Dystrophia Microruptures of Sharpey´s filaments Periostitis Ossifications, metaplasia Entesopatie- schéma Tendinopathy: disorders in tendons and tendon sheats (tenosynovitis) Normal insertion Entesopatie- schéma Pathological insertion Acute and chronic overloading Microtraumatisation Repetitive movements and activities Causes Tennis elbow Epicondylitis radialis humeri Ruka- epikondylitis Pain with activity of extensors Tenderness Painfull supination Painful resisted dorsiflexion of the wrist and of the third finger Chair test Tennis elbow- the causes Entesopathy Bursitis Ossifications of insertion of extensors Painfull annular ligament Painful synovial plica Osteochondrosis dissecans Pressure of radial nerve Referred pain from cervical spine and shoulder Tennis elbow- conservative treatment Rest, to avoid repetitive movements NSAID- localy (Voltaren gel, Fastum gel …) Corticosteroids locally (depo Medrol injection…) NSAID – oraly Orthesis, sling Physiotherapy ( ultrasound, laser PIR, magnetotherapy) Whirlpool, stretching Immobilisation Tennis elbow- operative treatment Exceptionally: disinsertion of extensor attachment to to the bone + it´s distalisation Op. sec. Hohman Op. sec. Boyd- Mc Leod Entezopatie - tenis loket 2 Golf elbow - Epicondylitis ulnaris humeri Entesopathy of insertions of flexors on the ulnar epicondyle Pain, tendernes Resisted movements Treatment: Conservative Operative Distalisation of flexor´s insertion Entezopatie Loket Bursitis of olecranon Entezopatie- bursa lokte Swelling and fluid in the bursa Tenderness Treatment: Aspiration, corticosteroids locally Bandage Rest Risk of pyogenic inflammation M. de Quervain Stenosing tenosynovitis of long abductor and short extensor of the thunb Tenderness over styloid process Finkelstein test Treatment Local corticosteroids Rest, orthesis NSAID localy Surgery Ruka- de Quervain Finkelstein test Ruka- de Quervain M. de Quervain Dissection of the tendon sheat Trigger thumb - pollex saltans •Snapping of the thumb •In childhood, in adults •Narrowing of flexor sheath •Entlargement of the tendon • •Therapy: •Rest •Local corticosteroids •Orthesis •NSAID ointments •Surgery- releasing of tendon sheat Ruka-pollex saltans op Trigger finger- digitus saltans Ruka- dig saltans op Th: , NSA ointments, local cortisteroids, rest, surgery Differential diagnosis Carpal tunel syndrom Guyon canal syndrom Carpal tunnel syndrom Compression neuropathy of median nerve Pain, diminished muscle power Hypotrophy of thenar muscles Paresthesia and numbness (thumb, 2-3. finger Limited function of fingers Tenderness Tinnel sign Phalen test Phalen test Ruka-karp Therapy Conservative Surgery Carpal tunnel syndrom Guyon canal syndrom Compression neuropathy of ulnar nerve in hand Paresthesia and numbness on ulnar side Hypotrophy of hypothenar Limited function of 4., 5. finger Therapy Conservative Surgery Ruka- anatomie2 Bursitis and entesopathies in the hip region Greater trochanter- abductors Ischial tubercle- hamstrings Adductor entesopathy Bursa ileopectinea Spina iliaca ant. sup. Spina iliaca ant. inf. Iliopsoas – lesser trochanter Painful groin- gracilis syndrom O entes Kyčel-cévy,burzy1 Therapy: Conservative Surgery Snapping hip Snapping sensation over greater trochanter or popping sound in the hip during walking, getting up from a chair Causes: Tendons move over a bony protrusion (overlapping) Thickening of tensor fascia lata Therapy: Conservative Surgery http://www.arthros.pl/public/images/fck/image/przeskakujace.jpg Snapping hip- surgery •Surgery: Z- plasty http://ajs.sagepub.com/content/32/2/470/F1.large.jpg Femoroacetabular impingement FAI •Pathological contact between femoral head • and the acetabulum • •Changes of the shape and orientation of the acetabulum and the femoral head • •Damage to the labrum and cartilage • •Limited movements, pain, progression into O.A. •Classification • •CAM type – femur •PINCER type – acetabulum – C:\Users\Lukas\Desktop\X\impimgement.jpg http://www.londonhiparthroscopycentre.com/images/3-stages-colour-final.jpg •Tests – •Imaging methods –X ray, CT, MRI http://t0.gstatic.com/images?q=tbn:ANd9GcQtZiHzIcjt7B3b5U8DiodflMRJKnjH7Gmcia72sFE2ro-eGdmKXQ http://www.ernestschilders.com/userfiles/image/pelvic-xray.jpg Jumper´s knee - distal pole of the patella m. Osgood- Schlatter Entesopathy in ligaments insertion -medial, lateral epicondyle - Pes anserinus entesopathy Entesopathy at Gerdy´s tubercle Entesopathies in knee region Entezo Osgood Schlatter ... C:\Users\Lukas\Pictures\JK.png Prepatellar bursitis Infrapatelar bursitis Bursitis of pes anserinus Ganglion of the meniscus Entezopathie- bursitis kolena Bursitis in the knee region Therapy: Rest, aspiration, corticoids NSAID, surgery https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcSR9l3x2y9DRK7uOL_QveRXtV-VY7sJnSBmM3SI7ZxYp0e I-JHo Baker´s cyst Bursa gastrocnemio- semimembranacea is connected with joint space Swelling, soft mass in popliteal region Limited movements Pressure onto large veins in popliteal region. Secondary to pathology in the knee joint Therapy: Conservative – aspiration, local corticoids, NSAID Arthroscopy of the knee- -meniscus, chondropathy, osteoarthritis Baker´s cyst dissepears spontaneously Removal of the bursa- exceptionally Entezo- Baker cysta1 Entezo- Baker 2 Bursitis and entesopathies in the foot Achilles tendinitis Calcaneal spur Haglund´s exostosis Osteophytes – dorsal Os tibiale externum Entezopatie - noha Noha Os tibiale externum Noha - ostruha Calcanear spur Therapy: Soft padding, NSA oitments, corticosteroids locally, Physiotherapy- magnetotherapy, ultrasound, laser, shock wave therapy, radiocobalt beams 4 Gy, arthroscopic removal Calcanear spur Dorsal exostosis Achilles tendinopathy Noha- ŠA2 Painful Achilles tendon at midportion and it´s insertion Thickening and pain Degeneration Haemorhage, ruptures Peritenonitis The risk of rupture Achilles tendinopathy Noha- ŠA3 Conservative treatment Rest, taping, NSAID Physiotherapy: Magnetotherapy Ultrasound Laser Hiltherapy Orthesis- soft, rigid Hyaluronic acid inj.(Hyalotend Sportvis) Collagen - GUNA inj. No corticosteroids-risk of rupture Achilles tendinopathy Noha- ŠA3 Surgery: Peritenonectomy Excision of necrotic tissue Entesopathy at the spine Entezopatie- záda Painfull insertions of ligaments and tendons Transverse or spinal processes Scapula Pelvis Entesopathies and tendinopathies in the shoulder region Tenosynovitis of tendon of long head of biceps Rupture of tendon of long head of biceps Subacromial bursitis Supraspinatus tendinitis Rotator cuff tear Tenosynovitis of long head of biceps Tenderness Resisted flexion and supination of the elbow Therapy: Corticosteroids locally Rest, sling NSAID Entezo- biceps Rupture of long head of biceps Rameno- rpt Tenderness Distalisation of muscle belly Diminished strength Rupture of long head of biceps Rameno- rpt bicepsu Therapy: Rest, sling NSAID Surgery – up to 40 years Conservative- over 40 years Surgery: Subpectoral tenodesis Suture to the short head of biceps C:\Users\PC\Pictures\subpectoral tenodesis 1.jpg C:\Users\PC\Pictures\supect tenod 1.jpg Subpectoral tenodesis Subacromialis bursitis Inflammation White fluid Severe, burning pain Restricted movements Tenderness Calcifications Rameno- bursitis subac Rameno-kalcifikace v burze Conservative treatment: Rest, sling Corticosteroids locally NSAID Later- physiotherapy Surgery: Arthroscopy- removal of bursa Subacromial bursitis Rameno- bursitis Supraspinatus tendinitis Tenderness over greater tuberosity Limited movements Therapy: Rest, NSAID Corticosteroids Physiotherapy Rameno-rpt Rotator cuff Rotator cuff: m. supraspinatus m. infraspinatus m. teres minor m. subscapularis Function: First 30 ° of abduction Pressure of the humeral head into glenoid cavity Depressor of the humeral head Entezo- RM Rameno- anatomie 2 C:\Users\PC\Pictures\RC tear 4.jpg Anatomy of the shoulder Entezo- rameno ze zadu Rotator cuff tear Rameno- rpt Partial tear: Severe pain Painful abduction Keeps the arm in position of adjusted abduction Ultrasonography Management: usually conservative C:\Users\PC\Pictures\RC tear 1.jpg C:\Users\PC\Pictures\RC tear 2.jpg Rotator cuff tear Complete tear: No active abduction Lifting of the shoulder Drop arm test Pain C:\Users\PC\Pictures\RC tear 3.jpg X-ray MRI C:\Users\PC\Pictures\RC repair 3.jpg Management: suture: Arthroscopy The aim: attachment to greater tuberosity C:\Users\PC\Pictures\RC reair 5.jpg Completed rotator cuff repair C:\Users\PC\Pictures\RC repair 1.jpg RM3.jpg Suture of RC RM1.jpg RM4.png Completed rotator cuff repair Management: suture: Open surgery The aim: attachment to greater tuberosity Rameno- rpt SLAP lesion •= superior labrum anterior, posterior • •Causes •Subluxation, dislocation •Microtraumatisation •Throwing shoulder – • http://ajs.sagepub.com/content/38/8/1584/F1.large.jpg SLAP - management Conservative Arthroscopy- debridement, suture Tenotomy Subpectoral tenodesis http://cdn5.arthrex.com/taxon-images/proximal_biceps_tenodesis/proximal_biceps_tenodesis_0-large.pn g suture Subpectoral tenodesis Other disorders of painful shoulder Impingement syndrom Frozen shoulder syndrom Osteoarthritis of glenohumeral joint Rotator cuff arthropathy Disorders of acromioclavicular joint Disorders of sternoclavicular joint Inflammations Tumors Referred pain to the shoulder Impingement syndrom Greater tuberosity impinges to distal surface of acromion and coracoacromial ligament Narrowing of subacromial space Causing damage of corator cuff Imping Impingement syndrom Imping Imping Causes • Acromion spur •Changes of acromion •Distal osteophytes of AC •Prominence of tuberculum maius Impingement syndrom Stages: 1.Swelling, hemorhage of supraspinatus 2. Fibrosis, tendinitis, bursitis degenerative changes of cuff 3. Rupture of rotator cuff and long biceps tendon Entezo- GH kloub Impingement syndrom Rameno-bolestivý oblouk Symptoms: Painful arc Impingement sign Impingement test Jobe test X-ray: Narrowed subacromial space Y view- outlet view Arthrography Ultrasonography 60-120 grades painful arc Impingement syndrom Therapy: 1.stage: conservative Rest, NSAID, Physiotherapy, Local corticosteroids 2. stage: the same + bursectomy, subacromial decompression 3. stage: subacromial decompression Burr acromioplasty Frozen shoulder- capsulitis adhesiva Rameno- sy zmrzlého ramene Progressive limitation of movements Pain No motivation for movement Shrinkage of capsule Adhesions in distal recesus Tightening of soft tissue Muscle spasm Low capacity of joint space The cause All conditions limiting joint movements: Impingement syndrom Arthrosis of AC joint Posttraumatic conditions Inflammations Thoralic outlet syndrom Tumors of the lungs Disorders of pleura Cardiac disorders Rameno- frozen shoulder Frozen shoulder Management: Long lasting period Heat Passive movements Positioning Active movements Physioterapy NSAID Local corticosteroids ASC- decompression Removal of adhesions Rameno- frozen shoulder Glenohumeral osteoarthritis - omarthrosis Rameno- artróza Therapy: Conservative Total shoulder replacement Rotator arthropathy • poperační předoperační Reverse total shoulder artroplasty Disorders of acromioclavicular joint Synovitis O.A. Sprain Subluxation Dislocations Rameno- luxace AC Disorders of sternoclavicular joint rameno-sternoklav Synovitis O.A. Sprain Subluxation Dislocations Chronic subluxation Referred pain to the shoulder Cervical spine Thoracic outlet syndrom Cardiac diseases Lung and pleura disorders Herpes zoster neuralgia