Bursitis, Tendinitis, and Other Soft Tissue Rheumatic Syndromes

Basics of Bursitis and Tendinitis

Bursitis and tendinitis are conditions that are also known as soft tissue rheumatic syndromes. A syndrome is a group of signs and symptoms that occur together and indicate a particular problem. This type of syndrome produces pain, swelling, or inflammation in the tissues and structures around a joint, such as the tendons, ligaments, bursae, and muscles (see figure 1).

Immediate Medical Attention

If fever, chills, persistent redness, or swelling occur in a person with a soft tissue rheumatic syndrome, the person should see a doctor immediately to rule out infection.

Facts and Myths

Because the structures affected by 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.

Incidence

Anyone can develop soft tissue rheumatic syndromes because the causes are so common. Soft tissue rheumatic syndromes like tendinitis and bursitis are very common in people who are otherwise healthy.

Acquisition

Bursitis, tendinitis, and other soft tissue rheumatic syndromes typically result from one or more factors. These include: Play or work activities that cause overuse or injury to the joint areas Incorrect posture Stress on the soft tissues from an abnormal or poorly positioned joint or bone (such as leg length differences or arthritis in a joint) Other diseases or conditions (rheumatoid arthritis, gout, psoriasis, thyroid disease, or an unusual drug reaction) Infection

Causes

Bursitis, tendinitis, and other soft tissue rheumatic syndromes typically result from one or more factors. These include: Play or work activities that cause overuse or injury to the joint areas Incorrect posture Stress on the soft tissues from an abnormal or poorly positioned joint or bone (such as leg length differences or arthritis in a joint) Other diseases or conditions (rheumatoid arthritis, gout, psoriasis, thyroid disease, or an unusual drug reaction) Infection

Types of Bursitis

Bursitis is inflammation or irritation of a bursa, a small sac located between a bone and muscle, skin, or tendon (see figure 1). The bursa allows smooth gliding between these structures. Below are some of the specific types of bursitis. Subacromial 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 upon moving the shoulder.

Trochanteric Bursitis

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 may occur spontaneously without specific injury. Also, it can be caused by walking abnormally due to arthritis in the hip, knee, ankle, foot, or back. Symptoms include pain gradually occurring over the side of the hip (and sometimes traveling down the thigh); pain when sleeping on the side affected by bursitis, rising from a deep chair, sitting in a car, or climbing stairs; and occasionally, pain when walking.

Ischial Bursitis

The ischial bursa is located below the bone in your 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."

Olecranon Bursitis

Swelling of this small sac at the tip of the elbow 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.

Prepatellar Bursitis

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.

Pes Anserinus Bursitis

This 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.

Retrocalcaneal Bursitis

This bursa is located at the back of the heel. Bursitis in this area is often associated with conditions such as ankylosing spondylitis or rheumatoid arthritis. It can occur in healthy individuals who wear improperly fitted shoes. Symptoms include painful swelling that develops at the back of the heel.

Calcaneal Bursitis

This 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.

Types of Tendinitis

Tendinitis is inflammation or irritation of the tendon, which is a thick cord that attaches muscle to bone (see figure 1). Tendons transmit the power generated from muscles to help move a bone. Some types of tendinitis are listed below.

Rotator Cuff Tendinitis and Impingement Syndrome

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 sudden, 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.

Bicipital Tendinitis

The biceps tendon is located in the front of the shoulder and helps bend the elbow and turn the forearm. 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

DeQuervain's (pronounced "duh-KUR-vans") 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.

Achilles Tendinitis

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.

Other Types of Soft Tissue Rheumatic Syndromes

Myofascial Pain

Myofascial pain occurs in areas of muscles, often in the back, neck, and shoulders. It is associated with tender, hard areas called trigger points. When the trigger points are pressed, you may feel pain that 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. Symptoms include painful muscle or fatty and fibrous bumps that, when pressed, may produce pain that travels down the buttocks and into the thigh.

Carpal tunnel syndrome

In carpal tunnel syndrome, the median nerve that passes between the wrist bones and a strong ligament on the bottom of the wrist may be compressed. This nerve supplies sensation to the first three fingers and part of the ring finger. This nerve also provides strength to the thumb muscles. Causes of carpal tunnel syndrome include injury from repetitive use or overuse, thyroid disease, diabetes, pregnancy, infection, rheumatoid arthritis, and other types of inflammatory arthritis. Symptoms include numbness or tingling in the hand, initially only at night or when the wrist is flexed for a long time; feelings of swelling in the hand; weakness of the thumb upon pinching; and unexplained hand pain. For more information, see our carpal tunnel syndrome article. A similar condition called tarsal tunnel syndrome can affect the nerve located in the inner part of the ankle that supplies sensation to the toes and the sole of the foot. Compression on the nerve at the ankle can occur with ankle fractures, rheumatoid arthritis, or foot deformities. Symptoms include painful burning feelings in the foot, often at night or after standing; pain or burning on the sole of the foot or toes; and pain partially relieved by movement of the foot, ankle, or leg.

Tennis Elbow (Lateral Epicondylitis)

The 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 (Medial Epicondylitis)

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.

Tenosynovitis

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 the locking of a finger in a painful bent position that suddenly snaps open (the other hand may need 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.

Plantar Fasciitis

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.

Credits

Some of this material may also be available in an Arthritis Foundation brochure. Contact the Washington/Alaska Chapter Helpline: (800) 542-0295. If dialing from outside of WA and AK, contact the National Helpline: (800) 283-7800. Adapted from the pamphlet originally prepared for the Arthritis Foundation by Nancy Liu, M.D., University of Massachusetts; John Baum, M.D., University of Rochester, New York; and Laura Robbins, D.S.W., Hospital for Special Surgery, New York. This material is protected by copyright.

Anatomy

Soft tissue rheumatic syndromes may affect the areas around the joints of the shoulders, chest elbows, wrists fingers, hips, back, knees, ankles, and feet. Initial symptoms Pain is the main symptom of soft tissue rheumatic syndromes. 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 in a person with soft tissue rheumatic syndrome, the person should see a doctor immediately to rule out infection. Specific symptoms and causes depend on which areas are affected. Diagnosis A doctor can make a diagnosis of a soft tissue rheumatic syndrome based on a physical exam and a medical history. A doctor will want to know when the pain was first felt, how intense the pain was, where it was located, and if any new physical activities had been started recently. Progression Most of these conditions occur suddenly, may last for days, weeks, or longer, and then go away. They can occur again in the same place or in other parts of the body. Many of the syndromes go away on their own time.

Conditions with Similar Symptoms

Because the structures affected by 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.

Treatment and Prevention

Treatment for soft tissue conditions focuses on reducing pain and inflammation, and on preserving mobility and preventing disability and recurrence. The treatment for many soft tissue conditions is similar. A doctor's recommendations may include a combination of rest, splints, heat and cold application, medications, physical therapy, or occupational therapy. A person with a soft tissue condition may try several treatments before he or she finds the best one for his or her specific condition.

Self-management

Cold compresses can help reduce the initial swelling and pain in acute (short-term but severe) soft tissue conditions. Cold therapy is usually most effective during the first 48 hours after swelling begins. Guidelines 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 if the cold temperature is too painful.
  • 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 guidelines:

  • 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.

Health Care Team

In most cases, a primary-care physician can treat soft tissue rheumatic conditions. Some people may need to be referred to a rheumatologist (a physician trained to diagnose and treat arthritis, rheumatic diseases, and related musculoskeletal conditions) for treatmen Exercise and therapy

Rest

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. Can physical therapy or exercise help treat bursitis and tendinitis? A doctor may refer a patient with soft tissue rheumatic syndrome to a physical therapist, who can provide the following therapies:

  • Ultrasound (sound waves) provides deep heat to help ease some forms of tendinitis, bursitis, or myofascial shoulder or back pain. Occasionally, using ultrasound to activate cortisone cream applied to the skin may provide relief.
  • Muscle massage can ease myofascial pain.
  • A personalized exercise program can help regain motion, strength, and function in the injured area.
  • Water therapy can allow the patient to move a joint more comfortably.
  • A physical therapist may recommend an exercise program that will help the patient regain motion in an injured area. Once the initial pain eases, the patient will need to strengthen the area to prevent re-injury. Conditions such as frozen shoulder and iliotibial band syndrome depend on exercise as a main form of treatment.

Can Occupational Therapy Treat or Manage Bursitis and Tendinitis?

Occupational therapists can identify modifications for daily activities and work habits to prevent re-injury. These therapists can also create hand and wrist splints and they can suggest devices to make daily activities easier. Occupational therapists can recommend exercises for fingers, wrists, and elbows.

Prevention

Because many soft tissue conditions are caused by overuse, the best treatment is prevention. 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. Be aware of potential overuse or injury in your daily activities and change your lifestyle to prevent problems. Otherwise, problems may persist or occur repeatedly. Following are some ways you can avoid future problems.

To Protect Your Shoulders:

  • Avoid activities that require you to reach overhead for long periods.
  • Don't move your shoulder 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.

To protect your elbows:

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

To Protect Your Wrists and Hands:

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

To protect your knees:

  • Use kneepads 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 your entire body rather than simply twisting at the waist.

To Protect Your Hips:

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

To Protect Your 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 as recommended by your doctor.
  • Exercise on level, graded surfaces.

Medications

A doctor may prescribe medication or may suggest that a patient with a soft tissue condition try over-the-counter drugs to help relieve pain and/or inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and pain. There are many different NSAIDs, including aspirin, ibuprofen, naproxen, and ketoprofen. These drugs are available by prescription and over the counter. A doctor will determine which drug is appropriate for a patient's condition based on factors such as age, other medical problems, daily habits, other medications taken, side effects, and cost of the drug. 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. Call a doctor if any of the following signs are noticed while taking NSAIDs: stomach pain or cramps; pain that decreases after eating or after taking antacids; bloody or black, tarry stools; vomiting blood. Most people with soft tissue syndromes do not need to stay on NSAIDs long because the condition being treated usually lasts only a few weeks. 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 (pill forms of glucocorticoids are not used for soft tissue conditions). Symptoms may improve or disappear within several days of an injection. Risks of glucocorticoid injections may include bleeding, infection, tendon rupture, or skin atrophy. Frequent injections into the same area are not recommended.

Surgery

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 or Braces

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, Achilles tendinitis, and carpal tunnel syndrome. The devices should not be used indefinitely because they can lead to decreased movement and strength. A doctor should advise how long and how often a patient should wear such devices.

For up-to-date and comprehensive resources on shoulder arthritis, please visit our new online Shoulder Arthritis Book and Rotator Cuff Tear Book!