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