Synopsis
Differentiate bursal, tendon and entheseal pain, recognise sepsis, rupture and inflammatory spondyloarthritis, use imaging or aspiration only for focused questions, and restore tissue capacity through progressive loading with safe selective medicines.
- Bursitis produces local swelling and pressure tenderness over a bursa; tendinopathy produces load-related tendon pain; enthesitis localises at an insertion and may be mechanical or inflammatory.
- A hot olecranon or prepatellar bursa with skin breach, fever or immune risk needs aspiration for Gram stain, culture, cell count and crystals when safe, plus prompt anti-staphylococcal treatment.
- Do not aspirate or inject an uncomplicated mechanical bursa routinely; repeated needle entry can introduce infection and fluid reaccumulates unless pressure or loading changes.
- Diagnose most tendinopathy clinically from location and reproducible load pain; ultrasound or MRI is useful for uncertainty, suspected tear or procedural planning, not routine severity scoring.
- Initial tendon care uses relative load modification followed by progressive isometric and isotonic, heavy-slow or eccentric loading appropriate to the tendon; complete rest delays recovery.
- Avoid intratendinous corticosteroid and do not inject around Achilles or patellar tendon routinely because relief may be brief and rupture risk is concerning.
- Persistent enthesitis at multiple sites or with psoriasis, uveitis, bowel disease, dactylitis or inflammatory back pain requires rheumatology referral and systemic assessment.
- A pop with immediate weakness, palpable gap, absent heel rise or abnormal Simmonds-Thompson test indicates rupture until excluded; protect and refer urgently.
Key red flags
Spreading erythema, fever, rigors, immunosuppression, a skin wound or systemic instability with superficial bursal swelling requires urgent septic-bursitis or sepsis management.
A sudden snap, immediate weakness, palpable tendon gap, inability to perform a straight-leg raise or abnormal calf-squeeze test suggests complete rupture and needs urgent protection and referral.
Disproportionate night pain, a mass, weight loss or persistent focal bone tenderness requires imaging for malignancy, fracture or infection rather than repeated soft-tissue treatment.
Multiple entheses, inflammatory back pain, psoriasis, dactylitis, uveitis or inflammatory bowel disease warrants timely spondyloarthritis assessment instead of serial local injections.
Calf swelling with breathlessness, chest pain or thrombotic risk may be venous thromboembolism rather than Achilles or calf tendinopathy and requires acute care.
Investigation priorities
Distinguish bursa, tendon, enthesis, joint, nerve and bone and identify infection or rupture before rehabilitation.
Management branches
A focal periarticular pain syndrome presents without systemic instability or obvious complete rupture.
- Map bursa, tendon course and insertion, test passive joint movement and resisted action, and examine skin, neurology and adjacent bone.
- Establish whether onset follows pressure or load, is infectious or crystal-like, or clusters with systemic inflammatory features.
- Use no imaging for a clear uncomplicated mechanical pattern; request ultrasound, radiography or MRI only for uncertainty, trauma, mass, failed care or procedure.
- Give safety-netting for fever, spreading redness, sudden power loss, calf swelling or mass and set a functional review.
Clinical tendinopathy is present without complete rupture, infection or bone stress injury needing protection.
- Temporarily reduce provoking work, running, jumping or gripping while maintaining tolerable movement and addressing footwear, technique and recovery.
- Begin isometric or low-load isotonic exercise when irritability is high, then progress slow resistance and finally tendon-specific speed and return-to-task loads.
- Use pain during and the following day to adjust dose rather than insisting on zero pain or exercising through escalation.