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Elbow Tendinopathies and Mimics

Ryan Dunlay, M.D.

Overview

Lateral Epicondylitis (“tennis elbow”)

Medial Epicondylitis (“golfer’s elbow”)

Distal Biceps Rupture

Olecranon Bursitis

Triceps Rupture

Radial Tunnel Syndrome

Cubital Tunnel Syndrome

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

Lateral Epicondylitis

Symptoms

Pain, burning, ache

• Lateral (outside) elbow

Elbow stiffness

• Sometimes swelling

Tenderness on the bone

No numbness

Lateral Epicondylitis

Worse with:

Grip activities

• Grocery bag

• Hammering

• Wrist extension

• Onset usually without injury

• Back hand shot in tennis

Lateral Epicondylitis

Treatments

Myriad

None are great

Goal is to relieve pain

• Not necessarily shorten course

Lateral Epicondylitis

Treatments

Activity modification

Therapy

Shock wave

(controversial)

Brace

Oral anti-inflammatories

Injection

Surgery

Lateral Epicondylitis

Treatment Goals:

Decrease Inflammation and pain

Promote tissue healing

Prevent loss of strength/weakness

Icing

Direct Icing Ice Pack

Massage

Increases blood flow to promote healing

Splints

Do’s and Don’ts

Forearm Stretches

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

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.

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.

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”

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

Medial Epicondylitis

Symptoms

Pain/ache on the inside of elbow

Can be accompanied by ulnar nerve symptoms

Medial Epicondylitis

Worse with:

Wrist flexion activities

• esp hitting golf ball

Onset often w/o injury

• May be activity related

Medial Epicondylitis

Treatment

Activity modification

Therapy

Brace

Oral anti-inflammatory med

Injection

Surgical debridement

Medial Epicondylitis

Treatment goals:

Decrease inflammation and pain

Increase range of motion, strength and endurance

Modify activities that aggravate symptoms

Rest | Ice | Massage

Forearm Stretches

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

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”

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

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

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

Distal Biceps Surgery

http://www.vumedi.com/video/distal-biceps-rupture-cortical-button-fixation/

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

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

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

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

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

Distal Triceps Repair

From Mazzocca et al JAAOS January 2010, Vol 18, No 1

Distal Triceps Repair

From Mazzocca et al JAAOS January 2010, Vol 18, No 1

Radial Tunnel Syndrome

What is it?

Compression of radial nerve in forearm

Rare

No history of injury

Often overlaps lateral epicondylitis

Radial Tunnel Syndrome

Symptoms

Ache in the back of the forearm

Burning sensation in back of wrist

Radial Tunnel Syndrome

Worse with…

Repeated forearm rotation

• esp with arm straight

Holding wrists extended

• typing

Radial Tunnel Syndrome

Treatment

Activity modification

• Work station rearrangement

Ice

Stretch/therapy

Injection

Surgical release – very unreliable

Radial Tunnel

Treatment Goals:

Reduce pain by decreasing inflammation of radial nerve

Regain mobility and strength

Modify or eliminating activities that aggravate radial tunnel

Icing

Massage

Rest | Ice | Massage

Splint

To rest and reduce pressure at the radial nerve

Forearm Stretches

Radial Nerve Glides

Waiter Tip Position

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

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

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

Cubital Tunnel Syndrome

Worse with…

Bent elbow for a long time

Resting inside of forearm

• Chair or desk

• While driving

Gripping activities

Throwing

Cubital Tunnel Syndrome

Treatment

Keep elbow straight

• Splints/pads at night

Therapy

• Nerve glide exercises

• Stretch

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

Do’s and Don’ts

Nerve Glides (exercise for ulnar nerve)

Splints - elbow cushions

Cubital Tunnel

Cubital Tunnel

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

Thank You Ryan Dunlay, M.D.