Elbow
Tenopathies
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Lateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about
the lateral aspect of the elbow, occurs more frequently in nonathletes
than athletes, with a peak incidence in the early fifth decade and a
nearly equal gender incidence. Lateral epicondylitis can occur during
activities that require repetitive supination and pronation of the forearm
with the elbow in near full extension. Runge first described the clinical
entity in 1873, and since then almost 30 different conditions have been
proposed as etiologies. Although originally described as an inflammatory
process, the current consensus is that lateral epicondylitis is initiated
as a microtear most often within the origin of the extensor carpi radialis
brevis. Microscopic findings demonstrate immature reparative tissue
that resembles angiofibroblastic hyperplasia. The pathological process
mainly involves the origin of the extensor carpi radialis brevis but
can involve the tendons of the extensor carpi radialis longus and the
extensor digitorum communis. |
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Symptoms
The diagnosis of tennis elbow is made by localizing
discomfort to the origin of the extensor carpi radialis brevis. Tenderness
is present over the lateral epicondyle approximately 5 mm distal and anterior
to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist
dorsiflexion and forearm supination, and there is pain when grasping objects.
Plain roentgenograms usually are negative; occasionally calcific tendinitis
may be present. MRI demonstrates tendon thickening with increased T1 and T2
signals but generally is not indicated.
Other entities that can produce pain in this
general vicinity are osteochondritis dissecans of the capitellum, lateral
compartment arthrosis, varus instability, and perhaps most commonly, radial
tunnel syndrome. Radial tunnel syndrome is a compressive neuropathy of the
posterior interosseous nerve caused by any of four different anatomical
structures in the radial tunnel, including a fibrous band near the anterior
aspect of the radial head, a vascular leash of the recurrent radial artery, the
distal extensor carpi radialis brevis tendon margin, or the supinator margin at
the arcade of Frohse. The pain of radial tunnel syndrome is located 3 to 4 cm
distal to the lateral epicondyle and may be reproduced with long finger
extension against resistance. The latter finding is inconsistent, as are
abnormalities on EMG. True lateral epicondylitis and radial tunnel syndrome may
coexist in up to 5% of patients.
Treatment
Regardless of the underlying cause, nonoperative treatment is successful in 95% of patients with tennis elbow. Initial non-operative treatment includes rest, ice, injections, and physical therapy centered around treatment such as ultrasound, iontophoresis, electrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exercises, and counter-force bracing.
A few patients (5% to 10%) are unresponsive to
conservative treatment. Patients who fail to respond to a nonoperative regimen
should be scrutinized for possible sources of secondary gain, perhaps through
the Minnesota Multiphasic Personality Inventory (MMPI) or psychological evaluation,
if other maladies in the differential diagnosis have been excluded. In some
patients, one or two local injections of a steroid preparation to the area
of maximal tenderness are helpful. About 40% of patients obtain complete and
permanent relief of symptoms after steroid injections. Other studies also
have shown a high rate of success using early local corticosteroid injection.
As an adjunct to local injection an attempt to “complete the lesion” by forcibly
flexing the wrist after local anesthetic injection to initiate the inflammatory
cascade and induce healing can be done. Preliminary data from studies reporting
newer treatment methods such as low-level laser and extracorporeal shockwave
therapy are promising, but further investigation is necessary.
If prolonged (6 to 12 months) nonoperative treatment
is ineffective, operative treatment may be considered; it is effective in
90% of properly selected patients. Some have advocated manipulation under
anesthesia, especially in patients with concomitant flexion contractures.
The technique involves sudden, forcible, full extension of the elbow with
the wrist and fingers flexed and the forearm pronated to place the extensor
carpi radialis brevis and extensors under tension. An audible, palpable snap
frequently can be elicited, and the results can be excellent.
A number of surgical procedures have been described
for the treatment of tennis elbow. The technique popularized by Boyd and McLeod
included excision of the proximal portion of the annular ligament, release
of the entire extensor origin, excision of an adventitious bursa originally
described by Osgood (if found), and resection of hypertrophic synovium in
the radiocapitellar articulation, as originally described by Trethowan.
Currently, many surgeons favor a more limited approach,
which consists of exposure of the diseased extensor carpi radialis brevis
origin, resection of degenerative tissue, and direct repair to bone.
Only a few patients with lateral epicondylitis (1%
to 2%) cannot be treated successfully by either nonoperative or operative
methods. Morrey divided these failures into two groups based on postoperative
symptoms. Patients in the first group had symptoms similar to those experienced
before surgery, whereas patients in the second group reported a different
symptom complex after surgery. Treatment failed in patients in the first group
because of inadequate release or incorrect initial diagnosis, most often
related to radial tunnel syndrome; in the second group, treatment failed
because of capsular or ligamentous insufficiency that resulted in either a
capsular fistula or posterolateral instability. Elbow instability can occur in
patients in either group (especially those with traumatic origins for their
lateral elbow pain) after overzealous release that includes the anterior band
of the lateral collateral ligament. Of 13 patients with failed primary lateral
release in Morrey's study, reoperation was successful in 11 after the correct
diagnosis was made. Morrey emphasized the importance of obtaining a thorough
history to determine if the patient's symptoms have changed and a careful
physical examination to identify instability, pain in the region of the
epicondyle, or radial tunnel syndrome. These should be supplemented with
arthrograms to detect synovial fistula and capsular insufficiency or with
arthroscopy and examination with the use of anesthesia to detect instability or
arthrosis.
According to most authors, patients who will improve
after surgery do so within 3 to 4 months. Repeat intervention may be considered
in one year if symptoms do not improve.
Medial
Epicondylitis
Medial epicondylitis is similar to lateral epicondylitis
although much less common and more difficult to treat. The origin of the flexor
carpi radialis and pronator teres (flexor pronator mass) are commonly involved
and less typically, the flexor digitorum superficialis and flexor carpi ulnaris.
This entity must be differentiated from ulnar nerve neuropathy and medial
collateral ligament instability. Ulnar neurapraxia exists in about 60% of
his patients with medial epicondylar symptoms, but in our experience this
is much less common.
Symptoms
Medial epicondylitis frequently occurs in overhead
athletes, including those involved in racket sports and others who participate
in activities that create a valgus force at the elbow. Physical examination
usually reveals pain along the medial elbow that becomes worse on resisted
forearm pronation or wrist flexion. The area of maximal tenderness is approximately
5 mm distal and anterior to the midpoint of the medial epicondyle. Loss of
range of motion and a flexion contracture may be present.
Roentgenograms usually are normal, but medial
ulnar traction spurs and medial collateral ligament calcifications may be seen
and may be associated with a chronic ulnar collateral ligament injury.
Treatment
Conservative treatment is the mainstay of management.
NSAIDs, splinting, and an occasional steroid injection provide sustained relief
in most patients. If nonoperative treatment fails, excision of the diseased
tendon origin and reattachment usually are successful. Techniques range from
a percutaneous release to open debridement with or without release of the
flexor pronator origin. Vangsness and Jobe described release of the flexor
pronator origin, excision of the pathological tissue, and reattachment of
the flexor pronator origin to bleeding bone. Nirschl preferred excising the
pathological tissue of the flexor-pronator origin in a manner that leaves
normal tissue intact and repairing the subsequent defect. The ulnar nerve
should be decompressed and transposed in patients who have ulnar nerve symptoms
preoperatively. Epicondylectomy also can be done, but no more than 20% of
the ulnar collateral ligament. Overall, the results are not as successful
as with lateral epicondylar procedures.
Olecranon
Bursitis
Acute or chronic irritation may result in swelling and pain in the olecranon bursae. Aspiration often relieves the pain and swelling, but care should be taken to use proper sterile technique. When the aspirate is not bloody, cell counts and cultures should be obtained. Gout, rheumatoid arthritis, and infection must be excluded. After aspiration, a compressive wrap is applied and is usually sufficient to prevent reaccumulation of the fluid. Elbow pads may be needed to prevent further injury and recurrences. Chronic cases of recurrent olecranon bursitis with fibrosis of the bursae may require surgical excision.
