Inflammation of soft tissue and tendons



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit




The term “soft tissue” refers to muscles, tendons, and ligaments. Most are located near or within joints.

Bursitis and tendinitis are considered forms of soft tissue inflammation.

Because the structures affected by these soft tissue rheumatic syndromes are near joints, pain in these areas may be mistaken for arthritis. The difference is that arthritis means inflammation in the joint itself, not in the structures around the joint.

Bursitis, tendinitis, and other soft tissue rheumatic syndromes typically result from one or more factors. These include:

Activities that cause overuse or injury to the joint areas
Incorrect posture
Stress on the soft tissues
Other diseases or conditions (rheumatoid arthritis, gout, psoriasis, thyroid disease, or an unusual drug reaction)
Infection


Soft tissue rheumatic syndromes may affect the areas around multiple joints.

Pain is the main symptom. Because the structures affected are located near the joint, moving the joint can be extremely painful and may be extremely difficult. Some conditions may cause redness, warmth, or swelling in the affected area. If fever, chills, persistent redness, or swelling occur, infection needs to be ruled out.

Bursitis is inflammation or irritation of a bursa, a small sac located between a bone and muscle, skin, or tendon. The bursa allows smooth gliding between these structures. Below are some of the specific types of bursitis.

The subacromial bursa lies just above the rotator cuff. Bursitis often develops due to injury, impingement (pinching), overuse of the shoulder, or calcium deposits. Symptoms include pain in the upper shoulder or upper third of the arm, and severe pain with shoulder movement.

The trochanteric bursa is located over the prominent bone on the side of the hip. Women and middle-aged to older people are more often affected by this type of bursitis. It can be caused by abnormal walking mechanics. Symptoms include pain occurring on the side of the hip (and sometimes traveling down the thigh); pain when sleeping on the side affected by bursitis, getting up from a deep chair, sitting in a car, or climbing stairs; and occasionally, pain with walking.

The ischial bursa is located below the bone in the buttock called the ischium. Inflammation may occur as a result of injury or prolonged sitting on hard surfaces. Symptoms include pain when sitting or lying down on the buttocks and pain that travels to the back of the thigh. Ischial bursitis is also called "weaver's bottom" or "tailor's seat."

Swelling of the small sac at the tip of the elbow- olecrenon bursitis- is caused by injury, gout, rheumatoid arthritis, infection, or prolonged leaning on the elbows. Symptoms include painful swelling and redness at the tip of the elbow.

The prepatellar bursa is located beneath the skin and in front of the kneecap. It becomes inflamed as a result of infection, injury, gout, or repeated irritation from kneeling. Symptoms include swelling in the front of the knee that may be painful. Redness and/or warmth may occur with infection or gout.

Infrapatellar bursitis (clergyman's knee), a similar condition, affects the infrapatellar bursa, located just below the kneecap.

The anserine bursa is located just beneath the knee on the inner part of the leg. It can irritated in people who jog, have "knock-knees" or osteoarthritis of the knees, or in those who are overweight. Symptoms include pain on the inner part of the knee; pain when sleeping on the side if the knees touch each other; pain while climbing stairs; and pain that travels to the back and inside of the thigh.

The retrocalcaneal bursa is located at the back of the heel. Bursitis in this area can occur in healthy individuals who wear improperly fitted shoes. There is painful swelling that develops at the back of the heel.

The calcaneal bursa is located at the sole or bottom of the heel. Inflammation usually produces pain in the heel when standing. Causes include heel spurs, excess weight, injury, and wearing improperly fitted shoes.

Tendinitis is inflammation or irritation of the tendon, which is a thick fibrous cord that attaches muscle to bone. Tendons transmit the power generated by muscles to move bone.

Four muscles make up the rotator cuff. These muscles move the shoulder away from the side of the body and turn it inward and outward. Rotator cuff tendinitis occurs when shoulder injury or overuse causes tendons to become irritated or inflamed. Impingement (pinching) occurs when the tendons are pinched between structures that are involved in shoulder motion. Symptoms include severe pain in the upper shoulder or upper third of the arm; aching in the shoulder region; difficulty sleeping on the shoulder; or pain when lifting the arm overhead.

The biceps tendon is located in the front of the shoulder and helps bend the elbow and turn the forearm in and out. Overuse or injury typically causes inflammation in the tendon. Symptoms include pain in the front or the side of the shoulder that can travel down to the elbow and forearm.

DeQuervain's tendinitis results from overuse of the thumb tendons, often caused by repeated pinching with the thumb while moving the wrist. It can occur with activities such as writing, gardening, or fine handiwork. It commonly occurs in women during and after pregnancy. Symptoms include pain over the wrist on the side of the thumb, especially with thumb motion.

The Achilles tendon attaches the calf muscle to the heel and lifts the heel off the ground. Achilles tendinitis usually occurs as a result of a sports injury or improperly fitted shoes. Symptoms include ankle stiffness and pain or swelling in the back of the ankle when pushing off the ball of the foot.

Myofascial pain occurs in areas of muscles, often in the back, neck, and shoulders. It is associated with tender, hard areas called tender points. When the tender points are pressed, pain spreads away from the points. Myofascial pain is associated with a firm knot or band within the affected muscle.

Myofascial back pain is a dull, aching pain located in the connective tissue (fascia) or in the muscles of the lower back and buttocks. Causes include minor injury or strain to the back without an actual herniated disc or fracture. This condition may be associated with degenerative arthritis of the back.

The lateral epicondyle is the area where muscles of the forearm attach to the outside bone of the elbow. Overuse of these muscles occurs in sports like tennis that require forced extension or rotation of the wrist or hand. Gardening, using tools, or clenching your hand for a long time may also cause epicondylitis.

Symptoms include aching pain on the outside of the elbow that can travel down the forearm, and pain with handshakes, movement of the fingers, lifting with the wrist, turning doorknobs, or unscrewing jar tops.

Golfer's elbow is similar to tennis elbow, but less common. It is caused by overusing the muscles that clench the fingers. Symptoms include pain in the inner part of the elbow and pain when bending the fingers or wrists.

Thickening of the lining around the tendons of the fingers can result in a condition called stenosing tenosynovitis or trigger finger. Bumps may develop on the tendon sheath from overuse. Symptoms include locking of a finger in a painful bent position. The finger may suddenly snap open. Often the other hand may be needed to straighten the finger. Symptoms include tenderness, swelling, or small bumps in the palm of the hand, and aching in the middle joint of the affected finger.

The plantar fascia is made up of thickened fibrous tissue that spans the sole of the foot from heel to toes. Running, prolonged standing, flat feet, heel spurs, and excessive weight can stress the fascia. Symptoms include pain in the sole of the foot and pain when walking.



Treatment

Many soft tissue conditions are caused by overuse, so the first treatment may include resting the painful area or avoiding a particular activity for a while. Rest allows the injured or inflamed area to heal.

Cold compresses can help reduce the initial swelling and pain in soft tissue conditions. Cold therapy is usually most effective during the first 48 hours after swelling begins. Tips for cold therapy include:

• Use a cold gel pack, a bag filled with ice cubes, or even a bag of frozen vegetables.
• Wrap the pack in a towel.
• Place the cold pack over the area for 20 minutes, three to four times a day.
• Rub an ice cube over smaller painful areas for a short time.


After 48 hours, or for chronic (long-term) pain, dry or moist heat may be more helpful than cold compresses. Follow these tips:

• Use a hot pack, a heating pad, or a damp towel heated in the microwave (make sure it's not too hot or it may burn your skin).
• Place a hot pack over the painful area for 15-20 minutes, three to four times a day.
• Never use analgesic creams or rubs with heat packs because the combination could severely burn your skin.
• Take a warm shower or bath.


Physical therapy is often helpful. The following therapies are used:

•Ultrasound (sound waves) provides deep heat to help ease tendinitis, bursitis, or myofascial shoulder or back pain.
•Massage can ease myofascial pain.
•An exercise program can help regain motion, strength, and function in the injured area.
•Water therapy helps a patient move a joint more comfortably.



Occupational therapists can identify and create modifications for daily activities and work habits to prevent re-injury.



Medications

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and pain. There are many different NSAIDs, including aspirin, ibuprofen, naproxen, nabumatone, celecoxib, and ketoprofen. These drugs are available by both prescription as well as over the counter.

Side effects of NSAIDs can include heartburn, nausea, diarrhea, easy bruising or bleeding, and dizziness. More severe side effects may include ulcers, kidney problems, and liver inflammation.

Glucocorticoids are synthetic forms of cortisol, which is a hormone found naturally in the human body. Glucocorticoids reduce inflammation. Most soft tissue rheumatic syndromes can be treated with glucocorticoids injected into a bursa, joint, or tendon sheath to reduce inflammation and pain. These injections typically are used if NSAIDs or other therapies don't provide relief after three to four weeks of treatment.

Risks of glucocorticoid injections may include bleeding, infection, tendon rupture, or skin atrophy. Frequent injections into the same area are not recommended.

Ultrasound-guided needle tenotomy with platelet-rich plasma is a minimally invasive procedure where the soft tissue injury is gently peppered using an ultrasound-guided needle. This creates an acute injury. Platelets are cells that contain growth and healing factors. Platelet-rich plasma is an ultraconcentrate of platelets from blood. When this is injected, the growth factors from the platelets are released when exposed to the acute injury caused by the peppering technique. The growth factors cause the tissue to heal rapidly. This procedure is recommended more now than cortisone injections because cortisone actually causes soft tissue to weaken.

Surgery is rarely need to treat most of these conditions. A patient with a soft tissue rheumatic syndrome may need surgery, however, if problems persist and other treatment methods do not help symptoms.

Splints, braces, or slings allow a particular area of the body to rest until the pain eases. Splints are often used to help treat tennis elbow, DeQuervain's tendinitis, and Achilles tendinitis.

It is important to avoid or modify the activities that cause problems. Underlying conditions such as leg length differences, improper position or poor technique in sports or work must be corrected.

Preventative maintenance can help a person avoid soft tissue injury.



Protect shoulders:

• Avoid activities that require reaching overhead for long periods.
• Don't move shoulders repeatedly for a prolonged period (such as when vacuuming or doing push-ups).
• Do range-of-motion exercises to maintain strength and flexibility.
• Use good posture.


Protect the elbows:

• Don't grip tools or pens too tightly.
• Don't clench the fists.
• Avoid repeated hand and finger motions.
• Don't lean on elbows, and avoid bumping them.
• Use a forearm band (tennis elbow strap) during physical activity.


Protect wrists and hands:

• Avoid repeating the same hand movement for long periods.
• Use your forearm or entire arm instead of just the wrist or hand.
• Take frequent breaks from doing fine handiwork or writing.
• Enlarge handles on tools, utensils, pencils, and pens with tape or foam so the grip won't be too tight.
• Carry objects with the palms open and flat.
• Wear a splint during prolonged activity.


Protect the knees:

• Use knee pads when gardening or kneeling on floors.
• Do daily thigh-strengthening exercises (straight-leg lifts). Strong thigh muscles (quadriceps) provide added support for your knees.
• Don't sit for long periods of time; get up and walk around every 20 to 30 minutes.
• Do proper warm-up exercises before exercising or playing sports.
• Turn the entire body rather than simply twisting at the waist.


Protect the hips:

• When bending down to lift an object, bend and straighten the knees instead of the back or hips.
• Sit on cushioned chairs.
• Get a shoe lift if there is a difference in the leg lengths.


Protect the ankles and feet:

• Wear walking or jogging shoes that provide good support. High-top shoes provide support for people with ankle problems.
• Wear comfortable shoes that fit properly.
• Wear heel cups or other shoe inserts.
• Exercise on level, graded surfaces.


Treatment for soft tissue conditions focuses on reducing pain and inflammation, and on preserving mobility and preventing disability and recurrence.

For more information about tendonitis, visit our sister site: Tendonitis Tendonitis and PRP provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.





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