Download Specific findings in lateral epicondylitis

Week 9 - Joints and Bones
Systems I
Dr. Alex Alexander
Next Week: Muscle and
Connective Tissue
Tendinitis and Bursitis
Epicondylitis
Achilles Contracture
Carpal Tunnel
Torticollis
Rhabdomyolysis
Tendinitis
is a painful
Tendinitis
and Bursitis
inflammation of the tendonmuscle attachment to the bone,
usually in the shoulder, achilles
or hamstring.
Bursitis is the painful
inflammation of one or more
bursae--closed sacs lubricated
with small amounts of synovial
fluid that facilitate the motion of
muscles and tendons over bony
prominences.
Toma(y)to-Toma(h)to
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The term tendinosis was first used in the 1940s by a
group of German researchers, however the term did not
receive much attention until it was used again in the mid
1980s to describe a non-inflammatory tendon condition.
The more commonly used term of tendinitis has since
been proven to be a misnomer for several reasons. The
first of which is that there is a lack of inflammatory cells in
conditions that were typically called a tendonitis. Since
inflammation is the key pathological process involved with
that term, and the discovery that there in fact were no, or
very few, inflammatory cells present in the condition, a
new term was adopted tendinosis. This has a much
greater impact then just the name one calls a condition, it
also has a profound impact on how the condition is
treated.
Tendinopathy
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Etiology
Although tendinopathy affects millions of people, its etiology is not clear.
While multiple factors including age, genetics, body weight, and muscle
weakness are believed to be involved, repetitive mechanical loading of
tendons is considered the major risk factor in the development of
tendinopathy.
Tendons serve several functions including mechanical force transmission,
joint stabilization, and shock absorption to limit muscle damage. Tendons
consist of collagens, proteoglycans, glycoproteins, water, and cells. They
are able to alter their structure and composition in response to mechanical
loads. While appropriate mechanical loading of tendons is beneficial,
overuse (chronic, repetitive mechanical loading placed on tendons) results
in pathologic changes.
Diagnostic Approach
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Clinical diagnosis of tendinopathy is based on careful palpation of the
tendon in question. Presentation and exam features of tendinopathy at
common sites are detailed below.
Imaging is not required to make a diagnosis but may assist in managing
recalcitrant cases. It is important to view imaging studies in the context of
their clinical findings.
Plain radiographs may show calcium deposits in calcific tendinopathy, but
are not useful in soft-tissue evaluation.
Ultrasound and MRI are generally not needed but may be utilized to
demonstrate tendinosis in cases that are not straightforward.
Ultrasound is quick and inexpensive, but it is highly operator dependent.
Although MRI is expensive, it allows evaluation of the surrounding
structures and may aid in the diagnosis.
Tendinopathy
Treatment Approach
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The main goal in the treatment of tendinopathy is to reduce pain and allow
return to activity. Tendinopathies are not complicated injuries, but can be
difficult to manage. Patients need to be monitored by the physician on a
regular basis for response to therapy. General principles of therapy are
shared among all tendinopathy sites, but details within each treatment
modality vary by anatomic site.
Treatment begins with relative rest and activity modification, with ice and
nonsteroidal anti-inflammatory drugs (NSAIDs) for acute pain relief.
Physical therapy may be enhanced by corticosteroid injections, topical
nitroglycerin, and/or specialized modalities, depending on anatomic site
and response to initial therapy.
Tendinopathy
Relative rest and activity modification
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Since tendinopathy is an overuse injury, the main initial
treatment is relative rest and activity modification.
Goal is to decrease the mechanical overload to promote
tendon healing and pain relief.
Also important to evaluate and correct athletic overtraining
errors.
For some anatomic sites, a brace or heel lift may be useful.
In epicondylitis, a counterforce brace over the proximal
lower arm may decrease pain and improve function. In
Achilles tendinopathy, heel lifts help with pain by
decreasing the amount of stretch on the Achilles tendon. In
cases where dorsiflexion is diminished (tight
gastrocnemius-soleus complex), a night splint may be used
to hold the foot in neutral to dorsiflexion for 6 to 8 weeks to
maintain passive dorsiflexion.
Bursitis
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History and exam
Patients with acute bursitis typically complain of pain localized to the site of
the bursa, particularly on movement. There may be a history of trauma,
repetitive occupational activity, autoimmune disease, or crystal arthropathy.
Infection may follow a penetrating injury or foreign body. If the bursa is
superficial, swelling and erythema may be evident. In bursitis secondary to
crystal deposition, the bursa is usually particularly erythematous, painful,
and warm to the touch.
Chronic bursitis may last for several months and flare up many times. If
inflammation persists near a joint, the patient is likely to have a limited
range of active movement. Typically in bursitis, the passive range of motion
is preserved, whereas active movement is limited.
Septic bursitis is most common in the prepatellar and olecranon bursae
due to their superficial position. Symptoms suggestive of septic bursitis
include a low-grade temperature, local erythema, swelling, and warmth,
sometimes with local cellulitis.
Subacromial bursitis: classically in subacromial bursitis, the patient will
complain of a painful arc on abduction of the arm due to impingement of
the bursa under the coracoacromial arch. This can also occur with rotator
cuff tears, and the two conditions may coexist.
Bursitis
Trochanteric bursitis: there may be risk factors present causing an alteration in gait. Diagnostic criteria have been
proposed, but their sensitivity, specificity, and predictive value have not been established. The criteria propose that
lateral hip pain and tenderness around the greater trochanter must be present in combination with 1 of the
following:
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Pain at the extremes of rotation, abduction, or adduction
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Pain of contraction of the hip abductors against resistance
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Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh.
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Bursae of the knee: with anserine bursitis, the patient will typically complain of tenderness on the upper medial tibia
at a point 3 cm to 5 cm distal to the medial knee joint line. A valgus deformity may be noted.
With prepatellar and infrapatellar bursitis, the prepatellar bursa is located between the skin and patella, and the
infrapatellar bursa is between the skin and tibial tuberosity. Swelling and erythema are common, and the patella
may be impalpable if a lot of fluid is present.
Olecranon bursitis: a superficial bursa, susceptible to infection and usually accompanied by significant swelling.
The patient may recall direct trauma to the elbow.
Retrocalcaneal bursitis: tenderness along the distal portion of the Achilles tendon associated with swelling is
typical. There may be a palpable bump, and poorly fitting shoes may play a role.
Septic Bursitis
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If septic bursitis is suspected, the fluid should
be aspirated and sent for laboratory analysis
with Gram stain and culture. If fluid is
aspirated, it is recommended that some also
be sent for crystal analysis, especially if there
is a history of gout or pseudogout. Aspiration
should be carried out in an aseptic manner.
Superficial bursae such as the prepatellar
and olecranon bursa can easily be drained,
but ultrasound guidance may be useful if the
bursa is deeper.
Risk Factors
occupation that causes mechanical stress on bursa
rheumatoid arthritis
gout or pseudogout
penetrating injury
osteoarthritis of the hip
infection in a nearby joint
lower limb length discrepancy
iliotibial band contracture
lumbar spondylosis
valgus knee deformity
low-riding shoes
anatomic or functional impingement within the coracoacromial arch
Key Diagnostic Features
pain at site of bursa
common
tenderness to palpation at site of bursa
common
decreased active range of motion
Treatment
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The first step in the treatment of nonseptic bursitis is to modify activity and lifestyle to
minimize mechanical stress on the inflamed bursa. This involves avoiding activities that
worsen symptoms (e.g., kneeling with prepatellar bursitis) and protecting the area
where possible (e.g., kneepads to help avoid further trauma in prepatellar bursitis).
Many patients with trochanteric and infrapatellar bursitis find crutches or a walking stick
useful. It is also advisable to try to identify any predisposing risk factors that can be
corrected to reduce the chance of recurrence, such as leg length discrepancy in
trochanteric bursitis. It is important to rest the affected area to allow the inflammation to
settle, but physical therapy may also be of benefit. Evidence from controlled trials is
lacking to recommend a particular regimen; the duration of rest, and type and intensity
of exercise is patient dependent. This combination of activity modification, intermittent
rest, and physical therapy is often effective.
Ice may be used in the first 24 hours to reduce swelling. It can be applied topically to the
area for 10 minutes at a time, every few hours (but not directly onto the skin; a thin
towel is placed between ice and skin).
Simple analgesia such as acetaminophen or NSAIDs may also be required. Topical
NSAIDs may be tried initially in preference to systemic NSAIDs if acetaminophen is
insufficient.
Epicondylitis
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Typically occurs during the 4th and 5th decades of life. Patients describe a
history of activities contributing to overuse of the forearm muscles that
originate at the elbow.
Patients with epicondylitis report pain during or following elbow flexion and
extension.
People with lateral epicondylitis are tender approximately 2 cm distal and
anterior to the lateral epicondyle. They report pain during resisted wrist and
digit extension, and during passive wrist flexion with the elbow extended.
People with medial epicondylitis have tenderness along the medial elbow,
approximately 5 mm distal and anterior to the medial epicondyle. Pain is
exacerbated with resisted forearm pronation and resisted wrist flexion.
Most patients will have complete resolution of symptoms with arm rest and
nonsteroidal anti-inflammatory drug (NSAID) therapy. Patients with continued
symptoms may require further treatment, including physical therapy, injection
therapy, or surgical debridement.
The principal complication is continued pain. All other complications may
arise from interventions attempting to alleviate the pain.
Definition
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Epicondylitis
Epicondylitis of the elbow is a
condition associated with repetitive
forearm and elbow activities. Both
lateral epicondylitis (commonly
known as tennis elbow), and medial
epicondylitis (commonly known as
golfer's elbow), are characterized by
elbow pain during or following elbow
flexion and extension. A
combination of poor mechanics,
microtears in areas of
Classification
Classification according to anatomic location
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Lateral
Prevalence is 1.3% to 3% in people aged 30 to 64 years.
Overuse injury commonly occurs within the origin of the extensor carpi
radialis brevis, but may also originate in the extensor digitorum
communis or extensor carpi radialis longus tendon. Associated with
activities requiring wrist extension or supination.
Classification
Medial
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Prevalence is 0.4% to 5% in people aged 30 to 64 years.
Overuse injury may occur in the pronator teres, flexor carpi radialis, palmaris
longus, flexor digitorum superficialis, and flexor carpi ulnaris.
Associated with activities requiring wrist flexion/pronation, particularly when there
is a valgus strain at the elbow.
Diagnostic Approach
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A diagnosis of lateral and medial epicondylitis can be made with a comprehensive history and physical exam.
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General findings on clinical evaluation
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Pain at either the lateral or medial aspect of the elbow is the main complaint. Patients will report pain during or following elbow flexion and
extension.
Typically all patients describe a history of repetitive recreational or occupational activity. These activities exacerbate their pain. Other risk
factors strongly associated with the development of epicondylitis may be present and include:
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Age 40 to 60 years
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Past medical history of epicondylitis
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Inadequate physical conditioning for the activities they are undertaking
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Poor mechanics during a repeated activity
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Smoking.
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Grip strength may be decreased in either medial or lateral epicondylitis, without pain associated with this function. Additionally, grip strength
can be diminished without a change in the typical epicondylitis pain. Therefore, measurement of grip strength may be used as an objective
tool to assess recovery. Although a rare finding, if symptoms are severe the patient's elbow may have mild swelling. Checking for Tinel sign
is recommended. This is performed by tapping lightly on the medial elbow over the ulnar nerve. It is described as positive if testing
generates paresthesia without pain. A negative Tinel sign can help rule out cubital tunnel or other neurologic conditions.
Lateral Epicondylitis
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Specific findings in lateral epicondylitis
Lateral epicondylitis is characterized by:
Tenderness over the common extensor tendon typically localized to the
extensor carpi radialis brevis; maximal tenderness occurs approximately 2
to 5 cm distal and anterior to the midpoint of the lateral epicondyle
Normal sensation
Complete range of motion at the elbow and wrist, but possibly a weak wrist
extension secondary to pain
Pain during resisted wrist and digit extension, and during passive wrist
flexion with the elbow extended
Positive extensor carpi radialis brevis stretch test: reproducible pain over
the origin of the common extensor mass when the arm is placed in
extension while the examiner maximally flexes the wrist.
Medial Epicondylitis
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Specific findings in medial epicondylitis
In medial epicondylitis:
The pain may have a more insidious onset
Tenderness is present distal and lateral to the medial epicondyle, over the
pronator teres and flexor carpi radialis
Pain may radiate along the medial elbow and be increased with resisted
forearm pronation or wrist flexion
Patients will also have normal sensation and strength, and complete range
of motion.
Treatment
Rest, Ice, NSAIDS, brace
Steroid injections
Achilles Contracture
Shortening of the achilles tendon that causes foot
pain and limits ankle dorsiflexion
Women who wear high heeled shoes
Joggers who land on balls of feet and not heels
Signs and Symptoms
Sharp spasmodic pain during dorsiflexion
Treat conservatively: Gradually lower the
heels of the patient if that is the etiology.
Surgery is last resort
Carpal Tunnel
Carpal tunnel syndrome, the most common
focal peripheral neuropathy, results from
compression of the median nerve at the
wrist.
epidemiology
Affects an estimated 3 percent of adult Americans
Three times more common in women than in men
High prevalence rates have been reported in persons who perform
certain repetitive wrist motions (frequent computer users)
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30% hand paresthesias
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10% clinical criteria for carpal tunnel syndrome
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3.5% abnormal nerve conduction studies
Clinical Features
Pain
Numbness
Tingling
Symptoms are usually worse at night and
can awaken patients from sleep.
To relieve the symptoms, patients often
“flick” their wrist as if shaking down a
thermometer (flick sign).
Clinical Features
Pain and paresthesias may radiate to the
forearm, elbow, and shoulder.
Decreased grip strength may result in
loss of dexterity, and thenar muscle
atrophy may develop if the syndrome is
severe.
Atrophy
Physical examination
Phalen’s maneuver
Tinel’s sign
weak thumb abduction.
two-point discrimination
Phalen’s maneuver
Tinel’s sign
Diagnostic
History
Physical examination
Nerve Conduction Study
Differential Diagnostics
Tendonitis
Tenosynovitis
Diabetic neuropathy
Compression of the Median nerve at the
elbow
Treatment
CONSERVATIVE TREATMENTS
GENERAL MEASURES
WRIST SPLINTS
ORAL MEDICATIONS
LOCAL INJECTION
ULTRASOUND THERAPY
Predicting the Outcome of
Conservative Treatment
SURGERY
GENERAL MEASURES
Avoid repetitive wrist and hand motions
that may exacerbate symptoms or make
symptom relief difficult to achieve.
Not use vibratory tools
Ergonomic measures to relieve symptoms
depending on the motion that needs to be
minimized
WRIST SPLINTS
Probably most
effective when it is
applied within three
months of the onset of
symptoms
Optimal splinting
regimen ?
WRIST SPLINTS
ORAL MEDICATIONS
Diuretics
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
pyridoxine (vitamin B6)
Orally administered corticosteroids
Prednisolone
20 mg per day for two weeks
followed by 10 mg per day for two
LOCAL INJECTION
A mixture of 10 to 20 mg of lidocaine
(Xylocaine) without epinephrine and 20
to 40 mg of methylprednisolone acetate
(Depo-Medrol) or similar corticosteroid
preparation is injected with a 25-gauge
needle at the distal wrist crease (or 1 cm
proximal to it).
LOCAL INJECTION
LOCAL INJECTION
LOCAL INJECTION
Splinting is generally recommended after
local corticosteroid injection.
If the first injection is successful, a
repeat injection can be considered after
a few months
Surgery should be considered if a patient
needs more than two injections
ULTRASOUND THERAPY
•May be beneficial in the
long term management
•More studies are needed
to confirm it’s usefulness
SURGERY
Should be considered in patients with
symptoms that do not respond to
conservative measures and in patients
with severe nerve entrapment as
evidenced by nerve conduction
studies,thenar atrophy, or motor
weakness.
It is important to note that surgery may
be effective even if a patient has normal
nerve conduction studies
SURGERY
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Complications of surgery
Injury to the palmar cutaneous or recurrent motor branch of the median
nerve
Hypertrophic scarring
laceration of the superficial palmar arch
tendon adhesion
Postoperative infection
Hematoma
arterial injury
stiffness
SURGERY
PREGNANCY
Alterations in fluid balance may predispose some
pregnant women to develop carpal tunnel
syndrome.
Symptoms are typically bilateral and first noted
during the third trimester.
Conservative measures are appropriate, because
symptoms resolve after delivery in most women
with pregnancy-related carpal tunnel syndrome.
Conclusion
Most common focal peripheral
neuropathy
Pain and paresthesias in the distribution
of the median nerve are the classic
symptoms.
While Tinel’s sign and a positive Phalen’s
maneuver are classic clinical signs of the
syndrome, hypalgesia and weak thumb
abduction are more predictive of
abnormal nerve conduction studies.
Conclusion
Conservative treatment options include splinting the wrist in a neutral
position and ultrasound therapy
Orally administered corticosteroids can be effective for short-term
management (two to four weeks), but local corticosteroid injections
may improve symptoms for a longer period.
If symptoms are refractory to conservative measures or if nerve
conduction studies show severe entrapment, open or endoscopic
carpal tunnel release may be necessary.
Torticollis - Basics
Neck deformity that involves shortening of the sternocleidomastoid (SCM)
muscle resulting in limited neck rotation and lateral flexion.
Infants tilt their head toward the side of the shortened muscle and rotate to the
contralateral side.
Plagiocephaly and craniofacial deformities can be associated with congenital
muscular torticollis (CMT) and can perpetuate one another.
Developmental hip dysplasia can be associated with CMT.
It is important to rule out nonmuscular causes such as ocular, vertebral, and
neurologic.
Treatment includes caregiver education on positioning and physical therapy;
botulinum toxin type A injections, or surgery are reserved for recalcitrant cases.
Torticollis
Congenital muscular torticollis (CMT)
is a neck deformity that involves
shortening of the
sternocleidomastoid (SCM) muscle
resulting in limited neck rotation and
lateral flexion. This results in a head
tilt to the affected side and rotation to
the contralateral side.
Rhabdomyolysis
Definition
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Rhabdomyolysis may result from any traumatic or medical injury to the
sarcolemma (the myocyte cell membrane). The subsequent release of
intracellular ions, myoglobin, CK, and urates into the circulation results in
electrolyte disturbances, disseminated intravascular coagulation (DIC),
renal failure, and multiorgan failure. The measurement of serum CK levels
at 5 times the upper limit of normal is used as diagnostic criterion.
Rhabdo
Etiology
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Rhabdomyolysis is a consequence of different disease entities that cause
myonecrosis. These processes may be classified as traumatic or
medically induced. Trauma, including overexertional states, results in
direct muscle injury. There are various medical causes. Rare, inherited
muscle enzyme defect disorders, as well as seizures, infections, metabolic
abnormalities, hypoxic conditions, temperature-related entities, and certain
immunologic diseases, may result in rhabdomyolysis.
Rhabdo
Numerous prescribed and abused drugs may lead to rhabdomyolysis:
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Cocaine, amphetamines, and phencyclidine may cause hyperdynamic
muscular states
Narcotics and other central nervous system depressants (barbiturates,
sedative-hypnotics) may cause tissue hypoperfusion and prolonged
immobilization and limb compression
Salicylate toxicity uncouples oxidative phosphorylation, which inhibits ATP
formation
Diuretics may lead to potassium depletion severe enough to result in
rhabdomyolysis
Statin therapy for cholesterol control has a significant unwanted effect of
rhabdomyolysis. The mechanism is not clearly defined.
Rhabdo
Toxins, such as cyanide, mercury, copper, carbon monoxide, and toluene,
disrupt ATP use or production at the cellular level and subsequently cause
muscle damage.
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Envenomation is a form of toxin-induced rhabdomyolysis. It has been
documented in bee stings, centipede bites, and snakebites.
In essence, any condition that causes intrinsic or extrinsic damage to
myocytes results in release of intracellular contents into the vascular
compartment and the ensuing complications. A small proportion of cases
are classified as idiopathic. These, however, are thought to be from as yet
unrecognized hereditary defects or earlier undiagnosed metabolic causes.
Rhabdo
The diagnosis of rhabdomyolysis is based on presenting complaints and a
high index of suspicion if risk factors are present. Obvious presentations
include trauma victims with an extremity crush injury or a physically
unconditioned person who presents with limb pain after jogging or
weightlifting. Patients with medical causes of rhabdomyolysis may present
much more insidiously. Complaints may be nonspecific such as
generalized malaise or dark urine.
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Examination is usually unremarkable, but muscle tenderness may be
present and signs of compartment syndrome (cool extremity with
diminished circulation) should be looked for in all cases of limb trauma and
cases of prolonged limb immobilization.