welcome []...elbow pain and tendinopathies without injury are common start with activity...
TRANSCRIPT
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Welcome
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Elbow Tendinopathies and Mimics
Ryan Dunlay, M.D.
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Overview
Lateral Epicondylitis (“tennis elbow”)
Medial Epicondylitis (“golfer’s elbow”)
Distal Biceps Rupture
Olecranon Bursitis
Triceps Rupture
Radial Tunnel Syndrome
Cubital Tunnel Syndrome
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Lateral Epicondylitis
What is it?
“A rite of passage of middle age…”
Very common
aka “tennis elbow”
Degeneration of tissue - angiofibroblastic degeneration and collagen disarray
Wrist EXTENSORS
attachment
the primary pathology is tendinosis of the ECRB tendon 1-2 cm distal to its attachment on the lateral epicondyle
Lasts up to 18 months
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Lateral Epicondylitis
Symptoms
Pain, burning, ache
• Lateral (outside) elbow
Elbow stiffness
• Sometimes swelling
Tenderness on the bone
No numbness
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Lateral Epicondylitis
Worse with:
Grip activities
• Grocery bag
• Hammering
• Wrist extension
• Onset usually without injury
• Back hand shot in tennis
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Lateral Epicondylitis
Treatments
Myriad
None are great
Goal is to relieve pain
• Not necessarily shorten course
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Lateral Epicondylitis
Treatments
Activity modification
Therapy
Shock wave
(controversial)
Brace
Oral anti-inflammatories
Injection
Surgery
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Lateral Epicondylitis
Treatment Goals:
Decrease Inflammation and pain
Promote tissue healing
Prevent loss of strength/weakness
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Icing
Direct Icing Ice Pack
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Massage
Increases blood flow to promote healing
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Splints
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Do’s and Don’ts
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Forearm Stretches
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Non-operative Rx
Cochrane review 2006 – high level of evidence ESWT provides little to no benefit in the rx of lateral epicondylitis
One cause of failure in the minority is a posterolateral plica in the RC joint (snapping in terminal extension + supination)
PLRI of the elbow has been linked to lateral epicondylitis – may be as a result of multiple steriod injections
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Injections vs Ionto
Stefanou et al. – 82 pts prospective randomized: Dexamethasone via iontophoresis produced short-term benefits in group grip strength and unrestricted return to when compared to corticosteroid injection
Iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis
J Hand Surg Am. 2012 Jan;37(1):104-9. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis.
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Injections
Gosens et al. – Level I in 51 pts – treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection at 2-years
Wolf et el. – JHS 2011 “autologous blood, corticosteroid, and saline injection provide no advantage over placebo saline injections in the treatment of lateral epicondylitis”
AJSM 2011 Jun;39(6):1200-8 Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.
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Surgery
Surgery varies from denervation to complete release; arthroscopic vs open
Results are unpredictable despite some positive reports in the literature
Cochrane Review March 2011 - “Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain”
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Medial Epicondylitis
What is it?
aka “golfer’s elbow”; occurs in other athletes: weight-lifters, throwers, etc.
Similar to lateral epicondylitis
• Medial side of elbow
• Much less common
(1/4-1/7 as common)
Degeneration of tissue
• Wrist FLEXORS attachment
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Medial Epicondylitis
Symptoms
Pain/ache on the inside of elbow
Can be accompanied by ulnar nerve symptoms
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Medial Epicondylitis
Worse with:
Wrist flexion activities
• esp hitting golf ball
Onset often w/o injury
• May be activity related
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Medial Epicondylitis
Treatment
Activity modification
Therapy
Brace
Oral anti-inflammatory med
Injection
Surgical debridement
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Medial Epicondylitis
Treatment goals:
Decrease inflammation and pain
Increase range of motion, strength and endurance
Modify activities that aggravate symptoms
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Rest | Ice | Massage
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Forearm Stretches
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Modifying Activities
Use large joints for lifting
Take breaks when performing repetitive activities
Respect pain:
Keep wrist in neutral especially when performing biceps curls or weight lifting
Don’t use a manual screw driver with elbow straight
Avoid repetitive twisting of the forearm
Avoid heavy pressure on computer keys
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Injections
Technically must beware of ulnar n. – especially in patients that have had a previous surgery
Stahl et al. – 1997 JBJS – Level I study comparing 58 pts assigned to receive a single injection of 1% lidocaine with either 40 mg of methylprednisolone (experimental group) or saline solution (control group)
Both groups were also managed with PT & NSAIDs
At 6 weeks experimental group had less pain
No difference between groups at 6-month and 1-year
Conclusion: “local injection of steroids provides only short-term benefits in the treatment of medial epicondylitis”
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Surgery
Considered after at least 6-months of failed non-operative treatments
Surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and re-attachment of the origin of the flexor pronator muscle group to the medial epicondyle
Surgical treatment may result in a high degree of subjective relief, although objective strength deficits may persist
More reliable results than lateral epicondylitis
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Distal Biceps Rupture
Ruptures off radial tuberosiity
Result of eccentric contraction
Incidence is 1.2 per 100,000 persons
Most common in 50-60 yo active males
30% decrease in flexion strength initially
40-50% loss of supination strength
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Distal Biceps Rupture
Diagnose with hook test, the passive forearm pronation (PFP) test, and the biceps crease interval (BCI) test – sensitivity & specificity 100% if all 3 positive (Sept. AJSM)
If diagnosis is in doubt, MRI can be helpful
Beware of musculotendinous tears/injuries
Partial tears can present similarly
Need surgery earlier (3-4 weeks at most) to prevent scarring to brachioradialis
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Distal Biceps Surgery
http://www.vumedi.com/video/distal-biceps-rupture-cortical-button-fixation/
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Olecranon Bursitis
Most common of the bursitis
Fluid is caused by traumatic, inflammatory and infectious processes
Infective bursitis represents 20% of acute cases
Etiology is often difficult to determine
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Olecranon Bursitis
Olecranon bursa forms at age 7
Entire bursa extends from distal insertion of triceps to several cm’s along subQ border of the ulna
If acutely distended, bursa may be 6-7 cm long & 2.5 cm wide
Septic and aseptic bursitis can often appear similar acutely
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Olecranon Bursitis
Diagnosis can be difficult – gram stains from aspirates are only + in 50-60% of cases
WBC >10,000/mm3 is consistent with septic bursitis
Septic bursitis demonstrates increased skin temps & may be more red/inflamed
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Olecranon Bursitis
Acute traumatic or idiopathic bursitis typically resolves without surgery
Ice, compression, avoidance of aggravating activities are mainstay
Surgery is last resort & has been wrought with less than stellar results – sensitive skin, adherent skin, hypoesthesia, prolonged drainage or wound complications
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Distal Triceps Rupture
Rare – associated with anabolic steroids, weight lifting, & laceration
Systemic factors associated include injections, olecranon bursitis, hyperparathyroidism
More difficult to diagnose than distal biceps rupture often times
MRI confirms
Incomplete tears
with active elbow
extension – non-op
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Distal Triceps Repair
From Mazzocca et al JAAOS January 2010, Vol 18, No 1
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Distal Triceps Repair
From Mazzocca et al JAAOS January 2010, Vol 18, No 1
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Radial Tunnel Syndrome
What is it?
Compression of radial nerve in forearm
Rare
No history of injury
Often overlaps lateral epicondylitis
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Radial Tunnel Syndrome
Symptoms
Ache in the back of the forearm
Burning sensation in back of wrist
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Radial Tunnel Syndrome
Worse with…
Repeated forearm rotation
• esp with arm straight
Holding wrists extended
• typing
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Radial Tunnel Syndrome
Treatment
Activity modification
• Work station rearrangement
Ice
Stretch/therapy
Injection
Surgical release – very unreliable
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Radial Tunnel
Treatment Goals:
Reduce pain by decreasing inflammation of radial nerve
Regain mobility and strength
Modify or eliminating activities that aggravate radial tunnel
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Icing
Massage
Rest | Ice | Massage
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Splint
To rest and reduce pressure at the radial nerve
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Forearm Stretches
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Radial Nerve Glides
Waiter Tip Position
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Modify Activities
Things to avoid:
Combined gripping and twisting motions (screwdriver, unscrewing lids)
Racquet sports
Yardwork (digging with a trowel, raking leaves, pulling weeds)
Scraping ice from windshield
Wringing out wet cloths
Writing with a tight grip or small shafted pen
Painting or washing windows
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Cubital Tunnel Syndrome
What is it?
Compression of ulnar nerve at elbow
• “funny bone”
Roof of the tunnel is retinaculum & FCU
aponeurosis
Retinaculum is remnant of anconeus
epitrochleus muscle & constrains the nerve in
the canal
Syndrome may be associated with subluxing
nerve
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Cubital Tunnel Syndrome
Symptoms
Pain at inside of elbow
• Ache in forearm
Numb pinky finger
Weakness of grip
Decrease in dexterity
• Typing speed, musical instruments
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Cubital Tunnel Syndrome
Worse with…
Bent elbow for a long time
Resting inside of forearm
• Chair or desk
• While driving
Gripping activities
Throwing
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Cubital Tunnel Syndrome
Treatment
Keep elbow straight
• Splints/pads at night
Therapy
• Nerve glide exercises
• Stretch
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Cubital Tunnel
Treatment goals:
Reduce symptoms by decreasing pressure on the ulnar nerve
Regain mobility and strength
Modify or eliminate activities that aggravate the ulnar nerve
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Do’s and Don’ts
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Nerve Glides (exercise for ulnar nerve)
Splints - elbow cushions
Cubital Tunnel
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Cubital Tunnel
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Summary
Elbow pain and tendinopathies without injury are
common
Start with activity modification
Therapy can be very helpful
Be patient – the longer it’s been a problem, often the
longer it takes to resolve
Surgery rarely indicated – biceps & triceps ruptures
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Thank You Ryan Dunlay, M.D.