Overuse Syndromes — Periarthritis, Tendovaginitis, Insertionitis, Bursitis

Introduction

The overuse syndromes — periarthritis, tendinosis and tendinitis (tendovaginitis), insertionitis (enthesopathy), and bursitis — constitute a heterogeneous group of conditions characterized by inflammation, degeneration, or both of the periarticular soft tissues. They are exceedingly common in clinical practice, affecting both occupational and recreational athletes as well as patients with sedentary lifestyles. The conditions share the general theme of mechanical overload exceeding the tissue’s adaptive capacity, with the specific anatomical site determined by the typical patterns of force and friction encountered in daily activities and sports. This chapter, synthesizing content from Apley & Solomon’s, Miller’s Review, and Dutton’s Orthopaedic Examination, addresses the principal overuse syndromes by anatomical region.

General Principles

The modern understanding of “tendinitis” has been substantially revised in recent decades. Histological studies of chronic painful tendons reveal mostly degenerative rather than inflammatory changes — disorganized collagen fibers, increased mucoid ground substance, focal microscopic tears, and angiofibroblastic proliferation — without significant infiltration by inflammatory cells. The term “tendinosis” (degeneration) is therefore more accurate than “tendinitis” (inflammation) for the chronic condition; the term “tendinitis” remains appropriate for acute inflammatory processes. The implication for treatment is that anti-inflammatory measures (NSAIDs, corticosteroid injection) address only one component of the disease, with the underlying degenerative changes requiring different approaches including eccentric exercises, extracorporeal shock-wave therapy, and biological injections (PRP, autologous blood, sclerosing agents). Bursitis is inflammation of a bursa — the fluid-filled sac that reduces friction between tissues at sites of mechanical stress. Bursae may be normally present (anatomically constant) or develop in response to repetitive mechanical stress (adventitial bursae). Bursitis may be inflammatory (from overuse), septic (from infection), or hemorrhagic (from trauma).

Shoulder Overuse Syndromes

Subacromial Impingement and Rotator Cuff Disease Subacromial impingement syndrome is the commonest source of shoulder pain in adults. The condition involves mechanical impingement of the rotator cuff (particularly the supraspinatus tendon) and the subacromial bursa against the undersurface of the acromion during shoulder elevation. The Neer classification recognizes three stages: Stage 1 (edema and hemorrhage of the cuff, reversible); Stage 2 (fibrosis and tendinosis of the cuff); Stage 3 (cuff tear, with or without bony changes).

Risk factors include acromial morphology (the Bigliani classification of Type I flat, Type II curved, Type III hooked, with Type III associated with the highest rates of cuff tear), overhead activities, age-related cuff degeneration, and prior injury. The classical clinical features include lateral shoulder pain, painful arc of motion (60-120° of abduction), positive Neer impingement sign (passive forward flexion of the internally rotated arm producing pain), positive Hawkins-Kennedy sign (forward flexion of the arm to 90° with internal rotation), and rotator cuff weakness in advanced disease. The natural history of rotator cuff disease is one of progressive degeneration with age, with full-thickness tears developing in many cases. The Goutallier classification of fatty infiltration of the cuff (Grade 0 normal to Grade 4 more fat than muscle) is the principal prognostic factor for surgical repair. Treatment of impingement syndrome begins conservatively: physiotherapy directed at rotator cuff and scapular stabilizer strengthening, posterior capsule stretching, postural correction, activity modification, NSAIDs, and selective subacromial corticosteroid injection. Surgical management — typically arthroscopic subacromial decompression with or without rotator cuff repair — is reserved for persistent symptoms refractory to conservative care. The role of acromioplasty as an isolated procedure has been increasingly questioned by recent randomized trials. For full-thickness rotator cuff tears, surgical repair is appropriate for younger patients with acute tears, for refractory symptoms, and for progressive cuff dysfunction. The technique is principally arthroscopic with suture anchor fixation. Outcomes depend strongly on tear size, chronicity, and Goutallier fatty infiltration. Massive irreparable tears may be managed by partial repair, superior capsule reconstruction, tendon transfer (latissimus dorsi for posterior-superior cuff tears, lower trapezius for similar pattern), or reverse total shoulder arthroplasty for cuff tear arthropathy. Calcific Tendinopathy of the Rotator Cuff Calcific tendinopathy is a self-limiting condition in which calcium hydroxyapatite deposits form in the rotator cuff, most commonly the supraspinatus tendon. Three phases are recognized: formative phase (chalk-like calcific deposits, often asymptomatic); resorptive phase (acute severe pain as the deposits dissolve and inflammatory cytokines are released); and post-calcific phase (resolution). Acute resorptive-phase pain is among the most severe shoulder pain encountered in clinical practice. Treatment in the formative phase is conservative (NSAIDs, physiotherapy); the resorptive phase is treated with NSAIDs, intra-bursal corticosteroid injection, and sometimes ultrasound-guided needle aspiration of the calcific deposit (barbotage), with surgical removal reserved for refractory cases. Frozen Shoulder (Adhesive Capsulitis) Frozen shoulder is a poorly understood condition of progressive shoulder pain and stiffness, with restricted active and passive motion in all planes. Three phases are described: freezing (painful, with progressive stiffness); frozen (stiff but less painful); thawing (gradual resolution of stiffness). The condition is associated with diabetes mellitus

(substantially increased prevalence), thyroid disease, and other systemic conditions. The natural history is typically resolution over 1-3 years, although a substantial minority have residual stiffness. Treatment combines physiotherapy directed at gentle range-of-motion exercises, NSAIDs, intra-articular corticosteroid injection (with evidence of benefit in the painful early phase), and selective use of manipulation under anesthesia or arthroscopic capsular release for refractory cases. Acromioclavicular Joint Disease The acromioclavicular joint is subject to both osteoarthritis and post-traumatic arthritis (often after AC joint separation). Treatment is initially conservative with NSAIDs, activity modification, and corticosteroid injection; surgical management is by distal clavicle excision (Mumford procedure) when conservative measures fail. Bicipital Tenosynovitis and Long Head of Biceps Tendinopathy The long head of the biceps tendon traverses the bicipital groove of the proximal humerus and is subject to inflammation, degeneration, instability (with subluxation or dislocation from the groove), and rupture. Presentation is with anterior shoulder pain. Treatment ranges from conservative measures through tenotomy or tenodesis of the biceps tendon.

Elbow Overuse Syndromes

Lateral Epicondylitis (Tennis Elbow) Lateral epicondylitis is a chronic tendinopathy at the origin of the wrist extensors, particularly extensor carpi radialis brevis (ECRB), at the lateral humeral epicondyle. The condition is the commonest cause of lateral elbow pain in adults, affecting approximately 1- 3% of the general population. The term “tennis elbow” reflects the association with the backhand stroke in tennis, but the great majority of cases occur in non-tennis players, typically with occupational repetitive wrist extension. Presentation is with lateral elbow pain provoked by activities requiring wrist extension or gripping. Examination reveals tenderness at the ECRB origin (approximately 1 cm distal to the lateral epicondyle) and reproduction of pain with resisted wrist extension and resisted middle finger extension (Maudsley test). The differential diagnosis includes radial tunnel syndrome (more distal tenderness, different provocative patterns), osteochondritis of the capitellum (in adolescent throwing athletes), and lateral collateral ligament insufficiency. Treatment is initially conservative: activity modification, eccentric exercise programs targeting the wrist extensors, counterforce bracing, NSAIDs, and selective corticosteroid injection (with evidence of short-term benefit but possible worse long-term outcomes). Newer treatments under investigation include extracorporeal shock-wave therapy, platelet-rich plasma injection, and other biological injections. Surgical management — open or arthroscopic ECRB release with possible debridement of pathological tissue — is reserved for the small fraction of patients who fail comprehensive conservative management over 6-12 months.

Medial Epicondylitis (Golfer’s Elbow) Medial epicondylitis is the analogous condition at the origin of the wrist flexors and pronator teres at the medial epicondyle. Presentation is with medial elbow pain provoked by gripping and wrist flexion. The differential diagnosis includes ulnar collateral ligament insufficiency (particularly in throwing athletes) and ulnar neuritis. Treatment principles parallel those of lateral epicondylitis, with attention to the ulnar nerve in surgical procedures. Olecranon Bursitis Olecranon bursitis is inflammation of the bursa overlying the olecranon process, with the classical “student’s elbow” or “miner’s elbow” presentation of a swollen mass over the posterior elbow. Causes include acute trauma, repetitive pressure, and septic infection (particularly Staphylococcus aureus). Aseptic bursitis is treated conservatively with rest, NSAIDs, and selective aspiration; septic bursitis requires antibiotic therapy and surgical drainage when needed.

Wrist and Hand Overuse Syndromes

De Quervain’s Tenosynovitis De Quervain’s tenosynovitis is inflammation of the first dorsal compartment of the wrist, containing the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. The condition is more common in women, particularly in association with pregnancy and lactation (“new mother’s wrist,” from the repeated lifting of an infant with the wrist in radial deviation), and in patients with occupational repetitive thumb use. Presentation is with radial-sided wrist pain. The Finkelstein test (active flexion of the thumb into the palm with ulnar deviation of the wrist, reproducing the symptoms) is the classical clinical sign; the Eichhoff test (passive thumb flexion within the closed fist with ulnar deviation) is similar. Treatment is initially conservative with thumb spica splinting, NSAIDs, and corticosteroid injection (high success rate of 60-80%). Surgical release of the first dorsal compartment is reserved for refractory cases, with attention to identification and protection of accessory APL slips (which are present in many patients and require release of any septated subcompartments). Stenosing Tenosynovitis (Trigger Finger / Trigger Thumb) Stenosing tenosynovitis of the digital flexor tendons — trigger finger — is a common condition in which thickening of the A1 pulley at the level of the metacarpal head produces resistance to tendon excursion, with characteristic “triggering” of the affected digit as the tendon catches and then releases through the constricted pulley. The condition is more common in women, in middle age, and in patients with diabetes mellitus (with substantially elevated prevalence and lower response to conservative treatment). Presentation is with painful catching or locking of the affected digit, most commonly the long, ring, or thumb. Examination reveals tenderness and a palpable nodule at the A1

pulley with reproduction of the triggering on active digital flexion. The Quinnell or Green classification grades severity from preclinical (palpable nodule without triggering) through fixed flexion contracture. Treatment is conservative initially with corticosteroid injection (high success rate of 60- 85% with one or two injections, lower in diabetic patients), splinting, and NSAIDs. Surgical release of the A1 pulley is highly successful (>95%) and is performed open under local anesthesia in a brief outpatient procedure. Other Wrist Tendinopathies Multiple other wrist tendinopathies are described: extensor pollicis longus tenosynovitis (sometimes associated with rupture, particularly after distal radius fracture); flexor carpi radialis tendinopathy; FCU tendinopathy; ECU tendinopathy with snapping or instability of the ECU subsheath; intersection syndrome (inflammation at the crossing of the first and second dorsal compartments). Treatment principles parallel those of de Quervain’s tenosynovitis.

Hip Overuse Syndromes

Greater Trochanteric Pain Syndrome (Trochanteric Bursitis) Greater trochanteric pain syndrome — the modern term for what was historically called “trochanteric bursitis” — is a heterogeneous condition of lateral hip pain typically combining gluteus medius and minimus tendinopathy or tears with associated bursitis. The condition affects women more than men and is associated with hip abductor weakness, prior hip surgery, leg-length discrepancy, and obesity. Treatment is principally conservative: physiotherapy directed at gluteus medius strengthening, weight loss, activity modification, NSAIDs, and selective corticosteroid injection. Newer modalities include PRP injection and shock-wave therapy. Surgical management — arthroscopic gluteus medius and minimus repair, or open repair for larger tears — is reserved for refractory cases or for established full-thickness tears with significant abductor dysfunction.

Ischial Bursitis (“Weaver’s Bottom”) and Snapping Hip Ischial bursitis produces buttock pain at the ischial tuberosity, often from prolonged sitting on hard surfaces. Treatment is conservative. Snapping hip describes a palpable or audible snap with hip motion. External snapping hip — the iliotibial band snapping over the greater trochanter — is the commonest pattern. Internal snapping hip — the iliopsoas tendon snapping over the iliopectineal eminence or femoral head — produces a clicking sensation in the anterior hip. Intra-articular snapping hip is from loose bodies or labral tears. Treatment is principally conservative with stretching and activity modification; surgical release of the iliotibial band or iliopsoas tendon is reserved for refractory cases.

Knee Overuse Syndromes

Patellar Tendinopathy (Jumper’s Knee) Patellar tendinopathy is degeneration of the patellar tendon at its origin from the inferior pole of the patella. The condition is common in athletes engaged in jumping sports (volleyball, basketball, high-jump). Presentation is with anterior knee pain. Treatment is principally conservative with eccentric exercise programs (the Alfredson protocol for the Achilles tendon, adapted for the patellar tendon, is the standard), shock-wave therapy, PRP injection, and selective surgical management for refractory disease. Quadriceps Tendinopathy and Patellofemoral Pain Syndrome Quadriceps tendinopathy is the analogous condition at the superior pole of the patella, less common than patellar tendinopathy. Patellofemoral pain syndrome is a complex condition of anterior knee pain, with multiple contributing factors including patellar maltracking, quadriceps imbalance (relative weakness of vastus medialis obliquus), tight lateral structures, hip abductor weakness, and various other factors. Treatment is principally conservative with physiotherapy and activity modification. Iliotibial Band Syndrome (Runner’s Knee) Iliotibial band syndrome is friction of the IT band over the lateral femoral condyle, producing lateral knee pain in runners. Treatment is conservative with stretching, activity modification, and selective injection. Pes Anserine Bursitis Pes anserine bursitis is inflammation of the bursa beneath the conjoint insertion of sartorius, gracilis, and semitendinosus on the medial tibia. The condition produces medial knee pain, often confused with medial meniscal pathology. Treatment is conservative.

Osgood-Schlatter and Sinding-Larsen-Johansson Diseases These are juvenile traction apophysitis conditions affecting the tibial tuberosity (Osgood- Schlatter) and the inferior pole of the patella (Sinding-Larsen-Johansson) in adolescents. Self-limiting conditions managed conservatively with activity modification and analgesics.

Foot and Ankle Overuse Syndromes

Achilles Tendinopathy Achilles tendinopathy is a degenerative condition affecting either the midportion of the Achilles tendon (2-6 cm above the insertion, the avascular region) or the insertion at the calcaneus. Insertional tendinopathy is often associated with Haglund deformity (a prominence of the posterior superior calcaneus) and retrocalcaneal bursitis.

Treatment of mid-portion Achilles tendinopathy is principally conservative with eccentric exercise (the Alfredson protocol), heel lifts, activity modification, NSAIDs, and selective injection therapies. Surgical management is reserved for refractory cases. Insertional tendinopathy is more difficult to treat conservatively; surgical options include resection of the Haglund prominence, excision of the diseased tendon portion, and reattachment of the tendon. Achilles tendon rupture is discussed in the chapter on muscle and tendon injuries. Plantar Fasciitis Plantar fasciitis is degeneration and inflammation of the plantar fascia at its origin from the medial calcaneal tuberosity. Risk factors include obesity, occupational prolonged standing, foot deformities (pes planus, pes cavus), tight Achilles tendon, and running. Presentation is with heel pain that is worst with the first steps in the morning or after periods of rest (“first-step pain”) and tends to improve with continued activity. Treatment is principally conservative with stretching (Achilles and plantar fascia stretches), heel cups and arch supports, night-time dorsiflexion splinting, NSAIDs, and selective corticosteroid injection (with caution about plantar fat pad atrophy from repeated injection). Extracorporeal shock-wave therapy is supported by evidence for refractory cases. Surgical plantar fascia release is reserved for the small fraction of patients who fail comprehensive conservative management. Tibialis Posterior Tendinopathy Tibialis posterior tendinopathy is the early stage of adult-acquired flatfoot deformity, discussed in the chapter on flatfoot. Peroneal Tendinopathy Peroneal tendinopathy and peroneal tendon subluxation produce lateral ankle pain. Treatment is initially conservative; surgical management addresses tendon pathology and superior peroneal retinaculum reconstruction for chronic instability.

Periarthritis and Other Regional Syndromes

The term “periarthritis” was historically used to describe pain around joints from various soft-tissue causes; in modern usage the term is largely replaced by more specific diagnoses (impingement syndrome, frozen shoulder, etc. for the shoulder; epicondylitis for the elbow; etc.). The historical concept of “periarthritis humeroscapularis” encompassed what is now understood as rotator cuff disease, impingement, calcific tendinopathy, and frozen shoulder.

Bursitis at Specific Sites

Bursitis can develop at any anatomical site where mechanical stress between tissues is repeatedly applied. The principal sites include:

• Olecranon bursitis (elbow) • Trochanteric bursitis (lateral hip) • Ischial bursitis (ischial tuberosity) • Pes anserine bursitis (medial knee) • Prepatellar bursitis (“housemaid’s knee,” from kneeling) • Retrocalcaneal bursitis (posterior heel) • Subacromial bursitis (shoulder) • Iliopsoas bursitis (anterior hip) The general principles of management — rest, ice, NSAIDs, activity modification, aspiration for symptomatic effusions, selective corticosteroid injection, and surgical excision for refractory cases — apply across all sites. Septic bursitis requires antibiotic therapy and often surgical drainage.

Summary and Take-Home Points

The overuse syndromes — tendinopathies, bursitis, periarthritis, and related conditions — constitute a major component of orthopedic practice. The modern understanding of “tendinitis” as principally a degenerative rather than inflammatory condition has shifted management toward eccentric exercise programs, biological injections, and other regenerative approaches rather than purely anti-inflammatory measures. The principal upper-limb syndromes include subacromial impingement and rotator cuff disease, frozen shoulder, lateral and medial epicondylitis, de Quervain’s tenosynovitis, trigger finger; the lower-limb syndromes include trochanteric pain syndrome, patellar and quadriceps tendinopathy, Achilles tendinopathy, plantar fasciitis. The general principles of management — accurate diagnosis based on anatomical knowledge and clinical examination, conservative measures including activity modification, physiotherapy with specific eccentric exercises, NSAIDs, and selective corticosteroid injection, with surgical management reserved for refractory cases — apply across the spectrum of overuse syndromes.