Overuse Injuries of the Upper Extremity. Overuse Injuries 7/23/2018. Peadiatric Overuse Sports Injuries. Al Hess, MD

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1 Overuse Injuries of the Upper Extremity Al Hess, MD 7/21/ 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 1

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 2

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, mucopolysaccharide deposition 8 9 3

4 Finkelstein Test Footer Text 10 DeQuervain Treatment Splinting Injection Surgical release

5 Injection Celestone (water soluable) % effective Beware of fat atrophy and depigmentation Complications Injury to radial sensory nerve Tendon instabilty 15 5

6 Intersection Syndrome Pain over the area where the EPL/APB tendons cross over the ECRL/ECRB Intersection Syndrome Audible and palpable crepitation over the second dorsal compartment Rowers and gymnists Can coexist with DeQuervains 18 6

7 Intersection Rest Splint Injection Surgical release 19 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

8 Symptoms Pain Clicking Locking Limited grip High incidence of coexisting CTS 22 Splinting Injection Surgical release Treatment 23 Injection Sato 2012, Baumgarten 2007 Cure rate 1 2 injections 57 97% Relapse 12% 1 injection 18% 2 injections Lambert 1992, Murphy % improvement with one injection 20% placebo 24 8

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, FCR PL, FDS, FCU 9

10 lateral epicondyle much smaller than medial epicondyle Medial Epicondyle: origin to five muscles PT FDS FCR PL FCU deep intermediate superficial muscles from medial epicondyle Pronator teres FCR PL FDS Flexor carpi ulnaris 10

11 Lateral Epicondyle origin to 5 muscles anconeus ECU ECRB EDC EDQ muscles from lateral epicondyle Anconeus ECU EDQ ECRB EDC Cross Sectional Anatomy 11

12 triceps biceps ECRL BR brachialis lat. epic. med. epic. BR ECRL Common extensor origin 12

13 BR ECRL ECRB joint capsule and annular ligament EDC EDQ anconeus

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 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 14

15 Pain centered at lateral epicondyle: tennis elbow Pain distal to lateral epicondyle: radial tunnel syndrome 44 Stress tests for radial tunnel syndome: not very specific. 15

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 16

17 Loose, disorganized collagen Normal tendon Randomly oriented fibroblasts Biopsy (light microscopy x100): tennis elbow Angiofibrous Dysplasia 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 +/ 17

18 52 53 Shock Treatment Extracorporeal 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 Epicondylitis J Bone Joint Surg 2005, 87A: double blinded, placebo control, 114 patients shocked patients did better blinding likely incomplete 18

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 19

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 60 20