Soft Tissue Rheumatism, Tendinopathy and Bursitis
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Direct answer
Soft tissue rheumatism is pain arising from the tendons, bursae, ligaments and fascia around a joint, without primary inflammation of the joint itself. Tendinopathy is usually a degenerative and overuse process rather than inflammation, so loading exercise is central and NSAIDs give limited lasting benefit. Steroid injection gives short-term relief but raises the risk of tendon weakening and rupture, so it is used sparingly and kept outside the tendon substance.
What you must remember
- Rotator cuff: supraspinatus tendinopathy causes a painful arc between about 60 and 120 degrees of abduction, tested with the Neer and Hawkins signs.
- Tennis elbow: lateral epicondylitis at the extensor carpi radialis brevis origin, provoked by resisted wrist extension, with the Cozen test as a classic clue.
- Golfer's elbow: medial epicondylitis at the flexor-pronator origin, with pain on resisted wrist flexion.
- Plantar fasciitis: heel pain worst with the first steps after rest, with a thickened fascia on ultrasound.
- De Quervain tenosynovitis: pain over the radial styloid from the abductor pollicis longus and extensor pollicis brevis, with a positive Finkelstein test.
- Trigger finger: stenosing flexor tenosynovitis at the A1 pulley, with catching and a palpable nodule.
- Bursitis: subacromial, olecranon and prepatellar bursitis are common, and fever with spreading redness suggests septic bursitis.
Matching the site to the diagnosis
Soft tissue rheumatism is recognised by its site and by the provocation test that reproduces the pain. The table pairs each common condition with its classic clue and its usual first-line care.
| Condition | Site | Classic clue | First-line care |
|---|---|---|---|
| Rotator cuff tendinopathy | Greater tuberosity | Painful arc, Neer and Hawkins tests | Exercise, NSAID, subacromial injection |
| Lateral epicondylitis | Lateral elbow | Pain on resisted wrist extension | Activity change and eccentric exercise |
| Plantar fasciitis | Medial heel | First-step pain in the morning | Stretching, orthosis, injection |
| De Quervain tenosynovitis | Radial styloid | Positive Finkelstein test | Splint and steroid injection |
| Trigger finger | A1 pulley | Catching and palpable nodule | Steroid injection, then surgical release |
| Trochanteric pain | Lateral hip | Pain on lying on the affected side | Exercise and injection |
Most of these conditions are self-limiting or respond to exercise, and steroid injection is the usual next step when they do not. Injection is placed outside the tendon substance, because repeated injection weakens tendon tissue and risks rupture.
Traps in tendon and bursa stems
Most lost marks come from treating a degenerative tendon as inflamed or ignoring the drug that causes tendon pain.
- Trap: tendon pain in a patient on a fluoroquinolone is treated as tendinopathy and the drug is continued. Correct: fluoroquinolone-associated tendinopathy needs the drug stopped, and the risk is higher with corticosteroids.
- Trap: tendinopathy is managed with anti-inflammatory drugs alone as if the tendon were inflamed. Correct: most tendinopathy is degenerative, so loading exercise is central and NSAIDs give little lasting benefit.
- Trap: a steroid is injected into the Achilles tendon to relieve heel pain. Correct: steroid injection into the tendon substance risks rupture, so it is avoided in the Achilles tendon.
Frequently asked questions
Which test identifies de Quervain tenosynovitis?
The Finkelstein test identifies de Quervain tenosynovitis, with pain over the radial styloid when the thumb is flexed into the palm and the wrist is deviated ulnarly. Tenderness over the abductor pollicis longus and extensor pollicis brevis tendons supports the diagnosis.
What is the painful arc in supraspinatus tendinopathy?
The painful arc in supraspinatus tendinopathy lies between about 60 and 120 degrees of active abduction. Pain eases above that range, and the Neer and Hawkins tests reproduce symptoms through impingement.
How does plantar fasciitis present in the morning?
Plantar fasciitis presents with heel pain that is worst with the first steps after rest, easing as the fascia warms up. Tenderness over the medial calcaneal tubercle is typical, and ultrasound may show a thickened plantar fascia.
When should steroid injection be avoided in tendon disorders?
Steroid injection is avoided directly into the Achilles tendon because it can weaken the tendon substance and cause rupture. Repeated injections are limited in other tendons too, and the injection is placed in the peritendinous space where possible.
How does septic bursitis differ from aseptic bursitis?
Septic bursitis presents with fever, marked warmth and spreading redness, and bursal fluid shows a high cell count with organisms on culture. Aseptic bursitis is typically painful without systemic illness, and it responds to rest, aspiration or injection.