AKT · Musculoskeletal/Fractures, trauma & soft tissuelow yield

Soft tissue injury, bursitis & enthesopathy

Injury/inflammation of ligaments, tendons, muscle or bursae (overuse, trauma, inflammatory)

Overview

Injury or inflammation of the periarticular soft tissues — ligament sprains, muscle/tendon strains, tendinopathy, bursitis and enthesopathy. They are common, usually managed conservatively (relative rest, analgesia, physiotherapy), and the main skill is recognising the few that need more — an Achilles tendon rupture, a septic bursitis, or an underlying inflammatory cause.

Recognise

Sprain (ligament) / strain (muscle-tendon): pain, swelling, bruising and functional loss after an injury; tendinopathy: activity-related pain at a tendon (e.g. Achilles, tennis/golfer's elbow)
Bursitis: localised swelling and tenderness over a bursa (olecranon, prepatellar 'housemaid's knee', trochanteric); carpal tunnel syndrome = median-nerve entrapment (nocturnal thumb/index/middle paraesthesia, Tinel/Phalen; a/w RA, pregnancy, hypothyroidism, acromegaly)
Achilles rupture: sudden 'kick'/pop in the calf, weak plantarflexion, positive Simmonds-Thompson (calf squeeze) test, a palpable gap
Knee ligament/meniscal injury: ACL (twisting, 'pop', haemarthrosis, positive Lachman/anterior-drawer), meniscal (twisting, locking/giving way, joint-line tenderness), the 'unhappy triad' (ACL + MCL + meniscus); MRI to image, refer for arthroscopy

Red flags

Septic bursitis (hot, red, fevered bursa) → aspirate + antibiotics
Achilles tendon rupture (positive Simmonds-Thompson test) → immobilise in equinus and refer; do not miss it
Inability to weight-bear/bony tenderness → apply the Ottawa rules and X-ray to exclude fracture

Differentials & how to tell them apart

Fracturebony tenderness/inability to weight-bear — Ottawa rules → X-ray

Septic arthritis / septic bursitishot joint or bursa with systemic upset — aspirate

Inflammatory enthesitis (spondyloarthropathy)multiple sites, inflammatory features

DVT (calf)can mimic a calf muscle tear — assess Wells if uncertain

Investigations

Usually clinical; apply the Ottawa ankle/knee rules to decide on X-ray (exclude fracture); ultrasound/MRI for tendon rupture/tear if uncertain; aspirate a bursa if septic bursitis suspected (Gram stain/culture).

Management

Relative rest + analgesia + physiotherapy; specific care for rupture/septic bursitis

1Most soft-tissue injuries → relative rest, analgesia and physiotherapy (use the Ottawa rules to decide whether to X-ray for fracture).Gate: Don't miss the exceptions: a positive Simmonds-Thompson test = Achilles rupture (immobilise in equinus, refer); a hot, red, fevered bursa = septic bursitis (aspirate + antibiotics, not a steroid injection).
2Tendon rupture → orthopaedic management (functional bracing or repair); recurrent tendinopathy → address overuse/biomechanics and graded loading.

PRICE / relative rest, analgesia (NSAID), physiotherapy — first-line for most sprains/strains/tendinopathy; early mobilisation and graded loading

Bursitis: rest, NSAID, aspiration; antibiotics ONLY if septic — avoid steroid injection if infection suspected

Achilles rupture: immobilise in plantarflexion (equinus) and refer — conservative functional bracing or surgical repair per orthopaedics

Address overuse/biomechanics — to prevent recurrence in tendinopathy

Key points

Most sprains/strains/tendinopathy → rest + analgesia + physio (Ottawa rules to exclude fracture). Catch the exceptions: Achilles rupture (sudden calf 'kick', positive Simmonds-Thompson, palpable gap → equinus immobilisation + refer) and septic bursitis (hot fevered bursa → aspirate + antibiotics, no steroid).

Monitor & prognosis

Functional recovery, recurrence, healing of tendon ruptures.

Most resolve with conservative care; tendon ruptures and septic bursitis need specific management.

Source: NICE CKS (sprains/strains, bursitis); BOAST (Achilles)