A number of periarticular disorders have become increasingly common over the past two to three decades, due in part to greater participation in recreational sports by individuals of a wide range of ages. Periarticular disorders most commonly affect the knee or shoulder. With the exception of bursitis, hip pain is most often articular or is being referred from disease affecting another structure.

1. Periarticular Disorders of
the Extremities
By: Fereshteh Sotva
Medical student

2. Bursitis
function of the bursa is to facilitate movement of tendons and muscles over bony
prominences.
Excessive frictional forces from overuse, trauma, systemic disease (e.g.,
rheumatoid arthritis, gout), or infection may cause bursitis.

3. 1.Subacromial bursitis (subdeltoid bursitis)
is the most common form of
bursitis.
The subacromial bursa, which is
contiguous with the subdeltoid
bursa, is located between the
undersurface of the acromion and
the humeral head and is covered by
the deltoid muscle.
Bursitis is caused by repetitive
overhead motion and often
accompanies rotator cuff tendinitis.

4. 2.trochanteric bursitis
Involvement of the bursa around
the insertion of the gluteus
medius onto the greater
trochanter of the femur.
Patients experience pain over
the lateral aspect of the hip and
upper thigh and have tenderness
over the posterior aspect of the
greater trochanter.
External rotation and resisted
abduction of the hip elicit pain.

5. 3. Olecranon bursitis
occurs over the posterior elbow, and when the area is acutely inflamed, infection or
gout should be excluded by aspirating the bursa and performing a Gram stain and
culture on the fluid as well as examining the fluid for urate crystals.

6. 4.Achilles bursitis
involves the bursa located above the insertion of the tendon to the
calcaneus and results from overuse and wearing tight shoes.

7. 5. Retrocalcaneal bursitis
involves the bursa that is located between the calcaneus and posterior
surface of the Achilles tendon. The pain is experienced at the back of
the heel, and swelling appears on the medial and/or lateral side of the
tendon.
It occurs in association with spondyloarthropathies,rheumatoid arthritis,
gout, or trauma.

8. 6.Ischial bursitis (weaver's bottom)
affects the bursa separating the gluteus medius from the ischial
tuberosity and develops from prolonged sitting and pivoting on hard
surfaces.

9. 7. Iliopsoas bursitis
affects the bursa that lies
between the iliopsoas muscle and
hip joint and is lateral to the
femoral vessels.
Pain is experienced over this area
and is made worse by hip
extension and flexion.

10. 8.Anserine bursitis
is an inflammation of the sartorius bursa located over the medial side of the tibia
just below the knee and under the conjoint tendon and is manifested by pain on
climbing stairs.
Tenderness is present over the insertion of the conjoint tendon of the sartorius,
gracilis, and semitendinosus.

11. 9. Prepatellar bursitis
(housemaid's knee) occurs in the bursa situated between the patella and
overlying skin and is caused by kneeling on hard surfaces. Gout or
infection may also occuar at this site.

12. Treatment of bursitis consists of:
1.prevention of the aggravating situation.
2.rest of the involved part.
3.administration of a nonsteroidal anti-inflammatory drug
(NSAID) where appropriate for an individual patient, or local
glucocorticoid injection.

13. Rotator Cuff Tendinitis and Impingement Syndrome
Tendinitis of the rotator cuff is the major cause of a painful shoulder and is
currently thought to be caused by inflammation of the tendon(s).
The rotator cuff consists of the tendons of the supraspinatus, infraspinatus,
subscapularis, and teres minor muscles, and inserts on the humeral tuberosities.
The process begins with edema and hemorrhage of the rotator cuff, which
evolves to fibrotic thickening and eventually to rotator cuff degeneration with
.tendon tears and bone spurs

14. :Rotator Cuff Tendinitis and Impingement Syndrome
Subacromial bursitis also accompanies this syndrome.
Symptoms usually appear after injury or overuse, especially with activities involving
elevation of the arm with some degree of forward flexion.
Those over age 40 are particularly susceptible.
Patients complain of a dull aching in the shoulder, which may interfere with sleep.
Severe pain is experienced when the arm is actively abducted into an overhead position.
The arc between 60° and 120° is especially painful.

15. :Rotator Cuff Tendinitis and Impingement Syndrome
Patients may tear the supraspinatus tendon acutely by falling on an outstretched arm
or lifting a heavy object.
Symptoms are pain along with weakness of abduction and external rotation of the
shoulder.
Atrophy of the supraspinatus muscles develops.
The diagnosis is established by arthrogram, ultrasound, or MRI.

17. :Calcific Tendinitis
This condition is characterized by deposition of calcium salts, primarily
hydroxyapatite, within a tendon.
The supraspinatus tendon is most often affected because it is frequently
impinged on and has a reduced blood supply when the arm is abducted.
The condition usually develops after age 40.
Calcification within the tendon may evoke acute inflammation, producing
sudden and severe pain in the shoulder.

18. Bicipital Tendinitis and Rupture
Bicipital tendinitis, or tenosynovitis, is produced
by friction on the tendon of the long head of
the biceps as it passes through the bicipital
groove.
When the inflammation is acute, patients
experience anterior shoulder pain that radiates down
the biceps into the forearm.
1.Abduction and external rotation of the arm are painful and limited.
2.The bicipital groove is very tender to palpation.
3.Pain may be elicited along the course of the tendon by resisting supination
of the forearm with the elbow at 90° (Yergason's supination sign).
4.Acute rupture of the tendon may occur with vigorous exercise of the arm
and is often painful.

19. De Quervain's Tenosynovitis
In this condition, inflammation involves the abductor pollicis longus and the
extensor pollicis brevis as these tendons pass through a fibrous sheath at the radial
styloid process.
1.The usual cause is repetitive twisting of the wrist.
2. Patients experience pain on grasping with their thumb, such as with pinching.
3.Swelling and tenderness are often present over the radial styloid process.
4. The Finkelstein sign is positive, which is elicited by having the patient place
the thumb in the palm and close the fingers over it. The wrist is then ulnarly
deviated, resulting in pain over the involved tendon sheath in the area of the
radial styloid.
It may occur in pregnancy, and it also occurs in mothers who hold their babies with
the thumb outstretched.

20. Patellar Tendinitis (Jumper's Knee)
Tendinitis involves the patellar
tendon at its attachment to the
lower pole of the patella.
Patients may experience pain when
jumping during basketball or
volleyball, going up stairs, or doing
deep knee squats. Tenderness is
noted on examination over the lower
pole of the patella.
Treatment consists of rest, icing,
and NSAIDs, followed by
strengthening and increasing
flexibility.

21. Iliotibial Band Syndrome
The iliotibial band is a thick connective tissue that runs from the ilium to the
fibula.
Patients with iliotibial band syndrome most cammonly present with aching or
burning pain at the site where the band courses over the lateral femoral
condyle of the knee; pain may also radiate up the thigh, toward the hip.
Predisposing factors for iliotibial band syndrome include a varus alignment of
the knee, excessive running distance, poorly fitted shoes, or continuous
running on uneven terrain.

22. Adhesive Capsulitis :
Often referred to as "frozen shoulder," adhesive capsulitis is characterized by pain
and restricted movement of the shoulder, usually in the absence of intrinsic
shoulder disease.
Adhesive capsulitis may follow bursitis or tendinitis of the shoulder or be associated
with systemic disorders such as chronic pulmonary disease, myocardial infarction,
and diabetes mellitus.

23. Adhesive Capsulitis :
Prolonged immobility of the arm contributes to the development of adhesive
capsulitis.
Pathologically, the capsule of the shoulder is thickened, and a mild chronic
inflammatory infiltrate and fibrosis may be present.
Adhesive capsulitis occurs more commonly in women after age 50.
Pain and stiffness usually develop gradually but progress rapidly in some
patients.
Night pain is often present in the affected shoulder and pain may interfere with
sleep.

24. Adhesive Capsulitis :
The shoulder is tender to palpation, and both active and passive movement are
restricted.
Radiographs of the shoulder show osteopenia.
The diagnosis is typically made by physical examination but can be confirmed if
necessary by arthrography, in that only a limited amount of contrast material,
usually <15 mL, can be injected under pressure into the shoulder joint.

25. Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, or tennis elbow, is a painful condition involving the soft tissue
over the lateral aspect of the elbow.
The pain originates at or near the site of attachment of the common extensors to the
lateral epicondyle and may radiate into the forearm and dorsum of the wrist.
The pain usually appears after work or recreational activities involving repeated
motions of wrist extension and supination against resistance. .

26. Medial Epicondylitis (golfer's elbow)
Medial epicondylitis is an overuse syndrome resulting in pain over the medial side
of the elbow with radiation into the forearm.
The cause of this syndrome is considered to be repetitive resisted motions of
wrist flexion and pronation, which lead to microtears and granulation tissue at
the origin of the pronator teres and forearm flexors, particularly the flexor
carpi radialis.
This overuse syndrome is usually seen in patients >35 years and is much less
common than lateral epicondylitis.

27. Medial Epicondylitis (golfer's elbow)
It occurs most often in work-related repetitive activities but also occurs with
recreational activities such as swinging a golf club (golfer's elbow) or throwing a
baseball.
On physical examination, there is tenderness just distal to the medial epicondyle
over the origin of the forearm flexors.
Pain can be reproduced by resisting wrist flexion and pronation with the elbow
extended.

28. Medial Epicondylitis (golfer's elbow) :
Radiographs are usually normal.
The differential diagnosis of patients with medial elbow symptoms include tears of
the pronator teres, acute medial collateral ligament tear, and medial collateral
ligament instability.
Ulnar neuritis has been found in 25–50% of patients with medial epicondylitis and
is associated with tenderness over the ulnar nerve at the elbow as well as hypesthesia
and paresthesia on the ulnar side of the hand.

29. Plantar Fasciitis
Plantar fasciitis is a common cause of foot pain in adults, with the peak incidence
occurring in people between the ages of 40 and 60 years.
Several factors that increase the risk of developing plantar fasciitis include:
obesity, pes planus (flat foot or absence of the foot arch when standing), pes cavus
(high-arched foot), limited dorsiflexion of the ankle, prolonged standing, walking on
hard surfaces, and faulty shoes. In runners, excessive running and a change to a harder
running surface may precipitate plantar fasciitis.

30. Plantar Fasciitis
The pain originates at or near the site of the plantar fascia attachment to the
medial tuberosity of the calcaneus.
Patients experience severe pain with the first steps on arising in the morning or
following inactivity during the day.
Pain is made worse on walking barefoot or up stairs.
On examination, maximal tenderness is elicited on palpation over the inferior heel
corresponding to the site of attachment of the plantar fascia.

31. Imaging studies may be indicated when the diagnosis is not clear;(Plain radiographs
may show heel spurs, which are of little diagnostic significance).
The differential diagnosis of inferior heel pain includes calcaneal stress fractures,
the spondyloarthritides, rheumatoid arthritis, gout, neoplastic or infiltrative bone
processes, and nerve compression/entrapment syndromes.