7/23/2018
1
Overuse Injuries of the Upper ExtremityAl Hess, MD
7/21/2018 1
Overuse Injuries
• Everything?
• Not ‐ Trauma, infection, tumor, rheumatoid arthritis, osteoarthritis
• Onset of pain associated with repetitive tasks
2
Peadiatric Overuse Sports Injuries
• Organized sports >40 million age 5‐18
– Skeletal immature
– Year round training
– Poor technique
– High intensity overuse
3
7/23/2018
2
Peds Sports
• Proximal humeral apophysitis(little league shoulder)
• Lateral epicondylar apophysitis(little league elbow)
• Ulnar collateral ligament injury (Tommy John)
• Osteochondral defect (OCD capitellum)
4
Compressive Neuropathies
• Carpal tunnel syndrome
• Cubital tunnel syndrome
• Pronator syndrome
• Radial tunnel syndrome
5
Tendonitis
• Pain and swelling
• Histology: collagen degeneration, Absence of inflammatory cells, vascular ingrowth
• Mechanical strain : microruptures
• Failed repair and accumulation of damaged tissue
6
7/23/2018
3
Tendonitis About the Wrist
• DeQuiervain’s
• Intersection Syndrome
• ECU tendonitis
• FCU tendonitis
• FCR tendonitis
7
DeQuervains
• Stenosing tenosynovitis of the first dorsal compartment (APL,EPB)
• Pain and swelling over the radial styloid
• Degenerative changes: myxoid degeneration, fibrocartilage metaplasia, mucopolysaccharidedeposition
8
9
7/23/2018
4
Finkelstein Test
7/23/2018 Footer Text 10
DeQuervain Treatment
• Splinting
• Injection
• Surgical release
11
12
7/23/2018
5
Injection
• Celestone (water soluable)
• 60 ‐100% effective
• Beware of fat atrophy and depigmentation
13
14
Complications
• Injury to radial sensory nerve
• Tendon instabilty
15
7/23/2018
6
Intersection Syndrome
• Pain over the area where the EPL/APB tendons cross over the ECRL/ECRB
16
17
Intersection Syndrome
• Audible and palpable crepitation over the second dorsal compartment
• Rowers and gymnists
• Can coexist with DeQuervains
18
7/23/2018
7
Intersection
19
• Rest
• Splint
• Injection
• Surgical release
Trigger Finger
• Stenosing Tenovaginitis
– Entrapment of the tendon in it’s fibrous sheath
– Thickening of the entrance of the flexor tendon sheath
– Accumulation of fibrocartilage
– Swelling and degeneration of the tendon
20
Trigger Finger
• Women:men 6:1
• Lifetime risk 3%
• DM: 10‐20%
• Gout, renal disease, hypothyroidism, RA
21
7/23/2018
8
Symptoms
• Pain
• Clicking
• Locking
• Limited grip
• High incidence of coexisting CTS
22
Treatment
• Splinting
• Injection
• Surgical release
23
Injection
• Sato 2012, Baumgarten 2007
– Cure rate 1‐2 injections 57‐97%
– Relapse 12% 1 injection
18% 2 injections
• Lambert 1992, Murphy 1995
– 60‐64% improvement with one injection
– 20% placebo
24
7/23/2018
9
Injection
25
Location
• Taras 1998, Taras 1995, Fitzgerald 2005, Wang 2006
• Locate the steroid in sq, sheath or mixed
• No difference in efficacy
• Less painful in sq
• Risks: fat atrophy, pulley rupture, tendon rupture, elevated glucose
26
Epicondyles:Muscle Anchors for FA, Wrist, Finger Motions
• Lateral Epicondyle: (extension, supination)
–ECRB, EDC, EDQ ECU, anconeus
• Medial Epicondyle: (flexion, pronation)
–pronator teres, FCRPL, FDS, FCU
7/23/2018
10
lateral epicondyle much smaller thanmedial epicondyle
PTFCR
PL
FCUFDS
Medial Epicondyle: origin to five muscles
deep intermediate superficial
muscles from medial epicondyle
Pronator teres
FCRPL
FDS
Flexor carpi ulnaris
7/23/2018
11
Lateral Epicondyleorigin to 5 muscles
ECRBEDC
ECU
anconeus
EDQ
muscles from lateral epicondyle
Anconeus ECU
EDQ
EDCECRB
Cross‐SectionalAnatomy
7/23/2018
12
triceps
med.epic.
BR
ECRLbrachialis
biceps
lat.epic.
Commonextensororigin
BR
ECRL
7/23/2018
13
BR
ECRL
ECRB
EDC
EDQ
anconeus
jointcapsuleandannularligament
38
39
7/23/2018
14
Summary of Cross-Sectional Views
• Dense fibrous common extensor origin
• Blends with joint capsule and annular ligament
• No comparable fibrous origin medially
41
Tennis Elbow: Demographics
• Age 30 ‐ 50 • lateral:medial ~20:1• onset following forceful, repetitive activity• often not tennis– carrying luggage, laptop computers, shopping bags–machinists, film editors: cranking motion
• ache in area of lateral epicondyle– often poorly localized– increased with resisted pronation, wrist extension
7/23/2018
15
Pain centeredatlateral epicondyle:tennis elbow
Pain distaltolateral epicondyle:radial tunnelsyndrome
44
Stress tests for radial tunnel syndome:not very specific.
7/23/2018
16
Tennis Elbow: Etiology
Tennis Elbow: Etiology
• Mechanical overload micro tears mucinoid degeneration partial tendon failure
• Tissue shows characteristics of degeneration
• Not inflammation, therefore not “‐itis”
epicondylitis tendinitis
• “Tendinosis” or “Tendinopathy”
preferred but meaningless
Normal tendon (light microscopy x100)uniform parallel collagen bundles,occasional tenocyte, no blood vessels
7/23/2018
17
Biopsy (light microscopy x100): tennis elbow“Angiofibrous Dysplasia”
Normal tendon Randomly orientedfibroblasts
Loose, disorganizedcollagen
Tennis Elbow Treatment: I• Avoid inciting activity
• Tennis elbow strap
• Heat, gentle stretching
• +/‐ NSAID
Tennis Elbow Treatment: II
• Cortisone
– injection– ionto/phono phoresis
• Wrist extension splint
• Ilfeld brace
• Blood/PRP injection
• Ultrasonic ablation
• Shock treatment +/‐
7/23/2018
18
52
53
Shock TreatmentExtracorporeal shock wave therapy in the treatment of lateral epicondylitis. A randomized multicenter trial. J Bone Joint Surgery 2002, 84A:1982.–double‐blinded, control group, 272 patients–no difference between treatment/control groups
Extracorporeal Shock Wave Therapy without Local Anesthesia for Chronic Lateral EpicondylitisJ Bone Joint Surg 2005, 87A: 1297.–double‐blinded, placebo control, 114 patients– shocked patients did better–blinding likely incomplete
7/23/2018
19
Tennis Elbow Treatment: III: Surgery
• for the resistant 1%• after 6‐12 m non‐op treatment• multiple procedures described
– Detachment– Reattachment– Cut ECRB
• all have in common– local denervation– acute injury– 4‐8 month recovery
57
7/23/2018
20
Tennis Elbow: Summary
• Stems from forceful repetitive elbow motion
• Middle age deterioration
• Degeneration of dense fibrous common extensor origin
• Avoid inciting activity, splint, rest
• Generally resolves after 6‐12 months
Medial Epicondylopathy: Golf Elbow
• Much less common than lateral epicondylitis
• Avoid inciting activity• Tennis elbow strap +/‐• Cortisone +/‐• Surgical release• Ulnar nerve nearby
7/23/2018 60