Transcript Upper Extremity Overuse Injuries

Kevin deWeber, MD, FAAFP, FACSM
Director, Military Sports Medicine Fellowship
Asst. Professor of Family Medicine
USUHS
March 2012
Overuse Injury types
Tendinopathy
 Muscle strain
 Apophyseal traction injury (adolescents)
 Nerve compression
 Fasciopathy
 Enthesopathy
 Stress fractures

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

KEY CONCEPT:
VICTIM AND CULPRITS

For every overuse injury (victim) there is
an underlying cause (culprit)
Risk factors for Overuse Injury:
The Usual Culprits
Intrinsic
abnormalities
Extrinsic abnormalities
Sports (or work) -imposed
deficiencies
Intrinsic abnormalities
Mal-alignment of body parts
 Instability of joints
 Imbalance of muscle strength
 Weakness of muscles
 Inflexibility
 Rapid growth

Extrinsic abnormalities
Training errors
 Equipment mismatch/failure
 Technique errors
 Environment factors

Sports-Imposed Deficiencies

Repetitive eccentric overload
 Example: pitching posterior structure
damage
Vicious Injury Cycle of Overload
Tissue overload
Tissue
damage
Clinical symptoms
Decreased performance
1. Microtears
2. Macrotears
Subclinical adaptations
1.
2.
3.
4.
Weakness
Inflexibility
Scar tissue
Strength imbalance
Substitute
biomechanical
movements
Example of overuse
1. Tensile load on posterior shoulder muscles
Musculotendinous
tensile overload
Muscle
damage
Clinical symptoms
Decreased performance
Substitute
biomechanical
movements
4. Alteration of
throwing
motions
2. Micro-tears to
Infraspinatus
and Teres minor
Subclinical adaptations
3. External rotation
strength imbalance
Tendon Overuse Injuries
The 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; NONinflammatory intra-tendinous collagen
degeneration.
Tendinosis: collagen disruption
and neovascularization
Normal tendon
Overuse Injury Management
Pyramid
Activity
participation
5. Control abuse
4. Fitness exercise
3. Promote healing
2. Control pain
1. Make accurate patho-anatomical diagnosis
Nerve Entrapment
Syndromes
in the Upper
Extremity
Median Nerve
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
Carpal Tunnel Evaluation

History
 Forearm, wrist and hand pain;
 Paresthesias involving 1st-4th fingers, often worse at night
 Thumb weakness, possibly worse post-exercise

Examination
 Thenar eminence 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
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

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
Carpal Tunnel Injection
Placement: ulnar to FCR (& plamaris longus
if present)
Distal-to-proximal approach OK too
Anterior Interosseous Syndrome

ANATOMY
 Compression from deep fascia of pronator teres or
flexor digitorum superficialis tendon
 Innervates:
○ flexor pollicis longus
○ flexor digitorum profundus
○ pronator quadratus

HISTORY:
 deep proximal volar forearm pain
 Finger/thumb flexor weakness

EXAM FINDINGS
 Weak FDP and FPL  weak pinch – can’t form “O”
Ulnar Nerve Entrapment

Entrapment at the elbow most common

At risk: Desk jockeys, throwing athletes,
weight-lifting, gymnastics, stick-handling
sports
 Traction vs. Compression?
Cubital Tunnel
Ulnar Nerve Entrapment


Most commonly entrapped at Cubital Tunnel
Less likely sites:
 PROXIMAL to TUNNEL: Medial triceps, ligament of
Struthers
 Anconeus epitrochlearis
 DISTAL to TUNNEL: FCU hypertrophy, Guyon’s canal

Causes of Traction Injury




UCL insufficiency
Osteophytes
Scar/adhesions
Nerve subluxation
Ulnar Nerve Evaluation

History
 medial elbow pain, increased with overhead activities;
 paresthesias in 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
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
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
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

Radial Tunnel Syndrome
Treatment
Relative Rest
 Wrist or elbow splinting
 Nerve mobilization techniques
 NSAIDs


Surgery for persistent symptoms usually
involves releasing the entrapment
location
Posterior Interosseous Nerve
(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
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
PIN Syndrome Treatment
Exercises as for RTS
 Splint to minimize
supination
 US-guided steroid
injection

Tendinopathies
DeQuervain Tenosynovitis
First Dorsal compartment: APL, EPB
 Overuse of thumb Abd/Ext

DeQuervain Tenosynovitis Treatment
Injection most effective
 NSAID short course
 Phono-/Ionto-pheresis
 Rare: surgery

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

Pathophysiology of Epicondylopathies

Degenerative tendinopathy
 Micro tears
 Hypervascular
 Calcifications
 Partial tears
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
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)
Platelet-Rich Plasma
Elbow epicondylopathy Prolotherapy
•
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
Lateral epicondylopathy RCT
Ozturan et al 2010



N=60
Steroid v. Blood v.
ShockWave
Injections: ONE time
100
Percent “success”
90
80
70
60
Steroid
50
Blood
40
Shockwave
30
20
<
10
0
4 weeks
52 weeks
Lateral epicondylopathy RCT
Kazemi et al 2010



N=60, Steroid v. Blood
SINGLE Injection
Outcomes:

 BLOOD better than
steroid on pain, grip,
disability, tenderness
 Grip strength
 Pain
 Function
4 weeks: BOTH
BETTER

 Disability
 tenderness
>
8 weeks: BLOOD
better in ALL outcomes
Lateral epicondylopathy RCT
Peerbooms et al 2010




N=100
Percent “success” 100
90
Steroid v. PRP
80
SINGLE Injections
70
60
Outcomes at 1 year
 DASH disability
 VAS pain

Success: >25% better
Steroid
50
40
30
20
10
0
PRP
Disability
<
Pain
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??
Lateral epicondylopathy RCT
Creaney et al 2011




N=150
Blood v. PRP
100.00
Injections: 0 & 1 month 90.00
Outcome: Pt-Related 80.00
70.00
Tennis Elbow Eval
60.00
(PRTEE) @6mo
50.00
Blood
PRP
40.00
Percent “success” 30.00
20.00
10.00
0.00
=
6 months

Corticosteroids:
 Short-term ( 4 weeks)
○ analgesia proven
 Intermediate and long-term (12-52 weeks)
○ WORSE THAN OTHER INTERVENTIONS
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.
Rotator Cuff Impingement

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
Impingement
Impingement screening maneuvers

Neer: full Flexion
 “Neer to the Ear”

Hawkins: Internal
Rotation
Impingement confirmatory maneuver

Full Can Test:
Resistance applied
in forward flexion
and abduction
(SCAPULAR
PLANE)
Neer test: Subacromial Injection
relieves pain





5cc 1% lidocaine
25-27g needle
Postero-laterally
Wait 10 minutes for
result
>50% pain reduction
confirms
Impingement

Imaging not initially needed
 4-view shoulder series
 MRI if considering surgery
○ Failed rehab
○ Pain with ADLs
Impingement Treatment

Acute Phase:
 Avoid Exacerbating
Factors
 Control
Pain/Inflammation
 Physical Therapy
 Corticosteroid Injection

Prolotherapy
 Dextrose, PRP

Surgical Intervention:
Failed Conservative
Measures, Significant
Disability
Rotator Cuff Tears




Similar presentation as
Impingement
Failed rehab for
impingement
Persistent pain/weakness
after Neer injection test
Imaging: x-rays, US, MRI
Rotator Cuff Tear Exam

Supraspinatus:
 drop-arm test

Infraspinatus or Teres
Minor
 External rotation lag sign

Subscapularis
 Belly press test
Rotator Cuff Tears

Treatment
 Conservative: Similar to Impingement
 Surgical:
○ Young patient, large tears, dominant arm
○ Failed Conservative Therapy
○ High-Level Athlete
○ Unable to perform vocational activities
○ Success depends upon degree of tendon
damage and degeneration
AC Joint Arthritis
Chronic pain at AC joint
 Exam: ACJ ttp, + scarf test, + active
compression test
 X-rays: narrowed AC jt, +/- osteophytes
 Tx:

 Avoid painful activities
 Steroid injections
 Surgical removal of distal clavicle (Mumford)
Adhesive Capsulitis

Painful restriction of
active and passive GH
ROM

Risk Factors







Idiopathic
Diabetes Mellitus
Female Gender
Ages 40-60
Immobilization
Inflammation
Stroke
Adhesive Capsulitis

Stage I

Stage III: “Frozen”
 1-3 months
 9-15 months
 Pain with normal ROM
 Severe ROM restriction
with decreased pain

Stage II: “Freezing”
 3-9 months
 Pain and progressive
ROM restriction

Stage IV: “Thawing”
 15-24 months
 Progressive restoration
of ROM
Adhesive Capsulitis: Treatment
NSAIDs
 ROM, Stretching
 Steroid injection into
subacromial space
or GH jt
 Surgical

 Dilatation
 Manipulation
Labral Tears


Causes: Traction Injuries,
FOOSH, Overhead motion
overuse, MVA Trauma
Locations:
 Superior Labral Anterior-
Posterior (SLAP) tear
 Posterior
 Anterior (from dislocation)
Labral Tears

History:
 Pain with overhead or
cross-body activity
 Popping, clicking,
catching
 85% incidence of
coexisting pathology

Physical (none
diagnostic):
 Crank Test
 Anterior Slide Test
 Yergason Test
SLAP Tears

Type 1: Fraying Injury

Type 2: Biceps tendon
detached

Type 3: “Buckethandle” tear

Type 4: “Buckethandle” with Biceps
detached
Labral Tears
Diagnostic: Radiograph, MR arthrogram
 Treatment:

 Physical Therapy for > 3 months
 Usually don’t heal. Aim for PAIN CONTROL
 Surgery:
○ Types I and III: Debridement
○ Types II and IV: Debridement and Reattachment
 Post-Op Rehabilitation
○ Immobilize for 3 weeks
○ Progress with AROM
○ Return to full activity after 12-14 weeks
Questions?