What additional information (e.g., clinical findings, laboratory test results) will confirm the diagnosis?
In addition to tenderness, patients often present with joint stiffness and swelling. This is because the condition is common in young athletes who overuse specific joints and inefficient biomechanics resulting from inflammatory systemic diseases or microtrauma (Bellew et al., 2017). In most patients, there is notable erythema on the skin overlying the tendon on the affected foot (Burke, 2019). Some cases are characterized by symmetric enlargement and baseline contracture of the posterior tibial tendon (Ray et al., 2021). It is worth noting that while plain film radiographs may show no evidence of fractures, there may be signs of inflammation, such as periosteal reaction and synovial membrane calcification (Ray et al., 2021). Ultrasonographic features such as thickening of the tension and accumulation of peritendinous fluid can confirm the diagnosis (Bellew et al., 2017). In addition, specific markers associated with autoimmune illnesses may help identify the illness.
What are your differential diagnoses for this patient?
The differential diagnoses include posterior tibial tendon dysfunction, inflammatory arthritis, traumatic disruption of midfoot ligaments, and Charcot arthropathy.
What is your likely diagnosis?
The likely diagnosis for this case is posterior tibial tendon tenosynovitis.
What is (are) the desired treatment outcome(s)?
It is expected that after completing treatment, the patient will resume normal activities without pain. Most patients experience complete relief within 6 to 10 weeks of treatment (Ray et al., 2021). Patients typically regain the full range of motion in the affected joints.
What non-pharmacological therapy would you recommend?
Non-pharmacological treatments are often used in the management of the disease. For instance, mechanical offloading of the affected tendon can be accomplished using custom-molded orthotics or ankle braces with deep heel cups and the required medial wedging (Whitney, 2019). Other treatment modalities include splinting and the use of cold or heated packs. Transcutaneous electrical nerve stimulation is commonly used to relieve pain. However, it should be noted that the procedure may cause skin irritation in situations where the current is high.
How would your pharmacotherapeutic plan differ based on special population patients (such as children, obstetrics, geriatrics, etc.)?
The mainstay of treatment in posterior tendon tenosynovitis is the administration of non-steroidal anti-inflammatory drugs and glucocorticoid injections. The latter are contraindicated in patients with cardiovascular diseases such as coronary heart disease. For instance, patients taking more than 7.5mg of prednisone daily have a high risk of developing myocardial infarction, heart failure, and angina (Alan & Alan, 2018). Individuals with a history of pre-diabetes or diabetes should avoid the use of glucocorticoids because these medications cause exaggerated post-prandial hyperglycemia and lead to reduced sensitivity to exogenous insulin (Alan & Alan, 2018). It is advisable to limit the use of these drugs in the elderly population because they cause secondary osteoporosis. It is vital to note that this class of drugs increases fracture risk in both men and women. Elderly individuals on glucocorticoid treatment have a 26-fold higher risk of developing vertebral fractures than younger individuals (Alan & Alan, 2018). Individuals with compromised immune systems should use glucocorticoids with caution. This is because treatment with these drugs leads to immune suppression, which increases susceptibility to infections.
Children are adversely affected when subjected to treatment with the aforementioned category of drugs. For instance, they suffer adrenal insufficiency caused by the suppression of the hypothalamic-pituitary-adrenal axis. This inevitably triggers adrenal cortical atrophy and insufficiency, which negatively impacts the affected individuals’ health (Alan & Alan, 2018). Non-steroidal inflammatory medications should be avoided in patients with gastroesophageal reflux disease since they may lead to gastric and ileal ulceration.
What pharmacotherapeutic plan (include prescription and non-prescription drugs) would you design for this patient (specific to the chapter you are currently reading)?
The first step of treatment involves conservative management with non-steroidal anti-inflammatory medications such as naproxen. In addition, glucocorticoid injections are administered to affected individuals to relieve inflammation. This step is taken in individuals who are poorly responsive to non-steroidal anti-inflammatory drug therapy. In the event the patient does not respond to disease-modifying antirheumatic drugs, surgery is considered after three to six months of treatment (Ray et al., 2021). Surgery involves debridement of inflammatory tissues and decompression of the implicated tendons.
The rationale for pharmacotherapy to include mechanism(s) of action list drug(s), dose, route of administration, frequency, duration of treatment, and one monitoring parameter.
Mild to moderate cases of tenosynovitis should be managed using non-steroidal anti-inflammatory (NSAID) medications. Orally administered naproxen at 550 mg twice daily is sufficient to manage the pain and inflammatory symptoms associated with the illness. NSAIDs are effective in view of the fact that they decrease soft tissue swelling and inflammation, thus alleviating nerve compression. In addition, they accelerate healing by facilitating the formation of cross-linkages between collagen fibers in the affected tissues (Nainwal & Arunmozhi, 2020). Glucorcoticoid sheath injections can be administered to patients in severe pain with poor response to NSAIDs. 100-500 mg of Hydrocortisone acetate is often administered intramuscularly depending on the inflammatory process’s severity. These drugs inhibit inflammation by limiting prostaglandin synthesis and stopping the migration of white blood cells to the injured areas (Nainwal & Arunmozhi, 2020). However, these medications also inhibit collagen synthesis and may weaken the affected tendon.
What are the clinically significant adverse effects and drug interactions for the agents discussed?
Glucocorticoids cause a variety of adverse effects when used in the management of tenosynovitis. For instance, they have been implicated in depressing the immune system, diabetes, hypertension, and dyslipidemia (Alan & Alan, 2018). In addition, they cause weight gain, reduce insulin sensitivity, and may cause osteoporosis. Naproxen is an NSAID that may cause headaches, visual changes, and ringing in the ears. In addition, it may predispose susceptible individuals to the development of peptic ulcer disease.
How will you monitor the patient’s response to therapy?
Response to therapy can be monitored by conducting a repeat ultrasound to observe the resolution of symptoms. Reduced tendon thickening and the absence of echotexture changes are indicative of improvement (Ray et al., 2021). In addition, magnetic resonance imaging can be used to identify reduced fluid collection around the tendon (Whitney, 2019). The resolution or aggravation of clinical features is an effective modality for monitoring progress. Patients should progressively regain full functionality of the affected joint and experience a reduction in pain and swelling. It is vital to prevent and assess for the development of the stenosing form of tenosynovitis that causes flexion deformities and chronic contractures that may require surgical intervention (Ray et al., 2021). Finally, range of motion exercises may be used to assess the degree of healing.
How will you counsel your patient about the pharmacotherapeutic plan?
It is vital to highlight the mechanism of action and side effects associated with each of the drugs administered. This is vital because it will allow the client to differentiate between the symptoms associated with the disease and the sensations caused by the administered medicine. The patient must understand the importance of adhering to the outlined schedule because it determines how quickly they will recover. It is important to note that medical treatment goes hand in hand with specific behavioral changes. For instance, the affected joint must be rested, and the nature of the activity re-evaluated to find better and safer ways of exercising or running. The patient must also be advised to report worsening symptoms so that the medication may be altered or alternative modalities of treatment explored. Finally, it is crucial to inform the patient on when to stop treatment to avoid drug-related complications.
References
Alan, I. S., & Alan, B. (2018). Side effects of glucocorticoids. In Pharmacokinetics and Adverse Effects of Drugs – Mechanisms and Risks Factors. InTech.
Bellew, S., Colbenson, K., & Bellamkonda, V. (2017). Posterior tibial tendon tenosynovitis diagnosed by point-of-care ultrasound. Clinical Practice and Cases in Emergency Medicine, 1(4), 439–440.
Burke, D. (2019). Tendon sheath inflammation (tenosynovitis). Healthline. Web.
Nainwal, D., & Arunmozhi, R. (2020). A literature review on De-Quervains tenosynovitis. International Journal of Advanced Research, 8(7), 824–835.
Ray, G., Sandean, D. P., & Tall, M. A. (2021). Tenosynovitis – . StatPearls – NCBI Bookshelf. Web.
Whitney, K. A. (2019). Tibialis posterior tendinosis and Tibialis posterior tenosynovitis: Musculoskeletal and connective tissue disorders. MSD Manual: Professional Edition. Web.