Cumulative trauma and acute tendon injuries of the elbow: Diagnosis and treatment Lance Rettig, MD October 11, 2012  Lateral Tendinopathy  Medial Teninopathy  Distal biceps injuries Epicondyles: Muscle Anchors for Wrist & Finger Motions  Lateral Epicondyle: (extension, supination)  ECRB, EDC, EDQ ECU, anconeus Lateral Epicondyle: origin to 5 muscles Anconeus ECU EDQ EDC ECRB Anatomy Most people that get “tennis elbow”… …don’t play tennis Pain centered at lateral epicondyle: tennis elbow Pain distal to lateral epicondyle: radial tunnel syndrome Tennis Elbow: Etiology  Mechanical overload microtears mucinoid degeneration partial tendon failure  Tissue shows characteristics of degeneration  Not inflammation, therefore not “‐itis” epicondylitis tendinitis  “Tendinosis” or “Tendonopathy” preferred but meaningless Pathology  Orderly tendon fibers disrupted by invasion of fibroblasts and vascular tissue  “Angiofibroblastic hyperplasia”  Tendon appears hypercellular, degenerative, fragmented  Gross appearance – gray, shiny tissue resembling scar tissue  Microtrauma results from repetitive loading episodes at a force or elongation level within physiologic range Overuse  Level of repetitive microtrauma sufficient to overwhelm tissues’ ability to adapt Tendon Failure  < 4% stretch normal  4 – 8% elongation crosslinks break and collagen fibers slide past one another  > 8% failure of individual collagen fibers with overload of receiving elements complete rupture NIRSCHL Categories Category I Path – Acute, reversible inflammation – no invasion Clinical – Minor, aching pain usually after heavy activity Treatment – Anti‐inflammatory measures  Clinical  <6 weeks onset  Immature collagen produced‐susceptible to injury  Anti‐inflammatory measures, controlled motion Normal tendon (light microscopy x100) uniform parallel collagen bundles, occasional tenocyte, no blood vessels Category II  Path – Partial “Angiofibroblastic” invasion  Clinical – More intense pain with activity, symptoms at rest  Treatment – Anti‐inflammatory, rest recommended, injection?? Category III  Path – Extension invasion with partial or complete rupture tendon becomes thick and unyielding  Clinical – Pain at rest, night pain ‐ ADL difficult  Treatment – Usually requires surgery Loose, disorganized collagen Normal tendon Randomly oriented fibroblasts Biopsy (light microscopy x100): tennis elbow “Angiofibrous Dysplasia” Tennis Elbow: Demographics  Age 30 ‐ 50 lateral:medial ~20:1  onset following forceful, repetitive activity  often not tennis  carrying luggage, laptop computers, shopping bags  machinists, film editors: cranking motion  ache in area of lateral epicondyle  often poorly localized  increased with resisted pronation, wrist extension  Lateral epicondylopathy  Clinical history/presentation  Lateral elbow pain, pain with active wrist and/or elbow extension  Physical exam  Lateral elbow tenderness at or just distal/anterior to lateral epicondyle  May lose elbow extension if severe & longstanding enough  Chair lift test or grip test with elbow extension  Rule‐out radial tunnel syndrome, especially in recalcitrant/unusual cases  Imaging  Typically not needed; will show up on MRI Signs of Lateral Tennis Elbow  Tenderness at insertion of ECRB tendon  Pain with stressing of extensors  Discomfort increases with elbow extended Lateral Tendinopathy (Lateral Epicondylitis)  Common in  Repetitive overload of wrist extensors  Pathology in extensor carpi radialis brevis (ECRB) Contributing Factors to Lateral Tendinopathy  Strength and Flexibility  Inadequate forearm strength  Inadequate wrist flexibility   forearm muscular flexibility Medial Epicondylitis  Repetitive tensile microtears – Flexor – Pronators Treatment of Tendionpathy  Relief of pain  Promotion of healing  Return to vocation  Lateral epicondylopathy  Treatments (usually a self‐limiting entity, how to control symptoms while awaiting resolution):  Therapy referral/expectations/communications:  Stretching program, activity modification  Tennis elbow strap/counterforce brace  Other modalities  Pharmacologic:  NSAIDS (oral or topical)  Injections:  Corticosteroid injections; others  Surgical Indications/Expectations:  Inability to control symptoms to patient’s satisfaction such that they are willing to accept risks/benefits of surgery Relief of Pain  Rest  Ice  Splint  Anti‐Inflammatory?  Injection?  PT Modalities Rest  Gentle exercise instituted early  Immobilization cause loss of glycosaminoglycan (GAG’s)  Tender tensile strength decreases with immobilization and stress deformity Splinting  Short arm splint  Place tendon in shorted, relaxed position  Counter force brace  Decrease force at tendon insertion Anti‐Inflammatory Agents  ? Benefit  Useful in acute phase – If seen early  topical Injection  Usually do not use initially  If refractory to initial treatment may try up to 3  Inject – Xylocaine, Marcaine, Decadron, or Triamcinolone  Instill deep to extensor brevis tendon  Steroid weakens tissue – Recommend a period of 7 – 10 days rest following injection P.T. Modalities  No studies demonstrating efficacy  Ultra sound  Phonophoresis  Electric stimulation  ? Acupuncture Shock Treatment Extracorporeal shock wave therapy in the treatment of lateral epicondylitis. A randomized multicenter trial. J Bone Joint Surgery 2002, 84A:1982.  double‐blinded, control group, 272 patients  no difference between treatment/control groups Extracorporeal Shock Wave Therapy without Local Anesthesia for Chronic Lateral Epicondylitis J Bone Joint Surg 2005, 87A: 1297.  double‐blinded, placebo control, 114 patients  shocked patients did better  blinding likely incomplete Promotion of Healing  Absence of abuse  General rehab program  Specific rehab of injured tendon Specific Exercises  Isometric  Flexibility  Eccentric program – key element Eccentric Program  Length – stretching increases length and reduces strain with joint movement  Load – Increasing load results in increased tensile strength  Speed – Increasing speed of contraction increases force Duration of Recovery  3 – 5 months  Lateral  6 – 12 months  Medial Surgery  3% of all lateral tendionpathy  85% complete relief  Return to heavy labor 4 – 6 months Lateral epicondylitis: review and current concepts. Faro F, Wolf JM. J Hand Surg [Am]. 2007 Oct;32(8):1271-9. Distal Biceps Tendon Injuries  Male Predominance  Avg age 40‐50  3% of Elbow Injuries  Multiple vocations  Etiology  Blood supply‐ hypovascular zone (Seiler)  Mechanical Impingement ? Distal Biceps Tendon Injuries  Mechanism  History  Single traumatic event  Sudden pain in antecubital fossa  Weakness elbow flexion/supination  Eccentric load to the arm Extension load to flexed elbow  Altered biceps contour Physical Examination  Pain within antecubital     fossa Palpable defect in biceps tendon Ruland “squeeze test” Pain/loss of strength with supination/flexion Diagnosis may be missed if lacertus fibrosis intact Imaging  Plain x‐ray: Irregularity radial tuberosity  MRI  Evaluate for partial tears  Extent of retraction in chronic tears Imaging  MRI  Sagittal view Non‐operative Treatment  Incomplete Tears  40% have persistent pain  Complete Tears  Usually no pain after 3‐4 weeks  * Elbow Flexion weakness 15%  ***Supination weakness 30‐50%  Decreased Endurance Non‐operative vs. Operative  Freeman  Unrepaired  26% decrease supination strength  12% decrease flexion strength Partial Biceps Tendon Injuries  Conservative  Activity modification  Intermittent splinting  Gradual return to activities  Operative  Take down entire tendon and repair Distal Biceps Tendon Injuries  Usually recommend operative repair in active population  Benefits outweigh RISKS in young active population  Well documented strength deficits in with non‐operative care  May consider non‐operative treatment in > age 70 or significant co‐morbidities Distal Biceps Injuries  Initial management  Ice , pain medicine , sling or long arm splint for pain control  Operative intervention within 7‐10 days ideal  May be able to repair 4 weeks depending on level of retraction  Repair > 1month post‐injury may require graft Distal Biceps Tendon Injuries  Operative Treatment  Two‐Incision Technique Distal Biceps Tendon Injuries Operative Treatment Suture Anchors Lintner & Fischer, 1996 CORR Distal Biceps Tendon Injuries  Interference Screw Fixation  Arciero Distal Biceps Tendon Injuries  Biomechanical Comparison repair techniques (Load to Failure)  Endobutton Stongest (Mean pullout 584N)  Suture Anchor Mitek (254 N)  Bone Tunnel (178 N) Distal Biceps Repair  Tw0‐ Incision Technique  Increased risk HO  Possibly increased stiffness forearm rotation radioulnar synostosis  PIN(radial nerve) palsy  Re‐rupture Distal Biceps Tendon Injuries  Endobutton surgical technique  Outpatient surgery  Anterior approach – longitudinal incision extending from elbow flexion crease distally 3‐4 cm length  Careful handling of the lateral antebrachial cutaneous nerve  Gentle exposure of the biceps tuberosity  Create trough within the biceps tuberosity (biceps footprint) Operative technique  Lateral Antebrachial Cutaneous nerve  Dermatome anterior and lateral distal forearm Endobutton Technique  Identify tendon in retracted position Endobutton Technique  Instrument native tendon with locking cable stitch Endobutton Technique  Ensure good excursion of the tendon Endobutton Technique  Placement of guide pin biceps tuberosity anterior and posterior coertex  Drill over the guide pin with a 7.5mm acorn reamer Endobutton Technique Distal Biceps Tendon Injuries  Passage of kite strings from anterior to posterior through skin  Endobutton is guided onto the posterior cortex and flipped 90 degrees Rehabilitation Distal Biceps Tendon repair with endobutton  Splint for 3‐5 days  1st Therapy Visit: Removal post‐operative dressings placement into hinged elbow brace  1st Therapy Visit: AROM, flexion/extension, prono‐ supination, 30 deg extension block  10 ‐14 days post‐op: Sutures out, advance to 20 degree extension block  Full ROM by 4‐5 weeks is the goal Rehabilitation Distal Biceps Tendon repair with endobutton  Discontinue brace between week 4‐6  Theraband strengthening weeks 6‐8  Dumbbell strengthening weeks 8‐12  Job simulation activities 10‐12 weeks post‐op Return to work/activities  Light duty‐ writing /data entry @ 2 weeks post‐op  Light duty‐ 5 pound weight restriction after week 6/no repetitive twisting  Light duty‐ 10‐15 pound limit between 9‐12 weeks  Full duty @ 3months post‐op unless VERY HEAVY work loads (3‐4 months  MMI usually at 12‐14 weeks Distal Biceps Tendon Repair  PPI rating usually 0%, most patients regain motion /strength with minimal or no discomfort  Complications associated with Endobutton fixation  Persistent pain  LABC or superficial radial nerve paresthesias  Re‐rupture Thank You