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<v ->And we are now gonna turn to the tendons

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and I'm gonna discuss a bit

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about tendon pathology, including tenosynovitis

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and here the terminology gets very, very confusing.

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So I thought I would first start with,

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just to give you an idea

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about the way that the collagen is oriented

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typically within a tendon.

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So if you look at this drawing

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I'm showing you the individual collagen fibers

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in a kind of a dark green,

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and they're situated in collagen fascicles

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or bundles that I'm showing in this blue structure here.

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And you can see that the bundles themselves are oriented

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along the long axis of the tendon.

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Now that is an ideal arrangement

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because the typical four supply

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to a tendon is a tensile force.

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The typical direction is along the long axis of the tendon.

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So it is certainly ideal that the collagen fibers

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and the collagen bundles would be oriented

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along the long axis of the tendon.

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And that indeed is the major pattern of orientation.

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Now let's look at some of the terminology that is applied

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at least in the English language

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for the anatomy of the structures within a tendon.

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So here I show you a cross section of the tendon

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with four bundles or fascicles in blue.

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The first term I would introduce is a term that we use is,

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Endotenon.

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And you'll note that the spelling

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of this term does not include a D.

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So an Endotenon is a tissue

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that surrounds the individual fascicles

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and it helps keep them together.

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It binds them together.

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That is an Endotenon.

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The second term that we use is an Epitenon.

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Again, no D in that, Epitenon.

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And an Epitenon, again is tissue that is applied

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to the surface of the tendon.

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I show it in the green here

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and it's said to have connections to the Endotenon,

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and I kind of tried to illustrate that

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by these green stripes that you can see.

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So we have an Endotenon and an Epitenon.

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The third term that we use is a Paratenon,

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and this is a tissue that is not always present

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but sometimes applied to the Epitenon.

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Right at the surface, I show it in orange

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and it consists mainly of loose areolar tissue.

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Now, in some locations, rather than having a Paratenon

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we have a tendon sheath.

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And the typical tendon sheath has two layers, an outer layer

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which is fibrotic in nature

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and an inner layer, which is synovial.

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And there are apertures or openings

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within those layers that allow passage

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of nerves, of veins, of arteries into supplying the tendon

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and the various tissues that compose it.

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So these are the major terms that are used

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to describe the anatomy of a tendon,

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including the term tendon sheath.

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Therefore, when we use terms

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to describe the pathology that we see involving tendons

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we're very, very careful about the terms we use.

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Tenosynovitis, and we're gonna talk a great deal about it

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means inflammation of a tendon sheath.

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The example I show you is tenosynovitis

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about the flexor hallucis longus tendon.

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And I realize that sometimes there's physiologic

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tenosynovial fluid here

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but when the amount of fluid is greater than that

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in the ankle joint, it's usually pathologic.

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The second term is Paratenosynovitis

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and that indicates inflammation of tissues

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about a tendon that has a sheet in that location.

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I'm not illustrating that in this slide.

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The third is a term Paratendinitis,

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para in the English language means next to.

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So this relates to inflammation of tissues

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about a tendon that does not have a tendon sheath.

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A classic example is shown here

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and this is common in runners.

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It involves a central portion of the pre-Achilles fat pad.

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And it may not look like much to you

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but I can tell you if you're a runner and you have this

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it's gonna affect how often

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and how far and how fast you run.

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The next term is a Paratenonitis.

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No D.

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And that refers to inflammation of a paratenon.

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Now, where do we have paratenon?

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Well, I'll give you two locations.

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One is the patella tendon,

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so you can see patella paratenonitis

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and the other is the Achilles tendon

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and classically the paratenon of the Achilles tendon

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is C-shaped.

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It does not cover the anterior surface of the tendon

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hence the term para rather than peri, which means around.

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Sometimes paratenonitis extends more anteriorly

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into the pre-Achilles fat pad as well.

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This is extremely painful.

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Again, if you have that, you will know it.

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And then finally we use the term Tendonosis

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to describe degeneration of a tendon,

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more commonly appearing as a large,

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rather than an attenuated tendon with little spots

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that when they enlarge will stimulate the beginning

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of a partial thickness tear.

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So those are the proper terms.

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Now let's go into a little more detail

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about the term Tenosynovitis.

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There are two types of tenosynovitis,

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one is simple inflammation of a tendon sheath.

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That's not healthy but it's not as bad as this second type.

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The second type is known as Stenosing tenosynovitis,

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another term that's used for it surprising perhaps

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is Tenovaginitis.

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And it implies not only is there inflammatory changes

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in the tendon sheath, but there are are adhesions.

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I'm kind of showing it

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as these gray areas between the tendon and the tendon sheath

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so that the tendon does not normally move

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within the tendon sheath.

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So when you look at certain places

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well known to possess stenosing tenosynovitis

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you want to determine if the synovial fluid is clean

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or whether there are adhesions as in this particular case,

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that is stenosing tenosynovitis.