Elbow Tendonopathy & Enthesopathy Outline

7/7/2017

Elbow Tendonopathy & Outline Enthesopathy • Medial epicondylitis

• Medial elbow “snapping”

Patrick H. Smock, MD • Triceps enthesopathy Sports and Orthopedic Specialists 7 July, 2017 • Distal biceps tendinitis

• Lateral epicondylitis

Tendinopathy vs. Enthesopathy Medial Epicondylitis • “Tendinopathy refers to disease of the tendon and enthesopathy refer “Golfers elbow” to disease of the tendon bone junction (where the tendon joins the • 3‐6x less common than lat. Epicondylitis bone).... In the context of sports medicine, most of these conditions • Repetitive microtrauma (valgus stress are overuse in nature with repetitive loading leading to accumulative and wrist/forearm flexion/pronation) damage to the tendon or its insertion.” • “Angiofibroblastic hyperplasia” • Clinical features: Pain/tenderness over “With age, the circulation to some tendons decrease and this impairs medial epicondyle • Pain with grip and with resisted wrist the attempts of the body to repair the degenerated areas. flexion/pronation Tendinopathy and enthesopathy can also result in calcification within the tendon. In some cases, the progressive degeneration of the tendon • R/O Ulnar nerve pathology and medial or enthesis eventually causes the structure to fail and results in a tear.” elbow instability • Imaging as needed if diagnosis unclear Tendinopathies and enthesopathies: the bugbear of athletes • US vs. MRI https://www.ttsh.com.sg/patient‐guide/medical‐departments/page.aspx?id=1177

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Management Medial elbow snapping • Conservative management is the mainstay • Rest, avoidance of offending activity, • Ulnar nerve vs. Medial triceps stretch, ice, NSAIDs tendon (or both) • Wrist splinting vs. counterforce strap • Painful snapping palpated/visualized with elbow • Shock‐wave therapy? flex/ext • Injections (CSI, autologous blood products)* • Check for subluxation of the Ulnar • Medial antebrachial cutaneous nerve nerve • Surgical debridement/repair (address associated ulnar nerve compression) • Synovial pathology Shoulder Elbow. 2014 Jan;6(1):47‐56. doi: 10.1111/sae.12022. Epub 2013 Jun 10. Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Donaldson O1, Vannet N1, Gosens T2, Kulkarni R1.

Distal Biceps tendonitis Triceps Enthesoapthy • Incidence unknown • Pain with resisted elbow extension • Tendinosis vs. partial tear poorly • Tender bony prominence at the tip defined of olecranon • Suspect correlation with distal biceps rupture • Overlying olecranon bursitis • Ant. elbow pain with elbow • Plain films, +/‐ MRI flexion/supination • Conservative treatment first (rest, ice, • Conservative management (elbow stretching, modalaties) pad/compressive sleeve, ice, • PRP ? * NSAIDs) • Surgical detachment, debridement, • Steroid injection? repair Shoulder Elbow. 2015 Apr;7(2):110‐4. doi: 10.1177/1758573214567558. Epub 2015 Jan 16. • Surgical debridement, tendon repair Ultrasound‐guided platelet‐rich plasma injection for distal biceps tendinopathy. Barker SL1, Bell SN1, Connell D2, Coghlan JA1.

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Management Lateral Epicondylitis • Conservative management is the • “Tennis elbow” mainstay • Very common (1‐3% overall incidence) • Rest, avoidance of offending • Repetitive microtrauma (wrist/forearm activity, stretch, ice, NSAIDs extension) • Wrist splinting vs. counterforce • “Angiofibroblastic hyperplasia” strap* • Clinical features: Pain/tenderness over Lateral epicondyle • Shock‐wave therapy? • Pain with grip and with resisted wrist/elbow • Injections (CSI, autologous blood, extension PRP)* • R/O Radiocapitellar pathology, radial • Surgical debridement/repair tunnel syndrome • Open vs. arthroscopic

• Imaging as needed if diagnosis unclear Phys Sportsmed. 2017 May;45(2):97‐104. Epub 2017 Mar 3. • US vs. MRI Platelet rich plasma versus steroid on lateral epicondylitis: meta‐analysis of randomized clinical trials. Mi B1, Liu G1, Zhou W1, Lv H2, Liu Y1, Wu Q1, Liu J1.

Does anything really work? “Biopsychosocial approach”

“Numerous nonoperative modalities have been described for the (1) “Can I tell you how tennis elbow works?” treatment of lateral tennis elbow. Most are lacking in sound (2) “For no known reason, between the ages of 35 and 65 years, tennis elbow scientific rationale. This has led to a therapeutic nihilism with arises in healthy people doing healthy things.” respect to the nonoperative management of this condition. An (3) “Tennis elbow lasts about a year or so, goes away on its own, is unlikely examination of the literature can only lead us to believe that most, to return, and leaves no trace.” if not all, common nonoperative therapeutic modalities used for (4) “We have been working on this problem for years but have not yet the treatment of tennis elbow are unproven at best or costly and time‐consuming at worst.” found a way to shorten the time it takes to get better.”

Enthesopathy of the Extensor Carpi Radialis Brevis Origin: Effective Communication Strategies. J Shoulder Elbow Surg. 1999 Sep‐Oct;8(5):481‐91. Drake ML, Ring DC. Lateral tennis elbow: "Is there any science out there?". J Am Acad Orthop Surg. 2016 Jun;24(6):365‐9 Boyer MI1, Hastings H 2nd.

Phys Sportsmed. 2017 May;45(2):97‐104. Epub 2017 Mar 3. Platelet rich plasma versus steroid on lateral epicondylitis: meta‐analysis of randomized clinical trials. Mi B1, Liu G1, Zhou W1, Lv H2, Liu Y1, Wu Q1, Liu J1.

Clin Orthop Relat Res. 2015 Mar;473(3):1093‐107. Epub 2014 Oct 29. Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta‐ analysis. Sayegh ET1, Strauch RJ.

Shoulder Elbow. 2014 Jan;6(1):47‐56. Epub 2013 Jun 10. Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Donaldson O1, Vannet N1, Gosens T2, Kulkarni R1.

Shoulder Elbow. 2013 Oct;5: 239–250. Epub 2013 Jun 10. Tendinopathies Around the Elbow Part 1: lateral elbow tendinopathy. Donaldson O1, Vannet N1, Gosens T2, Kulkarni R1. J Hand Surg Am. 2009 Mar;34(3):566‐76. doi: 10.1016/j.jhsa.2009.01.022. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. Rineer CA1, Ruch DS. J Shoulder Elbow Surg. 1999 Sep‐Oct;8(5):481‐91. Lateral tennis elbow: "Is there any science out there?". Boyer MI1, Hastings H 2nd. J Am Acad Orthop Surg. 2016 Jun;24(6):365‐9 Enthesoapthy of the Extensor Carpi Radialis Brevis Origin: Effective Communication Strategies Drake ML, Ring DC.