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

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Nothing reminds of the inter-connectivity in everything better than the lyrics to the spiritual song Dem Bones, by James Weldon Johnson (1871-1938). The chosen words take us on a visual trip from the tips of our toes to the top of our heads and back again in the reverse mirror image! 

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 joints are synovial.  Now, 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) – small bones in foot, ankle, and wrist

Hinge – upper/lower arms, elbow, fingers, knuckles, knees, ankles, and toes

Pivot – neck vertebrae

Saddle – thumb joint

Ball-and-socket – hips and shoulders

Synovial joints permit the greatest range of motion allowing us to run, walk, write, type, and complete everyday activities. Since they are synovial, this means they all have the ability to experience synovitis!

 

 What is Synovitis?

Synovial joints are lined with a thin connective tissue layer called synovium or synovial membrane.  The membrane produces synovial fluid, filling the joint cavities, tendon sheathes and bursae with this lubricating liquid gold of the body. Synovial fluid cushions the joint and lowers friction and resistance during joint movement. It is the body’s joint protection. In addition, the fluid brings nourishment to the cells and removes cell waste products.

Developing synovitis means the synovial membrane or the lining of the joint becomes inflamed.  This soft tissue covers the joint capsule and usually affects the knees, hips, shoulders, ankles and wrists. Each condition is named by the body joint affected followed by the word synovitis.  So there is knee synovitis, ankle synovitis, and etcetera.  It can be acute, lasting for a short amount of time or persistent, chronic, continuing for long-term.

 

Synovitis-Synovial-Joint-of-the-Knee

 

They are also referred to a post traumatic synovitis, as one of the causes is direct injury and overuse of the body joint. Body movement mixed with extreme weight-bearing activity may inflame the synovium. 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 occurs in hip joints of children resulting in hip pain and limping. It is seen in children three to eight years old and happens to boys more than girls. It is painful and short lived by nature, healing itself within two weeks leaving no permanent harm.

A most severe type of this condition 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. It is very rare affecting 1.8 people per 1,000,000.

 

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, to remove and metabolize unwanted waste substances.

Inflammation of the synovium causes an imbalance of fluid. The inflamed synovial joint produces additional fluid in 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 and painful to move.

This condition can show up after a sprain or injury that has not quite healed causing trouble on the weight-bearing limbs. The symptoms tend to be worse upon awakening in the morning or after exercise. After mild movement which is gradual and slow with a warm shower or heating pad, symptoms tend to improve.

In acute and chronic conditions people can experience the following in any joint of the body.

  • Tenderness, swelling, pain, stiffness, 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
  • Quick onset due to a known event or advances slowly over time
  • Increased skin temperature, warm to the touch, redness, over the area
  • Difficulty in movement of the affected joint with limited range of motion
  • Increased pain and discomfort upon movement and use of joint
  • Feeling the joint is popping or clicking with movement or pressure
  • Patting hard lumps or nodules around the joint area
  • Joint dysfunction and increased rates of cartilage erosion 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 the condition due to re-injury, gout, rheumatoid arthritis, osteoarthritis, and other medical ailments or it may just appear on its own. Synovitis worsens if you continue to walk or run using the joint. This is intensified on uneven pavement and slopes. Do not begin on this type of path until at least three weeks post recovery and healing.

In children presenting with transient or toxic,  the conditions’ symptoms include:

  • Low- grade fever below 101F
  • Pain in the thigh, knee, hip areas
  • Limping or walking on their tiptoes
  • Pain may be off and on in one or several joints
  • Saying no or unable to walk or crawl all together
  • After a long rest, there may be a flare up upon moving
  • Weepy and short-tempered 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 or catch, lock-up, or freeze while trying to walk, run, or move. It is important to seek medical assistance as soon as possible and not try to self-treat these symptoms. Diagnosis is difficult and occurs with an average of 4.4 years.

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 is not the usual cast of characteristic clues. Meaning the synovial joint does not present with swelling, warmth, tenderness, and redness, flying under the wire or sub-clinical!

Causes

 

Synovitis-Synovial-causes-overuse

 

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

Health associations have been linked to:

  • Idiopathic- meaning the cause is not readily known. At the time the person may have had a negligible bump or may not remember. However, as a result of the trauma and inflammation synovial fluid accumulates in the joint.
  • Injury, trauma, a fracture to the joint- is a known by overuse, sprain, or damage.
  • Overuse – in an active, healthy person, overuse from sports, exercise, and activities.
  • Improper support- muscle weakness, imbalance, can inflame synovium.
  • Juvenile arthritis- means 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- is the wear-and-tear disorder. This occurs the cushioning tissue breaks down at the ends of the bones. This leaves bone rubbing against bone. Ouch~
  • Psoriatic arthritis – is a joint condition that 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 as red patches with silvery fish scales.
  • Rheumatoid arthritis – 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 – is an inflammatory disorder resulting as a complication from a group A streptococcus infection.
  • System lupus erythematosus– is an inflammatory disorder that occurs when the immune system incorrectly begins to attack the body’s own healthy tissues.
  • Tuberculosis- is a bacterial infection of the lungs. It is preventable and rare in the United States.
  • Viral or bacterial infections (chicken pox or a cold) – is a short-term, temporary, condition of the hip seen 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 a culture of the synovial fluid is 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 – is the overpowering rise of malformed cells that divide, and devastate the cells of the body.

Particular in runners are ankle and knee synovitis. Both occur after an initial serious sprain and persist in people 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, consistent weight bearing force impact, chronic unstable ankles or knees, and pronated, flat feet a negatively affect the large synovial joints.

Sub-clinical synovitis, the one with no overt symptoms that fit may be a byproduct of rheumatoid arthritis. This is a condition that fluctuates between active disease, remission, and active disease. Typical short-term, acute treatments are anti-inflammatory, ice, and 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 all bonded and held together with the same skeletal bone structure (pun intended). So, 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, we will be in a better position to minimize or prevent the condition and subsequent pain and damage.

It is very important not to ignore any pain and symptoms, as acute synovitis can become chronic.  During the inflammatory 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, and other medical conditions.

Elements that influence development:

  • Joint instability- indicates the support tissues, ligaments, and muscles are weak in and around the bone. Support equipment and muscle building and strengthening exercises can limit the impact.
  • Reduced elasticity or flexibility- joints and surrounding tissues become stiff and do 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, to exercising or training incorrectly with repetitive, impacts and strain to the tissues.
  • Weak joint biomechanics- muscle, joint, and skeletal movements can significantly influence performance, gait, and injury rate.
  • Inferior footwear and joint support equipment- use quality equipment recommended providing support, protection, and cushioning.
  • Supporting muscle and ligament weakness
  • Chronic medical history of joint injury, strains, and sprains

In children with transient or toxic synovitis, contact your health care provider for:

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

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

Diagnosis

 

Synovitis-Synovial-diagnosis

 

The tell tail sign of synovitis is swelling of the joint in question. It is important to rule out other causes and serious conditions that may present as synovitis. What can you expect from your health care provider are the following:

  • Determine location and levels of pain– upon physical exam, they will observe the presentation; swollen, red, warm, puffy and the point of origin.
  • Inquire about sports or other physical activities- examine history to determine or rule out a cause, condition, or illness.
  • Complete flexion and extension movements of your limbs and joints.
  • Test range of motion of joints, reflexes, and muscle strength.
  • Observe your gait, body movement, posture, upon standing and walking.
  • Palpate your joint, muscles, and surrounding tissues to test specific areas of pain.
  • Recommend a synovial fluid analysis– 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 the determine cause. This helps figure out if there is another condition in the joint.
  • Blood panel tests– will help determine the severity of the inflammation and overall health status of immune system, renal, and liver function. The presence of Lyme disease can also be checked by a blood sample. In addition, a complete blood count (CBC), erythrocyte sedimentation rate (ESR) will check for inflammation, and rheumatoid factor will check for the presence of rheumatoid arthritis.
  • Imaging diagnostics– orders for X-rays, ultrasound, and bone scan, computerized tomography (CT) or magnetic resonance imaging (MRI) scans to examine the bone and tissue structure and composition.
  • If the knee is the joint affected, he may do a patella tap test– by pressing down above the knee the fluid will move under the knee cap. This will help him determine if the muscles are swollen.
  • Sub-clinical synovitis may possibly show up on an MRI but not on an X-ray.

There are many conditions that 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 important. In addition to ruling out rheumatoid arthritis, osteoarthritis, meniscal injury, and patellofemoral pain your health care provider will look for signs of the following:

Septic arthritis– is cause by an infection, either bacterial or fungal that was introduced into the body. The immune system is overwhelmed and is unable to contain the infection without antibiotics. Lasting harm may result if treatment is delayed.

Lyme disease– can result from a tick bite that can go unnoticed. A bacterial infection can lead to joint problems. There is a Lyme disease blood tests and treatment.

Legg-Calve-Perthes- results from starvation and lack of oxygen as the bone slowly dies, the joint fails due to lack of blood flow. This usually occurs in the hip joints.

Slipped capital femoral epiphysis (SCFE) – is a high-risk event for the development of osteoarthritis. It is when the hip joint, thigh bone of femur disconnects from each other.

Treatment

 

 

Beginning a treatment plan is important even in your synovitis is intermittent. A health care provider may begin therapy or provide a referral to a rheumatologist, who is a medical doctor specializing in musculoskeletal and systemic autoimmune diseases.

Non-steroidal anti-inflammatory drugs are the initial line of medication treatment. They are available over-the-counter without a prescription. These include ibuprofen (Motrin®) or naproxen (Aleve® or Naprosyn®) to offer temporary relief. They block and reduce the number of inflammatory substances, like prostaglandins and Substance P that cause one layer of the pain. Aspirin must be avoided due to the increased risk of developing Reye syndrome, an acute swelling of the brain and liver in people under 20 years of age.  Some side effects include:

  • Nausea, vomiting
  • Constipation, diarrhea
  • Poor appetite
  • Headache, dizziness
  • Rash, drowsiness

Acetaminophen (Tylenol®) will provide analgesia or pain relief. It does not reduce or limit the inflammatory process. Do not exceed the maximum dose of 4,000 mg in 24 hours or take with alcohol as these increases the risk of liver damage or death. Some side effects include:

  • Light-headedness
  • Nausea, vomiting
  • Stomach pain, constipation
  • Sweating, weakness, fainting
  • Itching, hives

 

Numbing, pain ointments and rubs are available over the counter. The massaging action of applying the medication couples with the benzocaine or lidocaine will provide some pain relief. In addition, the mechanical action will bring more blood flow to the area, causing the inflammatory substances to be temporarily flushed out of the area, reducing the concentration. They may be used in conjunction with other therapies as the numbing agents work right away, while oral medications take a bit of time to begin working.

Before beginning any medication, check with your doctor, read the labels, and ask your pharmacist. Seeking treatment is early is essential. Delaying or ignoring the condition is not in your best interests. Progressive damage can eventually lead to surgery and/or total knee/hip replacement.

 

Rest- is the most difficult phase of treatment for many. Elevate and wrap the joint if possible. For the knees and ankles, compression Ace-bandage is available. Try not to put weight on the joint and minimize walking. Use crutches, tape, wedges, or braces as necessary. Stay away from sports and other activities until the joint is fully healed. This will avoid long-term problems in the future. This is no time to believe the motto, ‘no pain, and no gain’. Give your body the chance to heal.

Ice – can ease the pain, heat, and lessen swelling. It numbs the skin, reduces the inflammatory substances present by slowing the circulation to the area. Recommended usage is two to three times a day, no more than 10-20 minutes at a time.

 

Synovitis-Synovial-treatment-ice

 

Heat- some people find heat provides more relief than ice.

Physical therapy- under professional guidance adapted strengthening, flexibility, and balance exercises, massage, and mobilization may speed up recovery. The emphasis is to prevent further injury and return to pain-free activities. Goals are increasing flexibility, the range of motion, and core and trunk strength stability.

A full program is outlined below:

  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • joint mobilization, taping, bracing, splinting, the use of crutches
  • ice or heat treatment
  • exercises to improve strength, flexibility, and balance
  • education, activity modification advice
  • biomechanical correction, footwear advice
  • evaluate running biomechanics and gait retraining to reduce impact forces, if appropriate
  • a graduated return to activity program as gentle rehabilitation avoids reactivation of inflammation

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.

If infectious in nature, IV or oral antibiotics may be indicated. A culture and sensitivity test will determine the type and antibiotic of choice for treatment.

Autoimmune diseases including rheumatoid arthritis may include medications hydroxychloroquine, gold, penicillamine, methotrexate, and the newer injectable biologic agents.

Surgery– may be needed to remove overgrowth of bone tissue or inflamed materials. Depending on the synovial joint involved, this can be done by arthroscopic surgery.

Transient or toxic synovitis in children may take one to two weeks or up to five weeks to completely heal and resolve. The child must be taken to the doctor several times throughout the condition episode and at a six-month follow-up exam. It the cause is a viral infection the condition will resolve on its own. A medication treatment plan will make the child more comfortable.

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 needed to remove the tumor, inflamed lining, and any affected surrounding tissues. This is called a synovectomy.  Radiation therapy is 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 instructions of your personal treatment plan. Most patients will heal within days to several weeks.

Prevention

 

 

The truth is there is nothing that will literally prevent synovitis. There are measures you can take to reduce the risk and perhaps lessen the severity if you do get it.

  1. Avoid all activities that place stress on the joints! Well, what fun in life is that? Buy excellent quality running shoes. Look from cushioning at the heel strike, reinforced heels, shoe inserts, orthotic support, and protection. Yes, make the investment, the ROI (return on investment) is your lasting and enduring health and continued enjoyment of the sports and activities you love.
  2. Do not forget to walk, warm-up, and stretch slowly before the physical activity. Remember to do strengthening exercises, as they help the supporting muscles, ligaments, and tendons.
  3. Increase speeds and distances slowly and steer away from rapid sprints, uneven paths, and hill, slope, and stair running or climbing.
  4. Start up slowly after a rest, starting too quickly will contract calf muscles adding strain.
  5. Tight lacing can cause tendon inflammation of the foot called extensor tenosynovitis. Using variable lacing can prevent the condition.
  6. Practice a good cool down routine, consistently.
  7. Drink plenty of fluids.
  8. Healthy protein-rich nutritious diet.

 

 

False Positives

Pigmented Villonodular Synovitis (PVNS) is frequently mistaken for routine synovitis. Usually, this condition needs surgery to remove the tumor before it spread to other areas of the body. In approximately 50% of cases the tumor cells travel, metastasize, away from their point of origin. Therefore, there is a high rate of relapse after surgical removal of the tumor.

Tendonitis is an inflammation of the tendons and may present 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.

 

Synovitis-Synovial-tendons-and-muscle-anotomy

 

Conclusion

To all of you that relish and appreciate running, sports, walking, and any physical activities, occasional pain comes with the territory.  It is the price we pay. We can try to limit the outside factors with the tools, equipment, and techniques for prevention and correct, holistic healing.

The inside elements are more complicated for the toe bone connected to the foot bone, foot bone connected to the heel bone, heel bone connected to the ankle bone, and a domino effect does occur.

Synovitis is a condition of stress. Stressors on the body trigger the inflammation response in the cells from the base of the big toe upward to the hips and shoulders. It is a perpetual therapeutic challenge to keep the muscle strains, hamstrings, tendonitis, bursitis, and all the other ‘itis’s’ from sidelining you.

In all activities, there are degrees of amplified friction from our individual biomechanical make-up and any anatomical misalignment. These can include flat foot deformity, pronation, and yet to be discovered degenerative disease. Running, jumping, climbing, stair and ladder climbing to squatting and wearing high heels can lead to synovitis.

Newer athletes, those out of shape or returning to a sport after an absence, plus the weekend warriors must take special care. They are at risk not only for injury and synovitis but potential rupture of long time unused tissues. Sports such as soccer, basketball, football, and others that have sudden stop-start or push-off movements can be sneaky beginnings. The most important part in 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 slow reinstitution of training will go a long way in reactivation neurotransmitters, building and strengthening the supporting muscles, ligament, and tendons.  All these effects are additive, with every progressive injury comes to the piper to be paid as we age. That particular joint will be the soft spot or our Achilles heel for the rest of our life.

Remember it is better to be wise and do not return to running or your sport until you are fully healed, meaning pain-free for a week and are given medical clearance.  Being good to yourself with self-care, rest, and taking the time to restore and rebuild. Thus, minimizing any damage will add to a long, enjoyable quality of life and excellence in your sport and physical prowess!

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