Inflammation of soft tissue and tendons

by Nathan Wei, MD, FACP, FACR 

Nathan Wei is a nationally known board-certified rheumatologist and author of the

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The term “soft tissues” refers to muscles, tendons, and ligaments- areas outside the joints. 

Bursitis and tendinitis are forms of soft tissue inflammation 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. 

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. 

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. 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. 

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

Soft tissue rheumatic syndromes may affect the areas around the joints of the shoulders,
chest elbows, wrists fingers, hips, back, knees, ankles, and feet. 

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. 

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. 

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. 

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. 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

Bursitis is inflammation or irritation of a bursa, a small sac located between a bone and
muscle, skin, or tendon. The bursa allows smooth gliding between these structures. Below
are some of the specific types of 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. 

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. 

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." 

Swelling of the small sac at the tip of the elbow- olecrenon bursitis- 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. 
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. 

The anserine 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. 

The retrocalcaneal 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. 

The calcaneal 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. 

Tendinitis is inflammation or irritation of the tendon, which is a thick cord that attaches
muscle to bone. Tendons transmit the power generated from muscles to help move a bone. 

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. 

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 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. 

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. 

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. 

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. 

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. 

The lateral 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 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. 

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. 

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. 
Treatment

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.

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 treatment. 

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. 

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.

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. 

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, nabumatone, celecoxib, 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 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, 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. 

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.

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.

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.

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. 
• Enlarge 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.

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.

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.
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.

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. 

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