Inflammation of the foot muscles - tenosynovitis: signs, diagnosis, treatment

Traumatologist-orthopedist (adults and children)

Bogatov

Victor Borisovich

21 years of experience

Highest qualification category. Doctor of Medical Sciences, Professor of the Department of Traumatology and Orthopedics, First Moscow Medical University. I.M. Sechenov.

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Tendonitis is a disease that manifests itself as an inflammatory process in the tendon area. Pathology can occur in acute or chronic forms. In the second case, degenerative processes develop in the affected tendon. In most cases, the source of inflammation is localized in the tissues adjacent to the bone. Symptoms of tendonitis are nonspecific: the patient suffers from pain when moving the limbs and local fever. The formation of mild edema and a zone of moderate hyperemia is possible. Treatment of pathology in the initial stages involves the use of conservative techniques. An advanced inflammatory process may require surgical intervention.

General information

Tendonitis occurs in patients of all ages. The risk group includes professional athletes and people engaged in monotonous physical labor. The source of inflammation is formed due to excessive stress to which the human tendons are exposed. Tissue microtraumas cause pain and increased local temperature.

Most often, the pathology affects the tendons located next to the elbow, knee and hip joints. Less commonly, inflammation develops in the ankle and wrist joints. Age-related changes in joint tissues lead to weakening of ligaments - the likelihood of developing inflammation increases. Patients over 60 years of age may suffer from the deposition of calcium salts, leading to the appearance of a calcifying form of the disease.

Anatomy of the Achilles tendon

Developed Achilles tendon

present only in humans and is an evolutionary adaptation to upright walking. It is believed that the human musculoskeletal system has not yet had time to fully adapt to upright walking, so its individual elements experience increased loads.

Although evolutionary selection gave the Achilles tendon

high endurance (its tensile strength reaches 400 kg) and has made it the thickest tendon in the human body, it is nevertheless considered one of the most vulnerable.

The Achilles tendon from above, in its widest and thinnest part, is attached to the fusion of the heads of the triceps muscle (formed by the gastrocnemius and soleus muscles), and from below, tapering at a level of 3-4 cm above the heel bone, it is attached to the calcaneal tubercle.

Due to its anatomical features, the Achilles tendon

is responsible for normal supination and pronation of the foot (the main biomechanical processes that occur during human movement). It also provides anatomically correct movement and stability in the knee, ankle and subtalar joints.

Mechanical properties of the Achilles tendon

fully correspond to these tasks: when running, it can withstand loads that are 8 times the weight of the person himself.

Reasons for the development of pathology

Symptoms of tendinitis identified by an orthopedist during an examination of the patient may indicate the causes of inflammation in the tendon. Often tissue microtraumas result from a high level of human motor activity. The pathology is common among professional tennis players, golfers, javelin throwers and skiers. The monotonous movements typical of gardeners, carpenters or painters often cause inflammation of the tendons.

A quarter of clinically diagnosed cases of tendonitis develop under the influence of other factors: rheumatic pathologies or diseases of the thyroid gland. Inflammation of the tendons can be a consequence of gonorrhea, intoxication of the body or abnormalities of the bone skeleton (different lengths of limbs, etc.).

Publications in the media

Tendonitis is an inflammation of tendon tissue, usually observed at the point of attachment to the bone or in the area of ​​the musculotendinous junction; usually combined with inflammation of the tendon bursa or tendon sheath.

Etiology • Increased motor activity and microtraumatization • Diseases of a rheumatic nature •• Rheumatoid arthritis •• Gout •• Reactive arthritis.

Risk groups • Athletes • Manual workers.

Pathomorphology . Degenerative changes in tendons: presence of fibrinoid, mucoid or hyaline degeneration of connective tissue. Clinical picture

• Pain •• With active movements made with the participation of the affected tendon, while similar passive movements are painless •• With palpation along the affected tendon.

• Hyperemia, hyperthermia over the area of ​​the affected tendon.

• Crepitus when the tendon moves, audible at a distance or only through a phonendoscope.

• Most common location •• Rotator cuff tendinitis, biceps tendonitis (see Periarthrosis humeroscapular) • • Lateral epicondylitis (tennis elbow) - tendinitis of the wrist extensor muscles (brachioradialis, extensor carpi radialis longus and brevis) ••• Pain when palpating the area of ​​the lateral epicondyle of the humerus ••• Thomsen's test: when the patient tries to hold the hand clenched into a fist in the position of dorsiflexion, it lowers, moving to the position of palmar flexion ••• Belsh's test: the patient is given the command to simultaneously extend and supinate both forearms located at the level of the chin in a position of flexion and pronation, with the affected side lagging behind the healthy side • • Medial epicondylitis (“golfer’s elbow”) - tendinitis of the flexor and pronator muscles of the forearm (pronator teres, flexor carpi radialis and ulnaris, palmaris longus) ••• Pain on palpation of the medial epicondyle of the humerus ••• Pain with flexion and pronation of the forearm, radiating along its inner edge ••• Concomitant ulnar nerve neuropathy (25–50% of patients) • • Stenosing tenosynovitis of the extensor brevis and abductor longus muscles thumb (de Quervain's disease), accompanied by narrowing of the first canal of the dorsal ligament of the wrist ••• Pain when extending and abducting the thumb ••• Pain when palpating the styloid process of the radius ••• Elkin's test: pain when bringing the tip of the thumb together tips of the index finger and little finger • • Stenosing tenosynovitis of the extensor ulnaris (ulnar styloiditis) is accompanied by a narrowing of the VI canal of the dorsal ligament of the wrist ••• Pain in the area of ​​the styloid process of the ulna ••• Swelling in the same area • • Tendonitis of the patellar ligament proper ••• Pain in the area of ​​the tibial tuberosity when walking, running, going down stairs ••• Swelling in the area of ​​the tibial tuberosity • • Tendinitis of the Achilles tendon and plantar tendons (talalgia) ••• Pain when stepping on the heel and when flexing the plantar ••• Local swelling - with concomitant achillobursitis and subcalcaneal bursitis.

• Children and teenagers. The most common form is patellar tendinitis associated with inflammation of the tibial apophysis (Osgood-Schlatter disease).

Research methods • Laboratory studies: changes are observed only with concomitant rheumatic pathology • X-ray examination •• Possible calcium deposits in the tendons •• Heel spurs - with tendonitis and tendobursitis of the Achilles tendon or plantaris tendon •• With tendonitis of the patellar ligament, signs of aseptic necrosis of the tuberosity are possible tibia (Osgood-Schlatter disease) • Special studies •• Echography of the tendon - contraction of the tendon, changes in its structure. It is necessary to ensure that the ultrasound wave does not cross the tendon along the oblique diameter. •• CT/MRI are informative for identifying tendon ruptures, but are not very informative in diagnosing stenosing tenosynovitis.

Differential diagnosis • Tendon avulsion • Bursitis (often combined with tendonitis should be remembered) • Infectious tenosynovitis (usually on the arm; pain on palpation and swelling are located along the tendon sheath, and not at the point of attachment to the bone).

Treatment • Management •• In the acute phase - rest, immobilization ••• Shoulder sling or splints for the upper extremities ••• Braces, cane and/or crutches for the lower extremities ••• Plasters placed tightly on the forearm slightly distal to the elbow joint - for epicondylitis •• Exercise therapy • Drug therapy •• NSAIDs ••• Piroxicam 10 mg/day ••• Indomethacin 25 or 50 mg 3 times a day ••• Ibuprofen 1800–2400 mg/day ••• Ointments with NSAIDs, for example ibuprofen, 3 times a day •• GK (injection into painful areas) ••• 40 mg of methylprednisolone with 4–6 ml of 1–2% lidocaine solution ••• 1–20 mg of hydrocortisone with the same volume of 1–2% solution of procaine. It is necessary to avoid insertion into the tendon sheath; in case of medial epicondylitis, the proximity of the ulnar nerve should be taken into account. After periarticular injections, despite a significant reduction in pain intensity, it is recommended to exclude physical activity due to the risk of tendon rupture • Surgical treatment - dissection of tendon aponeuroses, is used in the absence of the effect of conservative treatment, in the presence of signs of stenosing tendinitis, in Osgood-Schlatter disease.

Complication is tendon rupture.

The prognosis is favorable.

ICD-10 • M65 . 2 Calcific tendonitis • M75 . 2 Biceps tendinitis • M75 . 3 Calcific tendinitis of the shoulder • M76 . 0 Gluteal tendinitis • M76 . 1 Psoas tendinitis • M76 . 5 Patellar tendinitis • M76 . 6 Heel [Achilles] tendinitis • M76 . 7 Fibular tendinitis • M77 . 9 Enthesopathy, unspecified

Pathogenesis

Tendons are formed in the form of dense, inelastic cords consisting of bundles of collagen fibers. Thanks to them, muscle tissue connects to bones. Tendons provide the transmission of movement from muscles to the skeleton and maintain stable joint function. Intense and monotonous movements interfere with the process of natural restoration of collagen fibers - the first signs of tendinitis appear.

The tendon structures swell and individual strands of collagen begin to break down. If the load remains high, foci of fatty degeneration, necrosis and deposition of calcium salts form in the tissues. Hardened calcifications lead to re-injury of the previously damaged area. The inflammatory process gradually spreads to the entire tendon.

Types of pathology

Tendinitis can affect tendons of any size - inflammatory processes develop in the tissues of the finger, hand, foot, elbow or knee. The classification of pathology used by orthopedists takes into account the localization of the source of pathology. Doctors distinguish the following forms of the disease:

• lateral,
• medial,
• inflammation of the patellar tendon,
• inflammation of the tendon of the shoulder joint.

The lateral type of pathology develops in the tendons adjacent to the wrist muscles (extensor brevis and longus, brachioradialis muscle, etc.). The patient experiences pain spreading along the outer surface of the elbow joint. Over time, professional and amateur athletes develop hand weakness. A person begins to experience difficulty performing basic actions: twisting clothes, lifting a cup of drink, shaking hands.

The medial form of the disease affects the tendons adjacent to the flexor muscles of the forearm, elbow and palm. The pathology is diagnosed 7–10 times less frequently than lateral tendonitis and develops in individuals who regularly perform rotational movements of the arms. Those at risk include golfers, seamstresses, professional scorekeepers, gymnasts, tennis players and baseball players. The main symptom of the disease is acute pain localized on the inside of the elbow joint.

Inflammation of the patellar tendon is diagnosed in people who frequently perform jumps. Microtrauma is caused by short-term intense loads on the quadriceps muscle. In the initial stages of development of the pathology, pain occurs after the patient completes physical activity. Later, pain appears during exercise or at rest.

Inflammation of the shoulder tendons affects the tissue adjacent to the rotator cuff muscles. Pain occurs during any activity that requires hand mobility. Acute attacks can develop at night. An increase in the size of the focus of inflammation leads to the formation of pronounced edema.

Treatment of foot tendonitis

Drug therapy for tendinitis is aimed at eliminating the source of inflammation and reducing pain. For this purpose, rheumatologists prescribe the following medications:

• Non-steroidal anti-inflammatory drugs (orally, intramuscularly or locally);
• Glucocorticoids (locally or at the site of localization of the focus of the inflammatory-degenerative process);
• Ointments that have an irritating effect on the skin of the foot.

You can improve your condition and reduce the severity of pain using traditional medicine methods. Patients use them if pain occurs during weather changes. In this case, healers recommend taking one teaspoon of sarsaparilla infusion and ground ginger root 3 times a day. Walnuts have an anti-inflammatory effect. You can use the partitions of walnuts infused with vodka. Herbalists recommend taking one teaspoon of the tincture 2 times a day.

If the patient prefers to resort to homeopathy, he is recommended to take Arnica Montana 9 CH. This homeopathic remedy should be taken 3 tablets under the tongue three times a day, an hour after meals or drinks. Do not use menthol-flavored toothpaste or chewing gum while using this drug.

If tendonitis occurs after an injury and does not respond to drug therapy, patients are offered surgery. Severe cases of plantar tendinitis are discussed at a meeting of the Expert Council with the participation of professors and associate professors, doctors of the highest category. Leading specialists in the field of bone and tendon diseases collectively decide on the need for surgical treatment. The operations are performed by experienced orthopedic traumatologists. Surgeons are fluent in the techniques of modern surgical interventions on tendons.

Symptoms

Symptoms of the disease appear gradually. In the early stages, the patient experiences pain at the time of maximum physical exertion. The rest of the time, the injured tendon does not cause any discomfort to the child or adult. Over time, the pain syndrome becomes more intense: discomfort occurs with minimal physical activity. If left untreated, the patient may be unable to perform everyday activities such as washing dishes, putting on clothes, fastening buttons, tying shoelaces.

The skin next to the source of inflammation turns red and swelling forms. Local temperatures may rise. Palpation of the tendon increases the pain. With sudden movements of the injured limb, the patient may hear a crunching or crackling sound.

Main causes of Achilles tendon injury

There are four groups of causes that can cause Achilles tendon rupture or inflammation
. This includes:

• tendon injuries (open and closed);
• inflammatory, metabolic, viral and other diseases that may not directly affect the Achilles (gout, rheumatoid arthritis) or occur in the immediate vicinity of it (heel spur, tendonitis, achilles bursitis);
• congenital problems with the Achilles tendon (its insufficient length from birth and paresis of the foot) or collagen synthesis, constitutional features;
• others (age-related, biochemical, related to patient habits).

Damage and pain in the Achilles tendon

may occur in case of infectious diseases while taking fluoroquinolone antibiotics. Already in the first 48 hours after the start of treatment with them, any high load on it can provoke a rupture of the Achilles tendon.

The tendon can also be damaged due to excess weight, constant wearing of uncomfortable shoes (too tight or high heels). These reasons cause deformation of collagen fibers and reduce their endurance. A sedentary lifestyle increases stress on the Achilles tendon

. This is due to poor development and shortening of the calf muscles - the “companions” of the Achilles in matters of load distribution.

Age-related changes in the body, which begin after 40 years, cause a decrease in the strength and elasticity of the tendons. Increasing physical activity at this age without prior long-term adaptation can cause inflammation and even rupture of the Achilles tendon

. At the same time, the correlation is different for men and women, because The microscopic structure of the tendon is different. The level of estrogen, the female sex hormone that is responsible for the elasticity of ligaments and tendons, also varies. Because men have less of it, their tendons are stiffer and less resistant to jerking loads.

Diseases

The Achilles tendon can hurt
due to the following diseases and pathologies:

• heel spur and Haglund's deformity;
• tendinitis and calcification of the tendon due to micro-tears;
• traumatic lesions of the heel and ankle;
• arthritis, arthrosis and other joint diseases (spine, knee, ankle, foot and toes);
• deformations in the musculoskeletal system (for example, flat feet);
• metabolic diseases (diabetes mellitus, gout) and endocrinological problems (ovarian dysfunction and others);
• systemic and autoimmune diseases that affect connective tissue (rheumatoid arthritis, rheumatism);
• systemic and local infections.

Injuries

Achilles tendon injuries

are accompanied by its partial or complete rupture, or separation of the tendon from the heel tubercle to which it is attached. Most often, the injury occurs at the start of sprinting, when landing in jumpers or dancers, and also during the game of tennis, volleyball, basketball or football. Particularly conducive to obtaining it:

• too rapid increase in load intensity, to which the musculoskeletal system does not have time to adapt;
• lack of normal warm-up and cool-down before playing sports;
• insufficient development of the calf muscles;
• physical overload;
• sudden jerking loads;
• uncomfortable shoes;
• running and jumping on unsuitable surfaces.

At the time of injury, the patient experiences a sensation of a sharp blow to the back of the ankle, which gradually passes, giving way to pain. A characteristic cracking sound may be heard. Traumatic damage to the Achilles tendon is often accompanied by severe hemorrhage and swelling. You can often feel a “groove” in the area of ​​the rupture. The left leg is most often injured.

With a traumatic rupture of the Achilles tendon, the patient cannot voluntarily bend the sole or rise on the toes, and all attempts are accompanied by severe pain.

First aid for Achilles tendon ruptures

consists of applying ice and applying a special splint.

Diagnostics

Diagnosis of tendinitis is performed by an orthopedist. The doctor examines the patient and collects data for anamnesis. Confirmation of the primary diagnosis is carried out through radiography, ultrasound and magnetic resonance imaging of the injured tendon.

X-rays can reveal foci of calcification that have formed in collagen fibers. Ultrasound imaging of tendons demonstrates tissue thickening and decreased echogenicity. MRI is used to determine the location of the inflammation and its size.

Treatment

The treatment strategy for tendinitis is determined by the orthopedist, taking into account the data obtained during diagnostic procedures. In case of severe pain, the patient is advised to undergo short-term immobilization of the limb. Drug therapy includes anti-inflammatory drugs. Tissue swelling is eliminated through phonophoresis and electrophoresis.

Relief of the pain syndrome will allow the patient to begin therapeutic exercises. If acute pain persists, the child or adult receives glucocorticosteroid drugs by injection. The ineffectiveness of conservative therapy becomes an indication for surgical intervention.

During the operation, surgeons can perform complete or partial cutting of the tendons from the muscles for the purpose of subsequent lengthening. The postoperative rehabilitation period can last several months.

4. Treatment of the disease

First aid for tendinitis

is to stop the traumatic impact and give rest to the damaged part of the body. You can apply cold to the area of ​​the damaged tendon. Local anti-inflammatory and analgesic ointments or anti-inflammatory drugs will help cope with pain.

If the condition does not improve within a week after tendinitis begins, see your doctor. Perhaps more serious methods are needed to treat tendonitis. It can be:

• Corticosteroid injections. This injection will quickly help reduce inflammation and pain;
• Physiotherapy. Physical therapy is very helpful for tendonitis. Especially with shoulder tendonitis. This group also includes splinting the damaged area of ​​the body.
• Surgical treatment of tendonitis. Tendinitis is rarely treated surgically, only when other methods of treating tendonitis do not produce any results.

If you are treating tendonitis at home, you should contact your doctor immediately if any of the following symptoms appear:

• Heat;
• Swelling, redness and warmth in the tendonitis area;
• General deterioration in health;
• Inability to move the affected part of the body.

All of the above symptoms may be signs of another health problem that requires careful diagnosis and treatment.

Prognosis and prevention

Timely initiation of treatment for inflammatory processes in the tendons allows doctors to form a favorable prognosis for most patients. When the pathology is advanced, systematic relapses and severe injuries to the extremities are likely. Surgical treatment allows for complete restoration of limb mobility in 85–90% of cases.

Prevention of tendinitis is based on avoiding excessive stress on the tendons. Amateur and professional athletes should do a thorough warm-up before starting training or competition.