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Upper Extremity Overuse Injuries

Kevin deWeber , MD, FAAFP, FACSM Director, Military Sports Medicine Fellowship Asst. Professor of Family Medicine USUHS March 2012. Upper Extremity Overuse Injuries. Overuse Injury types. Tendinopathy Muscle strain Apophyseal traction injury (adolescents) Nerve compression

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Upper Extremity Overuse Injuries

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  1. Kevin deWeber, MD, FAAFP, FACSM Director, Military Sports Medicine Fellowship Asst. Professor of Family Medicine USUHS March 2012 Upper Extremity Overuse Injuries

  2. Overuse Injury types • Tendinopathy • Muscle strain • Apophyseal traction injury (adolescents) • Nerve compression • Fasciopathy • Enthesopathy • Stress fractures

  3. Key features of overuse injury • Sub-clinical injury occurs before the patient feels it • The normal soft-tissue repair process is aborted • Degeneration cycle begins instead • Soft-tissue degeneration is NOT inflammatory

  4. KEY CONCEPT: VICTIM AND CULPRITS • For every overuse injury (victim) there is an underlying cause (culprit)

  5. Risk factors for Overuse Injury:The Usual Culprits • Intrinsic abnormalities • Extrinsic abnormalities • Sports (or work) -imposed deficiencies

  6. Intrinsic abnormalities • Mal-alignment of body parts • Instability of joints • Imbalance of muscle strength • Weakness of muscles • Inflexibility • Rapid growth

  7. Extrinsic abnormalities • Training errors • Equipment mismatch/failure • Technique errors • Environment factors

  8. Sports-Imposed Deficiencies • Repetitive eccentric overload • Example: pitching posterior structure damage

  9. Vicious Injury Cycle of Overload Tissue overload Substitute biomechanical movements Clinical symptoms Decreased performance Tissue damage 1. Microtears 2. Macrotears Subclinical adaptations 1. Weakness 2. Inflexibility 3. Scar tissue 4. Strength imbalance

  10. Example of overuse 1. Tensile load on posterior shoulder muscles Musculotendinous tensile overload Substitute biomechanical movements 4. Alteration of throwing motions Clinical symptoms Decreased performance Muscle damage 2. Micro-tears to Infraspinatus and Teres minor Subclinical adaptations 3. External rotation strength imbalance

  11. Tendon Overuse InjuriesThe spectrum of “tendinopathy” • Tenosynovitis - inflammation in tendon sheath • Paratenonitis - inflammation of only the loose areolar tissue surrounding tendon • Achilles tendon • Tendonitis - symptomatic degeneration with vascular disruption and inflammatory repair. • Tendinosis - intra-tendinous degeneration from repetitive microtrauma; NON-inflammatory intra-tendinouscollagen degeneration.

  12. Tendinosis: collagen disruption and neovascularization Normal tendon

  13. Overuse Injury Management Pyramid Activity participation 5. Control abuse 4. Fitness exercise 3. Promote healing 2. Control pain 1. Make accurate patho-anatomical diagnosis

  14. Nerve Entrapment Syndromes in the Upper Extremity

  15. Median Nerve

  16. Carpal Tunnel Syndrome • Compression of median nerve deep to the transverse flexor retinaculum in volar wrist • Activities with repetitive gripping, throwing, wrist flexion and extension

  17. Carpal Tunnel Evaluation • History • Forearm, wrist and hand pain; • Paresthesiasinvolving 1st-4th fingers, often worse at night • Thumb weakness, possibly worse post-exercise • Examination • Thenareminence atrophy is a late sign • Phalen’s, Tinel’s and median nerve compression signs • Imaging usually not needed (consider to exclude structural causes) • Electro-Diagnostic Testing (EDT) for confirmation, determination of severity

  18. Carpal Tunnel Syndrome tx • Splints at night: short term • Oral steroids: 2 weeks • Injected steroids: weeks to months • Surgery: best • EQUIVOCAL: Nerve gliding exercises • NOT EFFECTIVE: NSAID, Vit B6, diuretics • UNKNOWN: nerve hydro-dissection under US guidance

  19. Carpal Tunnel Injection • Indications: • Recalcitrant to conservative tx • Needle size and dosage: • 25 - 27 gauge 1 inch needle • 1ml of Anesthesia w/ 10 mg Triam OR 2 mg beta/dex • Palmar crease

  20. Carpal Tunnel InjectionPlacement: ulnar to FCR (& plamarislongus if present)Distal-to-proximal approach OK too

  21. Anterior Interosseous Syndrome • ANATOMY • Compression from deep fascia of pronator teres or flexor digitorumsuperficialis tendon • Innervates: • flexor pollicislongus • flexor digitorumprofundus • pronator quadratus • HISTORY: • deep proximal volar forearm pain • Finger/thumb flexor weakness • EXAM FINDINGS • Weak FDP and FPL  weak pinch – can’t form “O”

  22. Ulnar Nerve Entrapment • Entrapment at the elbow most common • At risk: Desk jockeys, throwing athletes, weight-lifting, gymnastics, stick-handling sports • Traction vs. Compression?

  23. Cubital Tunnel

  24. Ulnar Nerve Entrapment • Most commonly entrapped at Cubital Tunnel • Less likely sites: • PROXIMAL to TUNNEL: Medial triceps, ligament of Struthers • Anconeusepitrochlearis • DISTAL to TUNNEL: FCU hypertrophy, Guyon’s canal • Causes of Traction Injury • UCL insufficiency • Osteophytes • Scar/adhesions • Nerve subluxation

  25. Ulnar Nerve Evaluation • History • medial elbow pain, increased with overhead activities; • paresthesiasin 4th-5th fingers • Examination • Positive (asymmetric) Tinel’s sign • Possible intrinsic hand weakness and atrophy • Provocative testing with elbows fully flexed and wrist extended for 3 minutes • Imaging • Elbow x-rays to r/o osteophytes • IF CONSIDERING SURGERY: EDT and MRI

  26. Ulnar Nerve Entrapment Treatment • Mitigate risk factors • Optimize biomechanics • Relative rest, night splints to decrease full flexion • NSAIDs or oral steroids • Corticosteroid injection (controversial) • Hydro-dissection under US guidance • Anecdotal success • Surgical treatment indicated if • Refractory to conservative management • Significant atrophy already present • Structural abnormality (spur, etc.) as the cause • Potential UCL pathology must be addressed

  27. Guyon’s Canal compression • ANATOMY • Ulnar nerve rides between pisiform and hamate • Feeds interosseous muscles, hypothenar muscles, lumbricals (intrinsic muscles) • EVALUATION • r/o hamate fracture • Activities that exacerbate • TREATMENT • Pad area • NSAIDS

  28. Radial Tunnel Syndrome • Radial nerve entrapment at elbow • Racquet sports, rowing and wt. lifting • Sensory and motor complaints • Dull, deep lateral elbow pain, increased with elbow flexion and extension, forearm supination and wrist extension • Tenderness over extensor muscle group • Pain reproduced with resisted forearm supination with elbow flexed • May mimic or coexist with lateral epicondyopathy

  29. Radial Tunnel Syndrome Treatment • Relative Rest • Wrist or elbow splinting • Nerve mobilization techniques • NSAIDs • Surgery for persistent symptoms usually involves releasing the entrapment location

  30. Posterior InterosseousNerve (PIN) Syndrome • Purely motor branch of Radial n. • Extensor-Supinator muscles • Compression at Arcade of Frohse (proximal edge of Supinator m.) • At-risk: racquet sports, bowlers, rowers, discus throwers, golfers, swimmers • Repetitive supination and pronation

  31. PIN Syndrome • Similar symptoms and physical exam to RTS, except no sensory findings and more pronounced motor weakness • Pain/weakness with resisted supination • Weakness with resisted wrist, index finger, thumb abduction • EDT to confirm if refractory

  32. PIN Syndrome Treatment • Exercises as for RTS • Splint to minimize supination • US-guided steroid injection

  33. Tendinopathies

  34. DeQuervain Tenosynovitis • First Dorsal compartment: APL, EPB • Overuse of thumb Abd/Ext

  35. DeQuervain Tenosynovitis Treatment • Injection most effective • NSAID short course • Phono-/Ionto-pheresis • Rare: surgery

  36. Epicondylopathies • Chronic eccentric overload of common extensor tendon (lateral) or flexor tendon (medial) at elbow • Insidious onset, pain centered at or just distal to epicondyle • Pain w/ resisted wrist ext or flex • Focal TTP • Absence of neural symptoms

  37. Pathophysiology of Epicondylopathies • Degenerative tendinopathy • Micro tears • Hypervascular • Calcifications • Partial tears

  38. Treatment of Epicondylopathy • Relative rest from painful motions • Pain control • Ice, NSAID for several days • Steroid injection (2-6 weeks effective) • Physical therapy • Restore ROM and strength • Prolotherapies • Whole blood or Platelet-Rich Plasma injection • 3-12 months effective

  39. Platelet Alpha Granules Platelet-derived growth factor (PDGF) Transforming growth factor (TGF) Vascular endothelial growth factor (VEGF) Epidermal growth factor (EGF) Fibroblast growth factor (FGF)

  40. Platelet-Rich Plasma

  41. Elbow epicondylopathyProlotherapy • Traditional Therapies (eg Dextrose 25%) • Zeisig et al. 2006 series • Scarpone et al. 2008 RCT • Carayannopoulos 2011 RCT • Autologous Blood • Edwards/Calandruccio 2003 series • Connell et al. 2006 series • Suresh et al. 2006 series • Ozturan et al 2010 RCT • Kazemi et al 2010 RCT • PRP • Mishra and Pavelko 2006 series • Peerbooms et al, 2010 RCT • Creaney et al 2011 RCT, ABI = PRP • Hechtman et al 2011 series

  42. Lateral epicondylopathy RCTOzturan et al 2010 • N=60 • Steroid v. Blood v. ShockWave • Injections: ONE time Percent “success” <

  43. Lateral epicondylopathy RCTKazemi et al 2010 • N=60, Steroid v. Blood • SINGLE Injection • Outcomes: • Grip strength • Pain • Function • Disability • tenderness • 4 weeks: BOTH BETTER • BLOOD better than steroid on pain, grip, disability, tenderness • 8 weeks: BLOOD better in ALL outcomes >

  44. Lateral epicondylopathy RCTPeerbooms et al 2010 • N=100 • Steroid v. PRP • SINGLE Injections • Outcomes at 1 year • DASH disability • VAS pain • Success: >25% better Percent “success” <

  45. So, for tennis elbow, at one year after treatment… • Blood is better than steroid • PRP is better than steroid • Which is better: blood or PRP??

  46. Lateral epicondylopathy RCTCreaney et al 2011 • N=150 • Blood v. PRP • Injections: 0 & 1 month • Outcome: Pt-Related Tennis Elbow Eval (PRTEE) @6mo Percent “success” =

  47. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010 Nov 20;376(9754):1751-67. • Corticosteroids: • Short-term ( 4 weeks) • analgesia proven • Intermediate and long-term (12-52 weeks) • WORSE THAN OTHER INTERVENTIONS

  48. Compression of the rotator cuff in the subacromial space Symptoms: Pain with Overhead position Anterior, lateral shoulder pain Flexion, Internal Rotation Night Pain Risk Factors: Overhead activities Micotrauma GH Instability Shape of Acromion DJD Rotator Cuff Impingement

  49. Impingement

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