Top Elbow Problems: Founder, SportZPeak Inc. Tennis Elbow, Anyone? - PowerPoint PPT Presentation

12/10/2016 Disclosure • Founder, RunSafe™, RaceSafe ™ Top Elbow Problems: • Founder, SportZPeak Inc. Tennis Elbow, Anyone? • Sanofi, Investigator initiated grant Anthony Luke MD, MPH, CAQ (Sport Med) ABC ’ s of MSK Care UCSF Sports Medicine December 10, 2016 Outline Elbow Anatomy Ginglymus • Review basic Bones: anatomy Humerus, ulna and radius • Trochlea, coronoid, • • Review olecranon, capitellum, radial head common 3 articulations: problems 1) the radiocapitellar joint, • – Diagnosis 2) the ulnohumeral joint and 3) the proximal – Management radioulnar joint 1

12/10/2016 Elbow – Static Stabilizers Elbow – Static Stabilizers Below 20 ° ° and greater ° ° Bony = Ligament stability • Radial collateral than 120 ° ° ° ° of flexion � ligament (RCL) • Between 20 ° ° and 120 ° ° ° ° ° ° , • Lateral ulnar collateral osseous stability ligament (LUCL) • • Accessory lateral ligaments and capsule are collateral ligament the primary restraints (ALCL) • Annular ligament (AL) Medial – Ulnar collateral • ligament complex Safran MR. Elbow injuries in athletes: A review. Clin Orthop 310: 260, 1995 Elbow – Dynamic Stabilizers History: Demographics Lateral • Age • Extensors (wrist and digits) – • Occupation Supinator – • Recreation / Sports • Hand Dominance Medial • Flexors (wrist and digits) – Pronator teres – 2

12/10/2016 History is Key Traumatic vs Atraumatic • Pain • FOOSH = fall on the outstretched hand • Instability • Dysfunction Stiffness • Throwing? • Numbness, • Mechanical symptoms: catching, locking • Repetitive motion Lateral “ “ “ “ epicondylosis ” ” ” ” Atraumatic Elbow Pain • Lateral = Lateral • Males > Females epicondylosis • More common in • Medial = Medial dominant arm = 2:1 epicondylosis • Incidence = 9.1% • Lateral > Medial • Prevalence = 40 – (5-8 : 1) 50% • ECRB 3

12/10/2016 Elbow Tendinopathies Conservative treatment Passive stretches Lateral epicondylosis • (Wrist flexion, extension; Tender lateral epicondyle • keep elbow extended; Resisted third digit hold 30 seconds) • extension Gradual light resisted • weight program (start 1-2 Resisted wrist extension • lbs, up to 5-10 lbs) Medial epicondylosis Supination, pronation • Resisted wrist flexion • exercises Distal biceps Ice, NSAIDs • Resisted supination Ng & Chan, J Orthop Sports Phys • Ther, 2004 Conservative treatment Tendinosis Elbow Counterforce brace • Hyaline degeneration • No clear evidence • Affects wrist joint • Mucoid proprioception and degeneration increases the pain threshold to passive • Fibrillation of stretching of the wrist collagen extensors • Absence of Ng & Chan, J Orthop Sports Phys Ther, 2004 inflammatory cells 4

12/10/2016 Tendon Healing Treatment of Tendinosis Education • Requires around • 100 days to Modify Activities • synthesize collagen Alter Biomechanics / • Decrease tendon load Eccentric exercise programs • Mild – 2 to 4 weeks stimulate collagen synthesis and cross-linkage Moderate – 4 to 6 Icing helps • weeks No evidence that NSAIDs • Severe – 6 to 12 weeks improve healing Khan KM, Cook JL, Taunton JE, Bonar F. Phys Sportmed 2000; 28:5: 38-48. To inject or not inject Conservative vs Injection ? • Injections can be a • RCT, n= 198 useful adjunct – 8 sessions of PT – Steroid injection • Injections can be – Wait and See performed safely in the office • At 6 weeks, injection benefits regressed; PT better than both groups • At 52 weeks, no difference among groups Bisset et al, BMJ, 2006 5

12/10/2016 Epicondylitis Injections Conservative vs Injection ? Lateral and Medial • A randomized trial showed improvement with Use 25 (or 22) gauge corticosteroid injection at 1 month as well as • needle evidence of decreased tendon thickness and 2 mL local anesthetic • Doppler changes but no improvement at 3 1 mL steroid solution months . Insert needle toward point • of maximal tenderness (tendon insertion into epicondyle) May fan injection around • tendon insertion Do not inject if resistance • Results of “ “ Epicondylosis ” “ “ ” ” ” Platelet Rich Plasma ? interventions • N =230, multicenter • Limited evidence to support : • Tendon needling with PRP in patients with chronic – Autologous blood injection tennis elbow compared with an active control group – Phonophoresis • A successful outcome was defined as 25% or – Accupuncture greater improvement on the visual analog scale for – Dynamic extension brace pain – Extra-corporeal shockwave therapy Mishra AK et al, Am J Sports Med, 2014 – Botulinum Toxin A – Arthroscopic debridement Ahmad Z et al. Bone Joint J. 2013 6

12/10/2016 Thrower ’ ’ ’ s Elbow ’ Little League Elbow or Platelet Rich Plasma ? • At 12 weeks (n = 192), the PRP-treated patients • Medial epicondyle reported 55.1% improvement in their pain scores apophysitis or avulsion compared with 47.4% in the active control group (or UCL ligament (P=0.163). sprain) • Radial head • At 24 weeks (n = 119), the PRP-treated patients hypertrophy reported 71.5% improvement in their pain scores • Avascular changes in compared with 56.1% in the control group (P=0.019). the capitellum • No complications (osteochondritis Mishra AK et al, Am J Sports dissecans) • ? Clinically significant Med, 2014 Growth Plates Medial Apophysitis Capitellum (age 1-2) Radial head (age 3) Internal (medial) epicondyle (age 5) Trochlea (age 7) Olecranon (age 9) External (lateral) epicondyle (age 10 in girls and 11 in boys) (mnemonic “ “ “ CRITOE ” “ ” ” ) ” •Bradley JP. Upper extremity: elbow injuries in children and adolescents. In: Stanitski CL, DeLee JC, Drez D Jr, eds. Pediatric and adolescent sports medicine, Vol 3. Philadelphia: WB Saunders, 1994: 244 7

12/10/2016 MRI Conservative Treatment • Rest from valgus loading activity • NO THROWING • Batting and first base often OK • NSAIDs, Ice • May take 6 to 12 weeks • Gradual return to throwing Conservative Treatment Medial Apophyseal Avulsion If Medial Apophysitis is avulsed, Current recommendations for surgical casting for 2 to 3 weeks at 90 ° ° followed by ° ° treatment include: • Non-operative treatment typically involves 1) Fragment displacement greater than 2 mm protected motion with a hinge brace for at least 6 weeks. 2) Valgus instability greater than 3 mm • 31 out of 35 healed with fibrous non-union with 3) Entrapment of the fragment in the joint good function and range of motion 4) Ulnar nerve dysfunction. Hugheds PE, Paletta Jr. GA. Little Leaguer ’ s Elbow, Medial epicondyle injury and Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand, 1986; 57: 537-538. osteochondritis dissecans. Sports Med Arthroscopy Review 2003; 11:30-39. 8

12/10/2016 Osteochondritis Dissecans Baseball Typically present with • Consider limiting pitchers under symptoms between 11-16 y.o. 14 years old Gradual pain with activity • 1. 75 pitches a game Locking, catching and swelling 2. 600 pitches per season • if fragment unstable 3. 15 batters/game, 120 batters/season) 4. One league at a time Etiology unclear • Avoid curveball and slider Often repetitive stress • pitches under 14 (throwers, gymnast etc) Lyman S, Fleisig GS, Andrews JR, et al. Am J Sports Med, 2002. MRI can assess stability • May need surgical stabilization • Suggestions adopted by USA or removal baseball • Between 20 ° ° and ° ° Ulnar Collateral Ligament Conservative Treatment 120 ° ° , ligaments ° ° • RICE, Elbow Hinge brace • Conservative treatment better in younger and capsule are the athletes than in adults primary restraints • In throwing athletes with UCL injury (n= 31, average age 18), 42% were able to return to their • MRI previous level of play at an average of 24.5 weeks (13-54 weeks) of conservative Safran MR. Elbow injuries in athletes: management A review. Clin Orthop 310: 260, 1995 Rettig et al., Am J Sports Med, 2001 9

12/10/2016 Ulnar Collateral Ligament Ulnar nerve – Funny Bone Sprain • Numbness and tingling Tommy John Surgery over 4 th and 5 th fingers • UCL reconstruction • Weak finger adduction, abduction using autologous grafts of the palmaris longus or • Traction gracilis • Compression • Friction Ulnar nerve – Funny Bone Elbow dislocation vs fracture ? Elbow Flexion test • Aged (5 to 10 y.o.) • (Traction) supracondylar fracture Tinel sign (Compression) • • Adolescent (13-14 y.o.) Ulnar nerve subluxation • posterior dislocation (Friction) • Adults Treatment for ulnar – Dislocation • neuropathy usually – Coronoid fracture conservative Surgery: transposition of • ulnar nerve 10