1 Introduction

Soft tissue disorders are common focal pathological syndromes affecting soft tissue structures like tendons, ligaments, bursa, fascia, and the site of insertions of these structures to bones (enthesis). They are commonly encountered disorders in daily clinical practice particularly in outpatient settings. A systemic disease does not always accompany them;, however, they can be associated with spondyloarthritis. They are most likely caused by overuse, repetitive trauma, and occupational history. This chapter will present in a simplified approach different types of bursitis, tendinitis, enthesitis, and fasciitis encountered in clinical practice. The emphasis will be placed on diagnostic workup based on comprehensive history-taking skills and musculoskeletal (MSK) examination findings. Outlines of management principles will be reviewed as most of these disorders respond to conservative therapy (pain management, physiotherapy, and avoidance of aggravating movements) and it rarely needs surgical intervention. There are other soft tissue disorders discussed in “Diabetes and Rheumatology” Chap. 21. Detailed techniques of MSK examination of several of these disorders are discussed in Chap. 2.

1.1 Learning Objectives

By the end of this chapter, you should be able to:

  • Discuss the anatomy and classification of common soft tissue disorders (bursa, ligaments, tendons, and fascia) that cause localized pain syndromes.

  • Describe the clinical presentation of the most common types of soft tissue disorders.

  • Construct a diagnostic approach for different types of soft tissue disorders.

  • Outline management principles of these disorders.

1.2 Classification of Soft Tissue Disorders

A selective group of soft tissue disorders will be reviewed in this chapter based on the following classification (Fig. 22.1). It is based on the site of involvement of these structures. It is important to consider soft tissue disorders in the differential diagnosis of regional pain syndromes.

Fig. 22.1
figure 1

Classification of soft tissue disease in rheumatology

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1.3 Bursitis

It is important to realize the anatomical definition of a bursa in order to recognize the clinical presentation of bursitis. A bursa is simply the sac structure that is formed of two layers filled with synovial fluid that protects other structure underneath it from injuries caused by pressure. This sac acts as cushions. Bursitis is simply inflammation of this sac.

The most common sites are shoulder (subdeltoid, olecranon), hip (ischial tuberosity, trochanteric), knee (prepatellar bursa), and foot (retrocalcaneal) [1,2,3,4,5,6,7,8,9]. Table 22.1 represents a comprehensive a general review of the clinical presentation, investigation, and treatment of bursitis. Table 22.2 represents a review of specific types of bursitis.

Table 22.1 Review of the Bursitis history, physical examination, investigation, and treatment
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Table 22.2
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1.4 Tendinitis

A tendon is a thick fibrous cord that attaches muscle to bone. Inflammation in the tendon is called tendinitis. The most common sites for tendinitis are around shoulder, elbow, and ankle joints. One of the pathophysiological mechanisms for tendinitis is micro-tears, affecting these tendons from repeated stressors like in overuse, or in traumatic situations.

In some situations where there is inflammation of the tendon sheath, the condition is called tenosynovitis. Table 22.3 represents a comprehensive, general review of the clinical presentation, investigation, and treatment of tendinitis.

Table 22.3 Review of the tendonitis history, examination, diagnosis, treatment, and prevention
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Table 22.4 represents a review of rotator cuff tendinitis.

Table 22.6 Achilles Tendonitis [21, 22]
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Tendinosis is a chronic proses associated with an atrophic and degenerative change of the tendon caused by recurrent tendinitis. US or MRI is required to diagnose it and to differentiate between different causes.

1.5 Rotator Cuff Tendinitis and Rotator Cuff Tear

Rotator cuff tendinitis (RCT) is a common type of tendinitis that affects the shoulder. The patient usually presents with lateral shoulder pain and limited active ROM. It is the most common cause of shoulder pain in clinical practice. A brief approach to shoulder pain is presented in Chap. 2. Table 22.4 represents a comparison between RCT and rotator cuff tear (RCTr) in terms of definition, diagnostic, and therapeutic interventions.

Table 22.4 Review of the tendonitis history, examination, diagnosis, treatment, and prevention [21, 22]
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1.6 Enthesitis

It is inflammation at the site of insertion of ligaments, tendons, fascia, and articular capsules into the bone. It might be associated with pain at free nerve ending. It is the hallmark of spondyloarthritis (SpA) particularly when paravertebral ligaments are involved causing spondylitis. Extensive search for a systemic spondyloarthritic disease (see Chap. 1) should be sought in patients presenting with common enthesitis like Achilles tendinitis and plantar fasciitis [21, 22]. However, most of these enthesitis disorders have no systemic correlation, and they are induced by regional pathophysiological mechanisms. Table 22.5 represents a review about enthesitis. Tables 22.6, 22.7 and 22.8 summarize common enthesitis encountered in clinical practice: Achilles tendinitis, epicondylitis, and plantar fasciitis (Table 22.6).

Table 22.5 History, examination, diagnosis, and treatment of enthesitis
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Table 22.7 Lateral and medial epicondylitis
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Table 22.8 Planter fasciitis anatomy, history, physical exam, investigation and treatment
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Table 22.9 Palmar fasciitis: definition, risk factors, symptoms, physical exam, investigation and treatment
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1.7 Achilles Tendinitis

See Table 22.6.

1.8 Epicondylitis [26, 27]

See Table 22.7

1.9 Fasciitis

A fascia is a layer of fibrous connective tissue ( collagen ) below the skin that covers underlying tissues (muscles, blood vessels, and nerves). Fasciitis is the inflammation of the fascia that causes fibrosis and loss of elasticity. The most common types of fasciitis are planter fasciitis, palmar fasciitis, and eosinophilic fasciitis (these types can be secondary to autoimmune rheumatological diseases and malignancies).

1.10 Plantar Fasciitis

See Table 22.8.

1.11 Palmar Fasciitis

See Table 22.9.

1.12 Eosinophilic Fasciitis

See Table 22.10.

Table 22.10 Eosinophilic fasciitis definition, risk factors, symptoms, physical exam, investigation and treatment
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