Synovitis – The Runner’s Guide to Diagnosis, Treatment & Prevention

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Our bodies are all made up of small, intricate parts that combine to create a larger, complex organism. Nothing serves as a better reminder of this inter-connectivity than the lyrics to the spiritual song Dem Bones, by James Weldon Johnson (1871-1938). The words chosen in this song take us on a visual trip from the tips of our toes to the top of our heads and back again…

Toe bone connected to the foot bone
Foot bone connected to the heel bone
Heel bone connected to the ankle bone
Ankle bone connected to the shin bone
Shin bone connected to the knee bone
Knee bone connected to the thigh bone
Thigh bone connected to the hip bone
Hip bone connected to the back bone
Back bone connected to the shoulder bone
Shoulder bone connected to the neck bone
Neck bone connected to the head bone

Synovitis-Synovial-full-skeleton

According to Arthritis Health, there are 206 bones and about 300 joints in an adult human body. The majority of these joints are synovial, meaning that they are protected by a membrane filled with a viscous lubricating fluid. To better illustrate this point, here is a brief anatomy review lesson. You can follow along with the song if you wish! There are six types of synovial joints, each named for their dynamic force in the production of movement.

  • Plane (gliding) and condyloid (ellipsoid) – composed of small bones in your foot, ankle, and wrist
  • Hinge – located in your upper/lower arms, elbow, fingers, knuckles, knees, ankles, and toes
  • Pivot – found in your neck vertebrae
  • Saddle – located in your thumb joint
  • Ball-and-socket – comprising your hips and shoulders

Synovial joints permit the greatest range of motion, allowing us to run, walk, write, type, and complete everyday activities. However, as a consequence of these joints being synovial, this means they are all susceptible to a specific running injury known as synovitis.

 What is Synovitis?

Synovial joints are lined with a thin connective tissue layer. This tissue is called synovium, or synovial membrane.  The synovial membrane produces synovial fluid, filling the joint cavities, tendon sheathes and bursae with this lubricating liquid that serves a vital function in the body. Synovial fluid cushions the joint, lowering friction and resistance during joint movement. It is the body’s joint protection, preventing injury from repetitive movement or sudden shock. In addition, the synovial fluid provides nourishment to the cells and removes cell waste products.

Developing synovitis means the synovial membrane or the lining of the joint becomes inflamed.  This injury that targets the soft tissue covering the joint capsule usually affects the knees, hips, shoulders, ankles and wrists. Each condition is named by the body joint affected: knee synovitis, ankle synovitis, hip synovitis, and so on.  Cases of this injury can range in severity, lasting either for a short amount of time in an acute form, or causing persistent, chronic pain for the long-term.

Synovitis-Synovial-Joint-of-the-Knee

Cases of this running injury are also commonly referred to as post traumatic synovitis, as one of the causes for this condition is direct injury or overuse of the affected body joint. Body movement mixed with extreme weight-bearing activity may inflame the synovium, contributing to the potential of injury development. As the fluid builds up, the result is very painful swelling, tenderness, stiffness, and the inability to move the joint.

Another condition called transient or toxic synovitis can occur in the hip joints of children, resulting in hip pain and limping. It is seen most often in children three to eight years old, and happens to boys more than girls. It is painful and short lived by nature, commonly healing itself within two weeks and leaving no permanent harm if treated properly.

A more severe form this condition can take is when the synovial membrane continues to grow, resulting in a benign tumor.  This is called pigmented villonodular synovitis (PVNS) and generally affects the knee and hip joints. Fortunately, it is very rare, and only affects 1.8 people per 1,000,000 on average.

Symptoms

Inside the synovial membrane, there are cells that keep the joint healthy. One type lubricates the cartilage to ease friction and brings nutrients. The other cell type cleans and scavenges, in order to remove and metabolize unwanted waste substances.

Inflammation of the synovium causes an imbalance of this fluid. The inflamed synovial joint produces additional fluid in response, as an attempt to heal the injury. With the increasing fluid and pressure, the swelling, tenderness, and discomfort become more painful. This combination makes the joint difficult to move and causes pain.

This condition can show up after a sprain or injury that has not healed properly, causing trouble for the weight-bearing limbs that are affected. The symptoms tend to worsen upon first waking up in the morning, or immediately after strenuous exercise. After mild movement, which is gradual and slow, in conjunction with a warm shower or heating pad, symptoms tend to improve.

In acute and chronic conditions, people can experience the following symptoms in any joint of the body:

  • Tenderness, swelling, pain, stiffness, or puffiness at the front, sides, and around the joint
  • Sometimes pain is felt in the back of the joint
  • Sometimes there is pain without swelling or tenderness
  • A quick onset of the condition due to a known event, or slow advancement over time
  • Increased skin temperature, warmth to the touch, or redness over the entire area
  • Difficulty in movement of the affected joint with limited range of motion
  • Increased pain and discomfort upon movement and use of joint
  • Feeling a popping or clicking sensation in the joint with movement or pressure
  • Development of hard lumps or nodules around the joint area
  • Joint dysfunction and increased rates of cartilage erosion, eventually leading to osteoarthritis

Chronic synovitis can be called by its archaic name of ‘water on the knee.’ The inflammation keeps recurring after an initial acute synovitis episode. Some people may continue to develop periodic episodes of this condition due to re-injury, gout, rheumatoid arthritis, osteoarthritis, and other medical ailments. It may also simply appear on its own without these prior conditions. Synovitis worsens if you continue to walk or run using the joint, and this is intensified on uneven pavement and slopes. Therefore, it is important to not begin routines incorporating these elements until at least three weeks after recovery and healing.

In children presenting transient or toxic versions of this ailment,  the conditions’ symptoms include:

  • Low- grade fever below 101F
  • Pain in the thigh, knee, or hip areas
  • Limping or walking on their tiptoes
  • Pain coming and going in one or several joints
  • Refusing to walk or being unable to walk or crawl altogether
  • After a long resting period, there may be a flare up of pain upon moving
  • Weepy and short-tempered attitudes in smaller children and infants

In pigmented villonodular synovitis (PVNS), there can be a slow or rapid swelling with pain that progresses quickly or comes and goes. The joint can lock up, catch, or freeze while trying to walk, run, or move in general. It is important to seek medical assistance as soon as possible and not attempt to self-treat these symptoms if they are experienced. Diagnosis is difficult and occurs over the course of 4.4 years on average.

Sub-clinical synovitis is an awkward condition that does not have any real or external symptoms. You may feel stiffness in your joints; however, there aren’t the usual cast of characteristic clues. This means that the synovial joint does not present swelling, warmth, tenderness, and/or redness, flying under the wire of some initial diagnoses!

Causes

Synovitis-Synovial-causes-overuse

Synovitis is not the primary condition in many cases. It is often the result of another trigger, or a secondary illness. The range can be as simple as a known traumatic physical joint injury to something as complex as cancer. One of the consequences of a chronic long-term condition can be deterioration of the joint, developing osteoarthritis. A qualified health care provider must be consulted in these cases.

Health associations that this injury has been linked to include:

  • Idiopathic- This means the cause is not readily known. At the time the person may have had a negligible bump or may not remember any observable symptoms. However, as a result of the trauma and inflammation, synovial fluid accumulates in the joint.
  • Injury, trauma, or a fracture to the joint- This is known to be caused by overuse, sprain, or damage.
  • Overuse – In an active, healthy person, overuse from sports, exercise, and activities can contribute to the development of this running injury.
  • Improper support- Muscle weaknesses or imbalances can inflame synovium.
  • Juvenile arthritis- This is a form of arthritis in children, affecting those under 18 years of age.
  • Gouty arthritis- Uric acid is either over manufactured or not eliminated by the body. Inflammation results from the accumulation of uric acid crystals in the joints.
  • Osteoarthritis- This is a wear-and-tear disorder. It occurs when the cushioning tissue breaks down at the ends of the bones. The result of this is bone rubbing against bone, which can be very painful.
  • Psoriatic arthritis – This is a joint condition that commonly appears first, and affects about 15-25% of people who have the skin condition psoriasis. Psoriasis is an inflammation of the skin cells, showing up on the patient’s skin as red patches with silvery fish scales.
  • Rheumatoid arthritis – Synovitis is the hallmark of rheumatoid arthritis. Cells in the inflamed membrane serve as a magnet, attracting other inflamed cells in the body. This creates a progressive and escalating pain level.
  • Rheumatic fever – This is an inflammatory disorder resulting as a complication from a group A streptococcus infection.
  • System lupus erythematosus– This is an inflammatory disorder that occurs when the immune system incorrectly begins to attack the body’s own healthy tissues.
  • Tuberculosis- This is a bacterial infection of the lungs. It is preventable and rare in the United States, with many individuals commonly inoculated from this condition via vaccination.
  • Viral or bacterial infections (chicken pox or a cold) – This is a short-term or temporary condition of the hip, seen commonly with this type of infection. Also known as toxic synovitis, it may affect one or both hips and extend to other joints. It may occur repeatedly with a viral cold. If an infection is suspected, taking a culture of the synovial fluid is often warranted. Specific microorganisms to look for are aerobic (oxygen loving), anaerobic (do not need oxygen), fungal, acid-fast bacilli (AFB), and atypical AFB. Once an infectious species determination is made, effective antimicrobial treatment is to be started as soon as possible.
  • Cancer – This is the overpowering rise of malformed cells that divide and devastate the cells of the body.

Particularly common causes in runners are ankle and knee synovitis. Both can occur after a serious sprain, and can persist in individuals who continue to run while the joint is still swollen, painful, and tender. In addition, excessive walking or running contributes to the recurring pressure and burden on the joints. People with a history of running on uneven surfaces, performing consistent weight bearing force impacts, having chronic unstable ankles or knees, and pronated or flat feet can negatively affect the large synovial joints, contributing to the potential of this injury developing.

Sub-clinical synovitis is a form of this condition with no overt symptoms that may be a by-product of rheumatoid arthritis. This is a condition that fluctuates between active disease, remission, and active disease. Typical short-term acute treatments are anti-inflammatory medication, ice, and extended periods of rest. Long-term medication includes anti-rheumatologic agents to slow the progression of the disease and joint destruction.

Risk Factors

Synovitis-Synovial-risk-factors-old-shoes

We are all bonded and held together with the same skeletal bone structure (pun intended). Consequently, elite athletes, sports enthusiasts, runners, walkers, and everyday folks are all at a risk for developing this condition. By being aware of some of the risk factors, You can be in a better position to minimize or prevent cases of this condition, as well as the subsequent pain and damage.

It is very important not to ignore any pain and symptoms, as acute synovitis can become chronic without proper and timely treatment.  During the inflammation process, enzymes are released that may absorb and digest cartilage and bone.  If left untreated, this may result in a life-long problem with joint degeneration.  Consult your physician for methods specific to your body, age, fitness level, and other preexisting medical conditions.

Elements that can influence development of this injury include:

  • Joint instability: This indicates the support tissues, ligaments, and muscles are weak in and around the bone. Wearing supportive equipment and performing muscle building and strengthening exercises regularly can limit the impact this has.
  • Reduced elasticity or flexibility: This is when joints and surrounding tissue becomes stiff and does not bounce back as easily.
  • Intense or improper workout or training: Extreme, sustained exercise above what the body is able to handle at that moment can cause injury. In addition, exercising or training incorrectly with repetitive impacts can cause strain to the tissues, contributing to the likelihood of injury development.
  • Weak joint biomechanics: Muscle, joint, and skeletal movements can significantly influence performance, gait, and injury rate.
  • Inferior footwear and joint support equipment: Be sure to use quality equipment recommended for providing support, protection, and cushioning while exercising.
  • Supporting muscle and ligament weakness: These can be a result of inactivity from a sedentary lifestyle, or preexisting medical and/or genetic factors.
  • Chronic medical history: This includes a history of chronic joint injury, strains, and sprains in your joints.

In children with transient or toxic synovitis, contact your health care provider if the following conditions occur:

  • Sharp pain, fever or a worsening of symptoms while taking medication
  • Symptoms are unrelieved or not reduced by medication within 48 hours
  • Joint symptoms recur after the medication is discontinued, or if the condition lasts longer than two to three weeks.

These situations may indicate that additional diagnostic tests or medications need to be ordered, and a further examination of the presenting condition completed.

False Positives

In some cases, running injuries may occur in your body that imitate the symptoms of synovitis. This is why a diagnosis from a doctor or medical professional is important when determining the exact form of your running injury, as failure to properly treat your condition can result in a waste of time and money at best, and the potential of developing a permanently damaging condition at worst. Be sure to rule out these potential injuries before beginning treatment:

  • Muscle Strain: If you are experiencing swelling, pain, and limited mobility after a period of strenuous exercise or after some form of trauma, it is possible that what you are experiencing is a muscle strain rather than full-on synovitis. One way to determine if this is the source of your pain is to determine where the swelling is occurring, and what kind of pain you are experiencing. Muscle strain can be differentiated from synovitis if the pain and swelling come from areas near the joints but not directly on them, and if the pain is felt when flexing muscles instead of bending your arms or legs. Another symptom absent from muscle strain that is present in synovitis is a clicking or popping sensation when moving your joints, so this can rule out muscle strain as well.
  • Arthritis: This condition is related in many ways to synovitis, with one condition leading into the other interchangeably. If you are an older person, or if you have a genetic predisposition towards arthritis due to a family history of the condition, you should investigate if this is the cause of your joint pain. Arthritis comes in many forms, as does synovitis: rheumatoid and psoriatic arthritis are a result of immune system problems, and can be a precursor to chronic synovitis. Osteoarthritis is a condition that often comes about from degradation in the synovium, and may be present in your body if you failed to identify and treat an earlier case of synovitis. Gout can also be easily confused with this condition, as the buildup of uric acid in your foot joints can be easily misconstrued as the buildup of synovial fluid. Be sure to consult a doctor if you suspect arthritis, as treatment of this condition can also treat synovitis if it appears as a consequence of this condition, or prevent it from occurring in the future.
  • Stress Fracture: In the event of swelling near the joints, a clicking or popping sensation, and reduced mobility, another possible culprit can be microtears or bone spurs as a result of a stress fracture. The treatment process for a stress fracture is much different from synovitis, so failure to properly identify it as the cause of your injury can result in dire consequences. Fortunately, this can be easily ruled out as a false positive with the use of imaging technology such as an X-ray or MRI scan, so you may wish to pursue this course of action when speaking to your doctor.
  • Patellofemoral Pain Syndrome: Also known as runner’s knee, this is a catch-all term for a variety of potential injuries that affect your knee. Often caused by trauma and not inflammation, the symptoms of knee pain and swelling associated with runner’s knee can be confused with synovitis, and can also potentially turn into synovitis if improperly treated. For these reasons, it is important to determine whether your knee pain is caused by cartilage or tissue damage, rather than an issue with your synovial membrane.
  • Tendonitis is an inflammation of the tendons, and may present itself as joint synovitis or another problem with the joint bone itself. Your health care provider will work to locate the points of origin and provide effective treatment.
  • Pigmented Villonodular Synovitis (PVNS) is frequently mistaken for routine synovitis. Usually, this condition needs surgery to remove the tumor causing PVNS before it can spread to other areas of the body. In approximately 50% of cases, the tumor cells travel and metastasize away from their point of origin. Therefore, there is a high rate of relapse after surgical removal of the tumor.

There are many conditions that also involve hip pain, so transient or toxic synovitis is more difficult to diagnose. As this condition requires quick treatment, taking your child to the doctor at the first sign of a problem is of the utmost importance. In addition to ruling out rheumatoid arthritis, osteoarthritis, meniscal injury, and patellofemoral pain syndrome, your health care provider will look for signs of the following:

  • Septic arthritis: This is caused by an infection, either bacterial or fungal, that was introduced into the body. The immune system is overwhelmed and unable to contain the infection without antibiotics. Lasting harm may result if treatment is delayed.
  • Lyme disease: This can result from a tick bite that may have gone unnoticed. Commonly contracted after camping trips, it can result in a bacterial infection eventually leading to joint problems. There is a Lyme disease blood test and treatment process separate from the synovitis treatment process.
  • Legg-Calve-Perthes: This uncommon condition results from starvation and lack of oxygen. As the affected bone slowly dies, the joint fails due to lack of blood flow. This usually occurs in the hip joints.
  • Slipped capital femoral epiphysis (SCFE): This injury is a high-risk event for the development of osteoarthritis. It is when the hip joint, thigh bone or femur disconnects from each other.

Diagnosis

Synovitis-Synovial-diagnosis

The telltale sign of synovitis is swelling of the joint in question. It is important to rule out other causes and serious conditions that may present themselves as synovitis, outlined in the section above. Here are some of the steps you can expect your doctor to take when diagnosing your condition:

  • Observation of the affected joint’s presentation, seeing whether it is swollen, red, warm, and/or puffy, as well as the point of origin.
  • Inquiry into your history of sports or other physical activities, examining it in order to determine or rule out a cause, condition, or illness.
  • Complete flexion and extension movements of your limbs and joints.
  • Tests regarding the range of motion in your joints, as well as reflexes and muscle strength.
  • Observation of your gait, body movement, and posture upon standing and walking.
  • Palpation of your joints, muscles, and surrounding tissues to test specific areas of pain.
  • Recommendation of synovial fluid analysis. This is where the doctor injects a numbing agent into the joint and removes some fluid (aspiration) via a needle. It is examined for substances and components to help determine the cause of injury. This helps determine if there is another possible condition in the joint that is causing your pain.
  • Blood panel tests, which will help determine the severity of the inflammation and overall health status of your immune system, as well as renal and liver function. The presence of Lyme disease can also be checked by a blood sample. In addition, a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) will check for inflammation, and rheumatoid factor tests will check for the presence of rheumatoid arthritis.
  • Imaging diagnostics, including orders for X-rays, ultrasound, and bone scan, computerized tomography (CT) or magnetic resonance imaging (MRI) scans. These are performed to examine the bone and tissue structure, as well as composition.
  • If the knee joint is affected, a patella tap test may be performed by pressing down above the knee to gauge the movement of fluid under the kneecap. This will help determine if the muscles are swollen.

Treatment

Beginning a treatment plan is important even in cases where your synovitis is intermittent. A health care provider may begin therapy or refer you to a rheumatologist: a medical doctor specializing in musculoskeletal and systemic autoimmune diseases.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first line of medication treatment. They are available over-the-counter without requiring a prescription. These include ibuprofen (Motrin®) or naproxen (Aleve® or Naprosyn®), and they will offer temporary relief from pain and swelling. They accomplish this by blocking and reducing the number of inflammatory substances active in your body, such as prostaglandins and Substance P; these are the substances present in your body that cause some of the pain from synovitis. Aspirin should be avoided, however, due to the increased risk of developing Reye syndrome when taking it. This is a condition that results in acute swelling of the brain and liver, commonly affecting people under 20 years of age.  Some side effects of this condition includes:

  • Nausea and vomiting
  • Constipation and diarrhea
  • Poor appetite
  • Headache and dizziness
  • Rashes on the skin
  • Drowsiness and fatigue

Acetaminophen (Tylenol®) will provide analgesia, also known as pain relief. It does not reduce or limit the inflammatory process, but it can still help you through an otherwise difficult treatment process. It is important to not exceed the maximum dose of 4,000 mg in 24 hours. Additionally, you should avoid taking this medication with alcohol, as this can increase the risk of liver damage or death. Some other negative side effects include:

  • Lightheaded sensation
  • Nausea and vomiting
  • Stomach pain and constipation
  • Sweating, weakness and fainting
  • Itching and development of hives on the skin

Numbing pain ointments and topical rubs are available over the counter as well, and can provide additional relief from the pain associated with this injury. The massaging action involved when applying the medication, coupled with the benzocaine or lidocaine content in the medication, will result in some pain relief. In addition, the mechanical action required for application will bring more blood flow to the area, causing the inflammatory substances to be temporarily flushed out of the area and reducing their concentration. These substances are sometimes used in conjunction with other therapies as recommended by a physiotherapist, as the numbing agents will provide immediate relief while waiting for oral medications that take longer to work.

Before beginning any medication, be sure to check with your doctor, read the labels to check for warnings, and double check with your pharmacist. Seeking treatment early is essential to a smooth recovery process. Delaying treatment or ignoring your condition is not in your best interests, as progressive damage can eventually lead to surgery or total replacement of the affected limb.

Rest is the most difficult phase of treatment for many individuals, but it is extremely important. Elevate and wrap the affected joint if possible. For the knees and ankles, compression sleeves such as Ace bandages can be helpful. Try not to put excessive weight on the joint, and minimize your walking. Use crutches, tape, wedges, or braces as necessary. Stay away from sports and other strenuous physical activities until the joint is fully healed. This will avoid improper long-term problems in the future. ‘No pain, no gain’ does not apply in this situation; give your body the chance to heal.

Ice can ease the pain and uncomfortable warmth coming from the injured joint, and will also lessen swelling. It works by numbing the skin, and reduces the inflammatory substances present by slowing the circulation to the area. For ice treatment, you can use a standard ice pack, or can substitute a bag of frozen vegetables or a sandwich bag filled with ice. For those sensitive to extreme temperatures, it is recommended that you wrap the ice pack in a thin layer of cloth, in order to provide some protection to your bare skin. The recommended usage of ice is two to three times a day; be careful not to apply it for more than 10 to 20 minutes at a time.

Synovitis-Synovial-treatment-ice

Heat is something that some people find provides them with more relief than ice. In fact, many physical therapists will recommend alternating between applying cold and heat packs, in a process known as cryotherapy. Warmth from a heat pack will loosen up the muscles and tendons around the joint, preventing cramps and providing greater mobility. When used in alternation with ice treatment, the results can be very positive.

Physical therapy under professional guidance, utilizing adapted strengthening, flexibility, and balance exercises combined with massage and mobilization training may speed up your recovery process. The goal in this process is to prevent further injury and relieve pain, which should allow you to resume normal physical activity such as running. The main goals in physiotherapy are increasing flexibility, improving your range of motion, and building up core and trunk strength as well as stability.

A typical full physical therapy program involves several of these methods:

  • Soft tissue massage
  • Electrotherapy (ultrasound or TENS machine)
  • Anti-inflammatory diet or medication
  • Joint immobilization (tape, bracing, splints or crutches)
  • Cryotherapy (ice and heat treatment)
  • Exercises that improve strength, flexibility, and balance
  • Physical education and activity modification advice
  • Biomechanical correction and footwear advice
  • Evaluation of running biomechanics and gait analysis
  • Retraining in walking or running to reduce impact force
  • Gradual return to activity

Another treatment option is a short course of oral corticosteroids or an injection of a corticosteroid directly into the affected joint. This will reduce inflammation and pain, and can help in recovering muscle strength during physical rehabilitation.

If your case of synovitis is infectious in nature, IV or oral antibiotics may be necessary. A culture and sensitivity test conducted by a medical professional will determine the type of antibiotic best suited for your treatment.

Autoimmune diseases including rheumatoid arthritis may necessitate the use of medications such as hydroxychloroquine, gold, penicillamine, methotrexate, and newer biologic agents that are administered through intravenous injection.

Transient or toxic synovitis in children may take anywhere from one week to five weeks before they completely heal and resolve themselves. The child must be taken to a doctor several times throughout each episode of this condition, and at a six-month follow-up exam is also recommended. It the cause is a viral infection, the condition will resolve on its own. A medication treatment plan will make the child more comfortable during this process.

Pigmented villonodular synovitis (PVNS) typically requires an MRI and tissue biopsy for confirmation. As a growth of the synovial membrane that can spread, surgical treatment is often needed to remove the tumor, inflamed lining, and any affected surrounding tissues. This is called a synovectomy.  Radiation therapy is also recommended, as in about 45% of cases the tumor returns. In those cases, some people will opt for a full knee or hip replacement surgery.

The prognosis for routine cases of synovitis is good, if you follow the instructions of your personal treatment plan as outlined by a doctor or therapist. Most patients will heal within a range of a few days to several weeks.

Surgery

Surgery may be required in extreme cases of synovitis, in order to remove overgrowth of bone tissue, inflamed materials, or tumors. Depending on the synovial joint involved, this can be done by arthroscopic surgery, which is minimally invasive. However, more severe cases may require much more invasive procedures, such as the aforementioned synovectomy used when treating PVNS. Here are some commonly used surgical procedures when treating synovial injuries:

  • Arthroscopy: This is the mildest surgical procedure that can treat some cases of synovitis. It is commonly performed in the knee or hip, and can be used to treat acute, chronic , or pigmented villonodular synovitis. It involves making several small incisions in the targeted limb, allowing the surgeon to insert a tiny camera called an arthroscope. With the aid of a view screen connected to the camera, the surgeon can then use the other holes to guide very small instruments inside your limb, which they will then use to remove inflamed tissue. Due to its minimally invasive nature, the synovial membrane and nerve endings surrounding the joint are left unaffected. As a result, the recovery process post-surgery is swift, with many patients able to leave the hospital the day of the surgery. After a few days, most patients report a full recovery and are able to use their limbs regularly.
  • Synovectomy: This is a much more invasive surgical procedure, often requiring a full incision into the affected joint, which is referred to as arthrotomy. Occasionally, this procedure can be performed arthroscopically as well, and some surgeons may use a combination of arthroscopy and arthrotomy to perform this procedure. It is commonly used to remove tumorous growths from PVNS, although it may also be necessary for treating particularly severe cases of acute or chronic synovitis. An incision is made into the joint and the synovial membrane is opened up. From here, the surgeon can remove inflamed tissue, excessive cartilage buildup, or tumorous growths. In extremely severe cases, this procedure may be used to perform a clean amputation of the limb. Afterwards, the synovial membrane is sealed and the incision stitched back up. During the recovery process, extensive physical therapy is required in order to restore strength and flexibility to the treated joint. Additionally, several follow up visits to the doctor is recommended. A full recovery and return to regular functionality is possible in the best cases within 8 weeks.
  • Radiation Synovectomy: This is an alternative to more invasive procedures, often used on children with toxic synovitis or those that develop the condition as a result of hemophilia. With the aid of an arthrogram, or X-ray, a needle is inserted into the targeted joint and a radioactive isotope is injected into the joint. This will reduce the production of fluid inside the synovial membrane, stopping and preventing inflammation. Hospitalization is not usually required after the procedure, with children able to return home the day of the surgery. A full recovery and return to normal functionality should occur within a few days after the procedure is performed.

Prevention

The unfortunate truth is that there is nothing that will fully guarantee the prevention of synovitis. However, there are measures you can take in order to reduce the risk of it occurring, as well as lessen the severity of the injury if you do get it.

  1. Avoid all activities that place stress on the joints! This is the most effective method of prevention, but it may not be feasible in every case. Additionally, avoiding joint stress related activities would include running, which is the reason why we’re all here! Regardless, as the saying goes: you can never fail if you never try.
  2.  Buy high quality running shoes. Look from cushioning at the heel strike, reinforced heels, shoe inserts, orthotic support, and overall protection. A pair of running shoes with this level of quality can be much more expensive, but it is definitely a worthwhile investment. The return on investment, in this case, is your lasting and enduring health, as well as your continued enjoyment of the sports and activities you love.
  3. Take a brief walk, warm up with a light jog, and stretch slowly before running or engaging in other forms of strenuous physical activity. These methods will ensure your muscles, tendons and joints are loosened up and ready to perform high impact exercises such as running or sports, and can greatly reduce the risk of joint inflammation as well as other potential running injuries. For some examples of stretches that target specific joints, some examples are outlined below.
  4. Remember to do strengthening exercises, as they help build up the supporting muscles, ligaments, and tendons. Some examples of strengthening exercises to improve certain muscle groups are outlined below.
  5. When running, increase your speed and distance incrementally for each session. Adjust slowly and steer away from rapid sprints, uneven paths, incline running or stair climbing. If your exercise regimen involves wind sprints or incline exercises, be sure to warm up thoroughly, making sure to emphasize your calves and hamstrings.
  6. Start up slowly after an extended period of rest; starting too quickly will contract your calf muscles, adding strain and the potential for joint inflammation.
  7. Tight lacing of your running shoes can cause tendon inflammation of the foot, known as extensor tenosynovitis. Using variable lacing can prevent this.
  8. Practice a good cool down routine, consistently. Just as it is important to warm up before exercise, it is equally important to cool down afterward. In both cases, the goal is to ease your body in and out of rapid changes in activity, and the end result will be the prevention of strain and inflammation.
  9. Drink plenty of fluids. The common wisdom of ‘eight cups a day’ is an urban myth, but it is important to maintain a proper hydration level. The level of hydration that is necessary for proper body function varies from person to person; however, the best way to ensure you get the fluids you need is to trust your body and listen to it when it tells you to drink water. That can mean five cups, eight cups, or ten cups a day; just drink when you’re thirsty, and bring a bottle of water with you whenever you exercise just in case.
  10. Incorporate more healthy foods into your diet. This includes protein, which will help your muscles recover and grow stronger after exercise. Additionally, incorporating foods with anti-inflammatory properties, such as leafy green vegetables and brightly colored fruits, can prevent swelling in your joints. Finally, incorporating branched-chain amino acids into your diet, most commonly in a liquid form, can aid your body in turning the protein from your food into muscle, as well as providing you with extra energy when exercising.

Strengthening Exercises

As mentioned above, performing regular strengthening exercises can improve your muscle strength, and prevent injury when performing strenuous physical activity such as running. Performing these exercises regularly, coupled with a proper diet, should result in more protection for your joints. In addition to helping prevent synovitis, stronger muscles near the joints can prevent other painful injuries such as arthritis. Make sure that you are cleared to perform these exercises with a doctor or physical therapist. Some of these exercises may require additional materials, such as a mat, chair, or weighted dumbbells. Some soreness is to be expected, but stop immediately if you experience sharp pain.

  • Hamstring Curls: This exercise will protect your knee joints by strengthening your hamstrings, which are the muscles on the back of your upper legs. Begin by standing up straight, holding onto a chair in front of you to help you balance. Slowly bend the knee of one leg so that your foot rises up behind you, stopping at a 90-degree angle. Hold for a second or two, then slowly lower your foot back to the starting position. Perform this exercise ten times for one set, and perform three sets for each leg every day.
  • Leg Lifts: This exercise targets your quads and hips, building up their strength and weight bearing ability as well as protecting your hip joints. Start by lying down flat on your back using a mat or rug. Bend the knee of one leg so that your foot is touching the ground. Then, lift your other leg off the mat, keeping it straight. Raise it about a foot off the ground, then hold the position for three to five seconds. Slowly lower your leg back to the starting position. Switch the positions of your legs so that the other knee is bent and your formerly bent leg is outstretched. Repeat this exercise ten times for one set, and perform three sets with each leg every day.
  • Rotator Cuff Curls: This exercise will strengthen your rotator cuffs, protecting the joints in your shoulders and elbows. Begin by lying on your side, using a mat or rug. Roll up a small towel and place it between the arm that is upright and the side of your torso, just above the elbow. Holding a small weight (3-8 lbs) in the arm touching the towel, rotate your forearm so that your hand is lifted higher than your body, while your elbow stays in one place and the towel remains pressed between your upper arm and torso. Rotate your forearm as far as you comfortably can, then rotate it the other way so that your hand is lower to the ground. Alternate these rotations ten times to complete one set, then switch position so that your other arm is upright with the towel pressed between it and your torso, repeating the exercise. Perform three sets of ten reps with each arm every day.
  • Single Leg Dips: This is another excellent strength building exercise that targets your quads, hamstrings, and calves, which can protect your knee, ankle, and pelvic joints. Begin by standing upright, with a chair placed on either side of you in order to provide balance. Lift one leg off the ground, distributing your weight to the other leg and balancing yourself if necessary by placing your hands on the chairs. Then, slowly lower your body by bending your weight-bearing leg. Hold the position after lowering your body a few inches, then slowly raise your leg back to the starting position. Perform ten reps of this exercise to complete one set, and perform three sets with each leg every day.
  • Knee Rotations: This is another exercise that will increase your hip strength. In addition to protecting your hip joints, it can also improve your overall balance. Begin by laying down flat on your back, using a rug or mat. Place both feet flat on the ground with your knees bent and pointed straight upwards, toward the ceiling. Then, slowly rotate your knees to one side of the ground, keeping your back straight and lifting your feet off the mat if necessary. Once your knees are as far to one side as they can comfortably reach, reverse the movement and rotate your knees to the other side of your body. Repeat this back-and forth movement ten times for one set, and perform three sets every day.

Stretches

It is important to perform some light stretches before strenuous activity, as it will help warm up the muscles and tendons so they can be flexible and properly responsive to exercise. In addition, performing regular stretches and yoga poses on their own will help increase your flexibility over time, which can go a long way toward preventing painful cramps or inflammation. Most of these exercises will require you to have a mat or rug to lay on. Be sure to speak to your doctor or physical therapist before attempting any of these exercises. You can expect some soreness from performing these stretches, but stop immediately and seek medical attention if you experience sharp pain.

  • Knee to Chest: This stretch targets your hip joints and your hamstrings. Begin by lying flat on your back, using a rug or mat. Slowly lift one leg off the ground, bending your knee so that your lower leg is parallel with the leg on the mat. Grab the back of your knee with both hands and pull it towards your torso until you feel slight tension. Hold this position for ten seconds and then release, returning to the starting position. Repeat this exercise three times for each leg every day.
  • Standing Quad Stretch: This exercise will target your quadriceps, one of the largest muscle groups on your body, as well as increase flexibility in your knee joints. Begin by standing upright, and slowly lift one leg behind you while bending your knee. This movement begins similarly to the hamstring curl exercise listed above, with the difference being that once your lower leg reaches the 90-degree angle, you grab it with the hand on the same side of your body and pull it closer to your back until slight tension is felt. Hold this position for ten to twenty seconds, then release your leg and lower it to the starting position. Repeat this exercise three times with each leg every day.
  • Cobra Pose: This is a popular yoga pose, also known as trikonasana. It is a stretch that targets your lower back, and can strengthen your hip joint flexibility. Begin by lying flat on your stomach, using a rug or mat. Prop up your upper body with both of your hands, keeping your arms straight and your torso off the ground. Push your torso upright while keeping your legs and feet flat on the mat, applying tension to your lower back. Be careful not to apply too much tension, or you may develop back pain. Hold this position for ten to twenty seconds, then return to the starting position. Repeat this exercise three times a day.
  • Standing Hamstring Stretch: This stretch will increase your hamstring flexibility, improving the conditions in your hip and knee joints. Depending on how high a level of resistance you wish to experience when performing this exercise, you can use either a chair or a table higher off the ground. Begin by standing up straight, with the chair or table in front of you. Lift one leg off the ground and rest your foot on the table or chair. Then, lean forward while keeping your leg straight and placing both of your hands on the outstretched leg. You should only lean forward far enough to feel slight tension in your leg. Hold this position for ten to twenty seconds, then return to the starting position. Perform this exercise three times with each leg every day.
  • Standing Shoulder Stretch: This stretch is designed to target your shoulder flexibility, which can assist the synovial joints located there. You will need a rolled up towel or a foot-long length of rope. Start by standing up straight, with the rolled up towel or rope held in one hand. Lift this hand up over your head and slightly behind, so that the rope or towel is hanging down your back. With your other hand, reach behind you and grab the other end of the towel or rope. Then, pull up with your higher hand until slight tension is felt in the shoulder of your other arm. Hold this position for ten to twenty seconds, then let go of the towel or rope with your lower hand. Perform this exercise three times a day with each arm, every day.

Synovitis-Synovial-tendons-and-muscle-anotomy

Conclusion

To all of those that relish and appreciate running, sports, walking, and any other physical activity, occasional pain is something they understand comes with the territory. It is simply the price we pay to do the things we love. However, we can try to limit the outside factors that cause this pain with the aid of tools, equipment, and techniques for prevention and proper holistic healing.

The inside elements are a bit more complicated than saying the toe bone’s connected to the foot bone, foot bone connected to the heel bone, heel bone connected to the ankle bone, but there is still some wisdom to be found there: we are made up of interconnected parts, and if one stops functioning properly, a disastrous domino effect can occur. Some closing thoughts to take away from this article are:

  • Synovitis is a condition of stress. Stressors on the body trigger the inflammation response in the cells, from the base of the big toe up to the hips and shoulders. It is a perpetual therapeutic challenge to keep muscle strain, tendonitis, bursitis, and all the other ‘itis’s’ from sidelining you.
  • In all activities, there are degrees of amplified friction, as a result of our individual biomechanical make-up and any anatomical misalignment. These can include flat foot deformity, pronation, and yet to be discovered degenerative diseases. Activities ranging from running, jumping, and climbing, to squatting and wearing high heels can lead to synovitis.
  • Newer athletes, weekend warriors, out of shape individuals or those returning to sports after an extended absence must take special care. They are at risk not only for injury and synovitis but potential rupture of long-neglected tissues. Sports such as soccer, basketball, football, and others that have sudden stop-start or push-off movements can be triggers for devastating injuries. The most important aspect of treating any condition is rest.
  • Continued progression or re-injury over time will build up scar tissue. While it may take weeks to fully recover, the time investment is well worth the long-term consequences of declining health. A slower method of reintroducing physical training will go a long way in reactivating neurotransmitters as well as building and strengthening the supporting muscles, ligament, and tendons.  All these effects are additive: with every progressive injury, the cost will be greater as you age. Any particular joint that is subjected to frequent injury will be the soft spot or Achilles heel for the rest of your life.
  • It is wise to not return to running or sports until you are fully healed. You will know that your are fully healed when you are pain-free for a week, and have received full medical clearance from your doctor or physical therapist. Be good to yourself with self-care, rest, and taking some time to restore and rebuild after an injury. The result is that you will minimize any damage, and add to a long, enjoyable life, as well as excellence in your sport of choice!

Co-written by Mike Valverde

Curated by Diana Rangaves

Hopefully this has served as useful guide on the ins and outs of synovitis. One thing to keep in mind is that while the information here has been gathered from published scientific journals and articles written by doctors, The information listed here should not be considered medical advice. Always talk to a doctor or medical professional if you are experiencing pain and suspect that you are experiencing a running injury.

Sources

  1. Saski Suttona, 1, Abigail Clutterbuckb, 1, Pat Harrisc, Thom Genta, 2, Sarah Freemanb, Neil Fosterb, Richard Barrett-Jolleya, Ali Mobasherib, , The contribution of the synovium, synovial derived inflammatory cytokines and neuropeptides to the pathogenesis of osteoarthritis., Pub Med, Jun 24, 2017
  2. Scanzello, Goldring, The role of synovitis in osteoarthritis pathogenesis, Bone, Jun 24, 2017
  3. unknown, Synovitis Signs and Symptoms, Medical Look, Jun 24, 2017
  4. unknown, Toxic Synovitis, Health Line, Jun 24, 2017
  5. Harrison, A, Synovitis, Right Diagnosis, Jun 24, 2017
  6. Nathan Wei, MD, FACP, FACR , Tenosynovitis runners, Arthritis Treatment, Jun 24, 2017
  7. unknown, Ankel Synovitis, Athletic Edge, Jun 24, 2017
  8. unknown, Synovitis, Hospital Specialized Surgery, Apr 04, 2017
  9. Troy Smurawa, MD, Hip Pain in Runners, Beginner Triathlete, Apr 04, 2017
  10. unknown, Knee Synovitis, Sports Injury Clinic, Apr 04, 2017
  11. unknown, Knee Synovitis, E Pain Assist, Apr 04, 2017
  12. Mark R Foster, MD, PhD, FACS, Tenosynovitis , MedScape, Apr 04, 2017
  13. unknown, What is Ankle Synovitis? , Orthopaedics, Apr 04, 2017
  14. unknown, MTP Synovitis, Foot Scientific, Apr 04, 2017
  15. unknown, Pigmented Villonodular Synovitis of the Knee, Sports Physiotherapist , Jun 24, 2017
  16. Orhan AKINCI, Yavuz AKALIN, Mustafa ‹NCESU, Ahmet EREN, Long-term results of surgical treatment of pigmented villonodular synovitis of the knee, ACTA ORTHOPAEDICA , Jun 24, 2017