This document provides an overview of common soft tissue conditions in orthopedics, including bursitis, tendon injuries, and nerve entrapments. It discusses the anatomy, causes, symptoms, examinations, and treatment approaches for various conditions such as tennis elbow, carpal tunnel syndrome, trigger finger, and frozen shoulder. The document is intended as an educational guide for orthopedic practitioners.

1. Soft tissue conditions in
Orthopedics
Facilitator: Dr. Subarna Adhikari
Lecturer, KISTMCTH

2. Topics
• Bursitis
• Tenosynovitis
• Dupuytren’s Contracture
• Tennis Elbow
• Golfer’s Elbow
• De-Quervain’s Tenosynovitis
• Trigger finger
• Ganglion
• Carpal tunnel syndrome
• Frozen Shoulder
• Plantar Fascitis
• Fibrositis
• Painful-arc Syndrome
• Meralgia paresthetica
• Fibromyalgia
Exams: ★★★★☆
Clinical practice: ★★★★★

3. Bursitis
• Bursa: a small fluid-filled sac or saclike cavity situated
in places in tissues where friction would otherwise
occur
• Types: adventitious, subcutaneous, synovial, and sub-
muscular.
• Adventitious: non-native, repeated stress;
example Students' elbow and bunion.
• Housemaid’s knee, Clergyman’s knee, Student’s
elbow, Weaver’s Bottom, Tailor’s ankle, Bunion:
(Entrance Preparation)

4. Irritative Bursistis
• Excessive pressure or friction ☞ Inflammation☞ Effusion
• Prolonged inflammation☞Thickened sac☞ Erosion of adjacent bone
• Treatment:
• Analgesics, rest, removal of causative factor
• Intralesional steroid injection
• Excision of bursa
Infective bursitis
• Uncommon; pyogenic or tubercular; prepatellar or trochanteric
• Surgical drainage

5. Tenosynovitis
• Unaccustomed overuse/ spontaneous
• Synovial inflammation ☞ Secondary thickening of sheath ☞ Stenosis
of compartment ☞ further compromise
• Inflammation/infection; flexor/extensor tendon sheath of the hand
• Irritative: rest, analgesics, splinting, US therapy, intralesional steroid
(RUPTURE!)
• Infective: Pyogenic or tubercular

6. Trigger Finger (Digital tenovaginosis)
• Congenital or acquired
• Stenosing tenovaginosis of fibrous digital sheath
• Flexor tendon thickened at the entrance to its sheath (A1 pulley;
passes the sheath on forced extension with a snap (‘triggering’)
• Diabetes, Rheumatoid arthritis
• Clinical: thumb, ring finger and middle finger most commonly affected
• Click on flexion; PIP remains flexed as the hand is unclenched, sudden
straightening with a snap, tender nodule on flexor aspect of MCP

7. Infantile Trigger Thumb
• Baby cannot extend the thumb tip (IP joint), noticed by parents
• Often delayed diagnosis
• D/D congenitally clasped thumb (both MCP and IP incolved)

8. Treatment:
• Early cases: corticosteroid injection into
the tendon sheath
• Recurrent cases: Second injection
• Refractory cases: Operation; A1 pulley
release
• Infantile cases: wait until the child is
three years old for spontaneous
recovery ☞ Pulley release
• Cases with rheumatoid arthritis:
Preserve pulley, flexor synovectomy

9. De Quervain’s disease
• Reactive thickening of sheath around Extensor policis brevis and
Abductor Policis Longus: First extensor compartment
• Overuse/Spontaneous
• Middle age women/Pregnancy/Postpartum
• C/F Pain on wrist, H/O unaccustomed activity: eg wringing out clothes
• Tenderness over radial styloid process, sometimes swelling
• Finkelstein’s test
• Hitchhiker’s sign

11. • Differential Diagnosis: arthritis at the base of thumb,
Scaphoid non-union, Intersection syndrome
• (Intersection syndrome: extensor tenosynovitis due to friction
between first and second extensor compartment tendons)
• Treatment: Splintage, analgesics, Ultrasound therapy
• Resistant cases: operation: slitting thickened tendon sheath
• Case: 28 years old with a 7 months old child presented with a
history of wrist pain, usually on lifting the child. What is your
diagnosis?

12. Dupuytren’s contracture
• Nodular hypertrophy of the superficial palmar
fascia (Palmar aponeurosis)
• Autosomal dominant
• Common in European population
• Predisposition with: epileptics receiving phenytoin,
diabetes, smoking, alcoholic cirrhosis, AIDS, PTB
• Palmar fascia: connects palmar aponeurosis with
fibrous digital sheaths, four slips
• Ledderhose’s (soles), Peyronnie’s (penis)

13. • Fibrous tissue in palmar fascia and digital sheaths: Initial proliferative
phase ☞ Contracture ☞ Flexion deformities of MCP and PIP
• Digital nerve: displaced or enveloped
• Clinical: Middle aged man with nodular thickening in palm; usually
bilateral, palm is puckered, nodular and thick
• D/D: traumatic contracture, trigger finger, clawing
• Treatment: Partial or complete fasciectomy (excision of affected fascia)

14. Ganglion cysts
• 95% of swelling of the hand, benign; 60% of benign swelling, ganglion
cysts, 60% of ganglion cysts, dorsal surface
• Dorsal wrist ganglions: scapholunate ligament
• Palmar wrist ganglions: arise from scapho-lunate or scapho-trapezoid
ligament
• Leakage of synovial fluid from
a joint or tendon sheath

15. • Clinical Features:
• Female> Male; Young adult
• Painless/slightly painful well defined cystic lump, transilluminant
• Carpal tunnel ganglion: features of compression of median nerve
• Within bone; scaphoid or lunate: pain
• Treatment indications:
• Aesthetic: less invasive methods
• Pain, limitation of movement, nerve palsies:
surgical removal

16. Treatment
• Old traditional treatment: hit it with a book, since the cysts can burst
when struck
• Patient reassurance and no treatment
• Manual compression until bursting
• Aspiration with/without steroid injection:
recurrence (upto 60%)
• Open excision/ Arthroscopic excision:
recurrence (upto 40%)

17. Tennis elbow (lateral epicondalgia)
• Bony attachment of common
extensor tendon over lateral
epicondyle of humerus
• Repeated forceful wrist
extension: tennis players/non-
players
• Pathology: tears,
fibrocartilaginous metaplasia,
microscopic calcification, painful
vascular reaction

18. Clinical Features
• M=F, over 30-40 years of age
• Prolonged history of pain, usually after unaccustomed activities
• Localized to lateral epicondyle, may spread widely
• Aggravated by movements like pouring tea, turning door handle, shaking
hands, lifting with forearm pronated
• Elbow: normal on inspection with full range of flexion and extension,
tenderness at lateral epicondyle
• Cozen’s test: resisted dorsiflexion of wrist
• Acute passive flexion of wrist with forearm pronated
• Xray: Normal/ Calcification of tendon

19. • Differential diagnosis: consider radial nerve entrapment in resistant
cases (radial tunnel syndrome)
• Treatment:
• 90% cases resolve spontaneously within 6-12 months
• Identify and restrict activities causing pain
• NSAIDs
• Counterforce bracing and wrist splint

20. • Non-surgical Treatment:
• Intralesional steroid and local anesthetic injection
• Ultrasound therapy
• Autologous blood patching
• Platelet rich plasma injection
• Hyaluronate injections
• Operative treatment:
• Removal of diseased tendon and reattachment of healthy part
• Physiotherapy
• Strength training and stretching exercises, occupational therapy

21. Golfer’s elbow (Medial epicondylitis)
• Less common than tennis elbow
• Pronator origin affected
• Associated ulnar neuropathy may be present
• Treatment: similar to tennis elbow
• D/D medial collateral ligament of elbow injury

22. Carpal Tunnel syndrome
Boundaries:
• Palmar: flexor
retinaculum
• Radial: scaphoid tubercle
and the ridge of
trapezium
• Ulnar: pisiform and hook
of hamate
• Dorsal: Capitate,
trapezoid and trapezium

23. Contents:
• A total of nine flexor tendons
• flexor digitorum profundus (four tendons)
• flexor digitorum superficialis (four tendons)
• flexor pollicis longus (one tendon)
• flexor carpi radialis (one tendon) passes through the retinaculum
• A single nerve the median nerve between tendons of flexor digitorum
profundus and flexor digitorum superficialis

24. Clinical features
• Female>Male, 40-5- years of age
• Pregnancy, rheumatoid disease, myxedema
• Pain and paresthesia over lateral three and a half digits
• Worsening at night, waking up with pain, tingling, numbness
• Hanging the hand/ shaking may relieve pain
• Clumsiness of fine movements
• Wasting of thenar eminence
• Nerve conduction studies
• D/D cervical radiculopathy, thoracic outlet syndrome

26. Splintage
• Wrist splints
• Steroid injection into the carpal tunnel
• Open surgical release of transverse carpal ligament
• Physiotherapy: weight reduction aerobic training,
occupational therapy

27. Painful arc syndrome
• Rotator cuff: Supraspinatus, Infraspinatus
Teres Minor, Subscapularis
• Pass under the coracoacromial arch
• Function: Stabilize the head of humerus
when there
is abduction due to contraction of deltoid
muscle
• The Subacromial space contains:
• Belly and tendon of the supraspinatus muscle
• Long head of the biceps muscle
• Subacromial bursa
• Abductors of shoulder???

28. • Coronal sections through the shoulder: irritation of subdeltoid bursa
and supraspinatus tendon by repeated impingement under the
coracoacromial arch during abduction. (a) Joint at rest. (b) In
abduction.
1 Supraspinatus Muscle
2 Acromioclavicular Joint
3 Subdeltoid Bursa
4 Deltoid Muscle
5 Supraspinatus Tendon
6 Synovial Joint

29. Painful arc Syndrome
• Clinical examination may reveal tenderness along the acromion
• D/D: Frozen shoulder, Biceps tendinitis
• Clinical syndrome in which there is pain in the
shoulder and upper arm during mid-range of
abduction
• Causes:
• Subacute supraspinatus tendinitis
• Calcification of supraspinatus tendon
• Subacromial bursitis
• Greater tuberosity fracture

30. Treatment:
• Based on cause
• Ultrasound therapy
• NSAIDs
• Injection of corticosteroids in subacromial space
• Excision of anterior prominent part of acromion (acromioplasty):
open or arthroscopic; arthroscopic rotator cuff repair
• Physiotherapy

31. Frozen shoulder
• Adhesive capsulitis/ Periarthritis shoulder
• Clinically diagnosed
• Characterized by progressive pain and stiffness of the shoulder which
usually resolves spontaneously after about 18 months
• Cause: Unknown
• Associated with
• Diabetes, Dupuytren’s disease, Hyperlipidaemia, Hyperthyroidism
• Cardiac disease, Hemiplegia
• Occasionally after recovery from neurosurgery

32. Clinical features
• 40-60 years; History of trivial trauma
• Aching in the arm and shoulder, prevents sleeping on affected side
• Three characteristic phases
• Freezing phase: pain gradually increases over several months
• Frozen phase: pain decreases over 6-12 months, stiffness increases
• Thawing phase: Movement gradually regained, may not be as before
• Examination: wasting of muscles, loss of movement in all directions
(active and passive)
• Xrays: Normal
• D/D : infection/post-traumatic stiffness/post-immobilization
stiffness/reflex sympathetic dystrophy

34. Treatment:
• Conservative treatment
• Pain relief, prevent further stiffening
• Pendulum exercises
• Intra-articular steroid injection
• Joint distension with large volume of normal saline injection (50-200
ml)
• Manipulation under general anesthesia
• External rotation ☞ Abduction ☞Flexion
• Intraarticular injection at the end
• Careful to prevent fracture surgical neck humerus in the elderly osteoporotic
patient

35. Surgical Treatment
• Prolonged disabling restriction of movement which fails to respond to
conservative therapy
• Arthroscopic capsular release, and release of adhesions

36. Plantar fascitis
• Common cause of heel pain
• Self-limiting: 18-36 months
• Plantar fascia: originates from calcaneum,
divides into four slips, inserts into
metatarsal heads
• Stiffening and thickening with age
• Micro-tears and thickening of fascia

37. Clinical features
• Gradual onset, without history of injury
• Maybe a history of sudden increase in activity, change of footwear
• Worse when getting up in the morning, going downstairs, getting up
after rest
• Pain maybe sharp/persistent background ache
Examination
• Localozed tenderness medial aspect beneath the heel, sometimes
midfoot
• Xray: rule out stress fracture, spur on undersurface of calcaneum

38. Treatment
• Relative rest and NSAIDs
• Footwear modification
• Plantar fascia stretching exercises
• Cushioning of heel pad
• Ultrasound therapy
• Operative treatment: Limited fasciotomy
Differential diagnosis
• Painful fat pad
• Nerve entrapment

39. Meralgia Paresthetica
• Tingling, burning, numbness over skin
supplied by lateral cutaneous nerve of
thigh
• Entrapment in fascia lata just medial
to anterior superior iliac spine
• Treatment: analgesics, local steroid
injection, decompression of nerve

40. Fibromyalgia
• Disorder of chronic, widespread pain and tenderness
• Typically presents in young or middle-aged women but can affect patients
of either sex and at any age
Signs and symptoms:
• Persistent (≥ 3 mo) widespread pain (pain/tenderness on both sides of the
body, above and below the waist, and includes the axial spine [usually the
paraspinus, scapular, and trapezius muscles])
• Stiffness
• Fatigue; disrupted and unrefreshing sleep
• Cognitive difficulties
• Multiple other unexplained symptoms, anxiety and/or depression, and
functional impairment of activities of daily living (ADLs)

41. The American College of Rheumatology
• The presence of 11 tender points
among the nine pairs of specified sites
(18 points) as shown in the diagram
• Rule out conditions like:
hypothyroidism, SLE,
hyperparathyroidism and osteomalacia

42. Treatment
Nonpharmacotherapy
• Diet (eg, promote good nutrition, vitamin supplementation, bone
health, weight loss)
• Stress management
• Aerobic exercise (eg, low-impact aerobics, walking, water aerobics,
stationary bicycle)
• Sleep therapy (eg, education/instruction on sleep hygiene)
• Psychologic/behavioral therapy (eg, cognitive-behavioral, operant-
behavioral)

43. Pharmacotherapy
• Combine pharmacologic and nonpharmacologic therapy in the
treatment of fibromyalgia. Aggressively treat comorbid depression.
• Analgesics (eg, tramadol)
• Antianxiety agents (eg, alprazolam, clonazepam, zolpidem, zaleplon,
Trazodone, buspirone, temazepam, sodium oxybate)
• Skeletal muscle relaxants (eg, cyclobenzaprine)
• Antidepressants (eg, amitriptyline, duloxetine, milnacipran,
venlafaxine, desvenlafaxine)
• Anticonvulsants (eg, pregabalin, gabapentin, tiagabine)
• Alpha 2 agonists (eg, clonidine)

44. Polydactyly
• Most common congenital digital anomaly
of the hand and foot.
• Isolated: usually autosomal dominant/random
• Associated with other birth defects autosomal recessive.
• Preaxial polydactyly: the most common type, duplication of the first digit
or ray
• Central polydactyly: duplication of the second, third, or fourth digit or
ray.
• Postaxial polydactyly: fifth digit or ray.
• Radial, central, and ulnar vs tibial, central, and fibular

45. • Look for other
congenital anomalies
and association with
genetic syndromes
• X-ray: skeletal elements
• 3 years: aware of the
anomaly.
• 7 years: close scrutiny
of peers at school ☞
emotional stress
Treatment: Early surgical
removal

46. Syndactyly
• Greek συν- "together“; δακτυλος "finger"
• Condition wherein two or more digits are fused
together
• Complete or incomplete
• Complete: the skin is joined all the way to the tip of the
finger
• Incomplete: the skin is only joined part of the
distance to the fingertip
• Simple or complex
• Simple: adjacent fingers or toes are joined by soft tissue
• Complex: the bones of adjacent digits are fused

47. Treatment
• Surgical Release : syndactyly that prevents full range of motion (not
cosmetic)
• In complex syndactyly, separation of the conjoint fingers may make
the 2 individualized digits nonfunctional; only 1 set of tendons and 1
neurovascular pedicle may be present
• Elective surgical procedures at 5 or 6 months of age

48. Thank you!
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