Upper Extremity Overuse Injuries
Download
Report
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?