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Soft Tissue Rheumatism of the Bursae, Tendons And Ligaments

Musculoskeletal symptoms without frank arthritis are very common. They are often chronic and require multiple treatment modalities. They are the cause of lost time at work as well as frequent litigation and disability complaints.

Soft tissue rheumatism is a group of heterogeneous disorders classified according to pathological process (ex. tendinitis), by anatomic location (ex. shoulder pain) or by etiopathogenesis (ex. repetitive strain syndrome). One must also have a basic knowledge of the normal function of the affected structures, that is of bursae, tendons and ligaments.

Bursae and Bursitis

Bursitis encompasses a variety of structures that share the following features: (1) they are closed sacs; (2) they are synovial lined as are diarthrodial joints, (3) they are placed in anatomic locations to facilitate the gliding of one musculoskeletal structure upon another, such as skin or tendon over bone. Bursae act as cushions and reduce friction where tendons and muscles merge.

There are at least 78 bursae on each side of the body. There are two main types of bursae: the constant ones present from birth (ex. anserine or subdeltoid bursae) and the adventitial bursae, which are acquired later in life, in response to direct pressure over a bony prominence: the best recognized of these is that which overlies the first MTP joint of the great toe.

Anatomic classification divides bursae into superficial (subcutaneous) or deep, according to location. The superficial bursae that overlie the olecranon and prepatellar areas are particularly prone to repetitive injury, resulting in traumatic bursitis. Deep bursae, unlike superficial ones, often communicate with their surrounding joints. Some examples are the communication between the iliopsoas bursae with the hip joint and the communication between the gastrocnemius -semimembranosus bursa and the knee (the so-called "Baker's Cyst"). The clinically more important bursae are discussed briefly below.

The olecranon bursae covers the olecranon process of the elbow. With repeated trauma (usually mild) the bursal wall swells - often becoming thickened and sometimes filling up with fluid. On physical examination, the elbow has full motion without pain (often a hallmark of bursitis as opposed to arthritis). When distended by fluid, the bursae can rupture into the subcutaneous tissues along the ulnar border of the forearm.

The subacromial or subdeltoid bursae is located inferior to the coracoacromial arch and overlies the rotator cuff tendons. Inflammation of this bursae is a common cause of shoulder pain. The most common cause of shoulder bursitis are acute and chronic trauma. On physical examination, there is tenderness over the rotator cuff most marked over the lateral portion of the shoulder and the subacromial space.

Bursitis is a common cause of lower extremity pain in people at all ages and activity' levels. Hip pain in the elderly population is often attributed to osteoarthritis. Often overlooked and probably more common is hip bursitis.

The greater trochanter has up to three

Treatment of bursitis