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Common Tendon Disorders of the Upper Extremity
Mark Tait MD
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• History– Pain and swelling (any tendon, any location)– Overuse
• Physical examination findings– Localized swelling– Pain with resistance of that particular tendon’s function
• Imaging– Possible US or MRI to look for tear
• Consider systemic disease• Treatment
– Almost always non‐surgical– Steroid Injection– Rest and immobilization
Tendonitis
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Introduction
Tendinosis• Histology‐ collagen degradation, absence of inflammatory cells, vascular ingrowth
• Mechanical strain• Altered remodeling response leads to failed repair of tendon
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Tendovaginitis
• Entrapment of tendon within fibrous sheath• Thickening of tendon sheath• Degeneration of tendon (tendinosis)
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Trigger Digit
• HistorySymptoms• Pain, clicking, catching, limited
grip– Physical examination findings
– A 1 pulley tenderness (volar MC head)
– Finger may catch on extension or lock into the palm
• Imaging‐usually normal
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Trigger digit
Pathophysiology– Changes in A1 pulley and flexor tendon– Fibrous metaplasia of A1 pulley – Histological changes of tendonosis
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Trigger digit
• Epidemiology• Women: Men 6:1• Lifetime risk 2‐3%
– Higher in diabetics– Associated with gout, hypothyroid, renal disease, rheumatologic disease
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Trigger DigitTreatment• Splinting (short time only)• Symptomatic management• Steroid injection
– SubQ equally effective as intra‐sheath– How long: “1 week to 15 years”– 56% recur by one year– Diabetics: Higher recurrence
Valdes 2012 JHT
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Trigger digit
• Surgical treatment– Release
• Open• Percutaneous
– Equal Efficacy (Sato 2011)• Concern regarding injury to NV bundles, A2 pulley, or incomplete release
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DeQuervain’s DiseaseHistory• Radial sided wrist discomfort• Swelling• Pain along thumb ray
– Exertional• Ulnar deviation activities
–Post‐partum, pregnancy, lactation
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Dequervains
Stenosing tenosynovitis of the first dorsal compartment• Impaired gliding of APL/EPB• Pathology
– Degenerative changes, fibrocartilage metaplasia, mucopolysaccharide depsition
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Dequervains
Physical Exam• Finkelsteins’• Pain to palpation of radial styloid
Prevalence• 0.5% men/1.3% women
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Dequervains
• Treatment• Splinting
– Prevents motions and encourages rest
– 14% effective in isolation (Richie&Briner 2003)
• NSAIDS (topical or oral)• Steroid injections
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Dequervains
Corticosteriod Injection• 82% resolution after 6 weeks.• 52% “freedom from recurrence” at 6 months• 81% “freedom from intervention” at 6 months• Beware of steroid soft tissue atrophy
– Typically temporary but can be permanent
Papadopoulous 2009
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Intersection syndrome
• Proximal to Dequervain’s• Tenosynovitis of first (APL/EPB) and second dorsal compartment (ECRB/L)
• Audible and palpable crepitation• Classically
– Rowers, gymnasts
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Intersection syndrome
Treatment• Splint (15 degress wrist extension)• Injection
– 60% respond
• Surgery– Release
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ECU tenosynovitis• Ulnar sided wrist pain• Can be incited by traumatic
ulnar deviation or repetitive heavy loading
• May occur after twisting injury
– ECU subluxation/TFCC pathology
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Clinical Examination ECU
• Tenderness along 6th compartment
• Differential injection test
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Clinical Examination ECU
• FUSS maneuver: wrist flexion‐ulnar deviation, supination maneuver to elicit instability
• Compare to opposite side and assess for ligamentous laxity
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Clinical Examination ECU
• ECU synergy test (Ruland 2008)
– Forearm held in full supination and patient resists thumb‐index abduction recreating pain
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ECU tenosynovitis
• Treatment• Initial treatment splint, NSAIDS, injection
• Surgical treatment– Synovectomy – Tendon debridement or repair
– Bone spur excision floor– Sulcus deepening– Subsheath repair vs. reconstruction
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Lateral Epicondylitis‐Background
• Coined “tennis elbow” in 1880s due to association with lawn tennis
• However, most patients will point out they don’t play tennis.
• Most common ages 35‐60• Varying rates of male:female reported– Equal vs. 4x more common in men
• Dominant arm more common
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Lateral Epicondylitis‐Anatomy
• Lateral Epicondyle– Origin of ECRL/ECRB (extensor
carpi radialis longus/brevis)• Long wrist extensors insert at base of 2nd and 3rdmetacarpal.
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Lateral Epicondylitis‐Anatomy
• Pathologic change within ECRB tendon– Angiofibroblastic dysplasia– Undersurface of tendon is avascular to 2‐
3cm distal to insertion– High stress area likely leads to micro
tears.– Tendonosis is probably a more accurate
description.– Underlying periostitis of the bone can be
present as well as inflammatory changes in the surrounding tissues
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Lateral Epicondylitis‐Physical Exam
• Inspection– Skin normal with normal with no visible
deformity• Palpation
– Exquisitely tender over lateral epicondyle– The patient will show you the spot!
• ROM– Generally normal
• Provocative Tests– Resisted wrist extension– Resisted long finger extension
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Lateral Epicondylitis‐Diagnostic Modalities
• Plain X‐ray of elbow– 16% show change
• Generally calcification along tendon• Only changed management in 2/294 patients.
• MRI– Limited benefit, but can visualize
diseased tendon– 80‐90% sensitive
• Ultrasound– 64‐82% sensitive
• Largely a clinical diagnosis
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Lateral Epicondylitis‐Non operative Treatment
• NSAIDs– Oral and Topical
• Rest• Therapy
– Modalities (Iontophoresis)– Motion/stretching >> immobilization
• Bracing– Counterforce (Limits excursion of muscles decreasing stress on origin)– Wrist brace (Limits wrist extension decreasing stress on origin)
• Activity Modification• Injection
– Corticosteroid, PRP, Whole Blood
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Lateral Epicondylitis‐Non operative Treatment
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Lateral Epicondylitis• Which nonoperative treatment?
– Success rate at 1 year• Injection 69%• Therapy 91%• Observation 83%
– Multiple other studies showed no difference• Which brace?
– No difference at 6 weeks between counterforce/wrist brace
• Does therapy help in addition to brace?– Mixed results– Eccentric strengthening protocol may improve outcomes
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Lateral Epicondylitis
• The mainstay of treatment of lateral epicondylitis is non‐surgical treatment.
• Most patients will improve and symptoms will “burn out” in 2 years.– Recurrence is low (<3%)
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Lateral Epicondylitis‐When to Refer
• Surgery should be done sparingly – 4‐8% of patients
• Surgery involves release of the diseased ECRB tendon from its origin– Open vs Arthroscopic– 80‐90% success rate– No differences in success between procedures
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Lateral Epicondylitis‐Evidence with an Opinion
• “Evidence suggests that lateral epicondylitis may be best conceived of as a self‐limited rite of passage through middle age that most people handle effectively, we should be mindful that our well‐intentioned actions risk promoting a potentially counterproductive approach of returning to the physician for increasingly invasive treatments in a search of an as yet elusive disease‐modifying agent. Until we have a treatment that consistently outperforms a placebo (natural history), we should not encourage our patients to see themselves as disabled and in need of our services—rather we should do everything possible to encourage a sense of health and wellness that will decrease pain intensity and limit disability while waiting for this self‐limited disorder to resolve. “
• ‐David Ring, MD, PhD—Mass General
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Medial Epicondylitis
• The less common cousin of lateral epicondylitis• “Golfer’s Elbow”• 5x less common• Involves the origin of the flexor pronator mass which takes its origin from the medial epicondyle.
• Men=Women• 75% dominant extremity• Often co‐existent with ulnar nerve symptoms
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Medial Epicondylitis • Examination
– Tender over medial epicondyle– Pain with resisted wrist flexion
• Differential diagnosis– Ulnar neuropathy (possible subluxation)– Fracture– Ligament Instability
• Diagnostic Modalities– Plain x‐ray to look for osteophyte formation– MRI vs US can help– Mostly a clinical diagnosis– EMG/NCV for ulnar nerve symptoms.
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Thank You