Epicondylitis presentation

EPICONDYLITIS

BY OJO OLAJIIRE

OLAJIDE11/09/20221

OUTLINEIntroduction Anatomy of HumerusLateral Epicondylitis

-Causes-Clinical presentation-Treatment

Medial Epicondylitis-Causes-Clinical presentation-Treatment

ConclusionReferences. 11/09/20222

INTRODUCTIONEpicondylitis is one of the most common elbow problems in adults occurring both laterally and medially.

It is a type of musculoskeletal disorder that refers to an inflammation of an epicondyle

The first description was made by Runge in 1873 as ‘Schreibers Krampfes’ (writers cramps) then later described by Henry Morris in 1882 as ‘‘lawn-tennis elbow,’’ as they both examined lateral epicondylitis (Morris, 1882).

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INTRODUCTIONOriginally thought to be an inflammatory process, as the name suggests, epicondylitis has been shown histologically to result from tendonous microtearing, followed by an incomplete reparative response. (Ciccoti and Schwartz, 2004).

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INTRODUCTIONIn Lancet in 1882, Morris described epicondylitis in athletes and called it “lawn tennis arm.” The term “lawn tennis elbow” is attributed to Major in an 1883 article in the British Medical Journal. Since then, racquet sport athletes of all kinds have been noted to be particularly susceptible to the development of lateral epicondylitis.

Golfers and athletes involved in overhead throwing show a propensity to develop medial epicondylitis. In this presentation, both lateral and medial epicondylitis in the athlete are reviewed.

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ANATOMY OF THE RELEVANT AREA OF HUMERUS

The humerus is the bone that forms the upper arm, and joins it to the shoulder and forearm and it is the longest bone of the upper limb.

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LATERAL EPICONDYLE

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The lateral epicondyle of the humerus is a small, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow-joint, and to a tendon common to the origin of the supinator and some of the extensor muscles.

Muscles that extend the wrist (bend towards the back of the hand) are attached to the lateral epicondyle by tendons.

These muscles include extensor carpi radialis brevis, extensor carpi radialis longus, and extensor digitorum and anconeus.

MEDIAL EPICONDYLE

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This is the medial nonarticular process of the knuckle-like distal end of the humerus. It forms a prominent projection from the distal border of the medial supracondylar ridge.

It is subcutaneous, more prominent than the lateral epicondyle and easily palpable.

It gives attachment to the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, pronator teres, flexor digitorum superficialis.

It also gives attachment to the ulnar collateral ligament of elbow joint

LATERAL EPICONDYLITISAlthough lateral epicondylitis is commonly known as tennis elbow, the term is a misnomer because the condition is most often work-related and occurs in patients who do not play tennis (Conrad et al.,1973).

The disorder commonly occurs in the dominant extremity. (Stafford, 2010).

Acute onset of symptoms occurs more often in young individuals; chronic recalcitrant symptoms typically occur in older patients (Leach and Miller, 1987).

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CAUSESBiomechanical analysis has shown that eccentric contractions of the extensor carpi radialis brevis (ECRB) muscle during backhand tennis swings, especially in novice players, are the cause of repetitive microtrauma that results in tears to the origin of the tendon and resultant lateral epicondylitis. (Riek, 1999).

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CAUSES. Some other suggested causes of lateral epicondylitis areDirect trauma to the lateral region of the elbow

Relative hypovascularity (impaired blood flow) of the region, (Schneeberger, 2003)

Fluoroquinolone antibiotics, (LeHuec et al, 1995)

Anatomic predisposition (Bunata et al, 1963).

Similar to medial epicondylitis, lateral epicondylitis is characterized by disorganized, immature collagen formation with immature fibroblastic and vascular elements. (Van Hofwegen, 2010).

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CLINICAL PRESENTATIONPatients who have lateral epicondylitis present with pain at the lateral aspect of the elbow that often radiates down the forearm. (Cyriax, 1936).

Occasionally, the patient can recall a specific injury to the area, but often the pain is of gradual, insidious onset, further supporting its characterization as an overuse injury. (Tuite, 2007)

They often report weakness in their grip strength or difficulty carrying items in their hand. (Coel, 1993).

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NON SURGICAL TREATMENTNon-surgical treatment is the cornerstone of care for both medial and lateral epicondylitis.

The objective of such conservative care is to relieve pain and reduce inflammation, allowing sufficient rehabilitation and return to activities.

The success rate of non-surgical treatment can be up to 90% (Fairbank, 2002). It includes patient education, physical therapy, medications, acupuncture, braces, extracorporeal shock wave therapy (ESWT) and injections. (Johnson et al., 2007).

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SURGICAL TREATMENT4% to 11% of patients ultimately require operative intervention for recalcitrant symptoms (Nirschl, 1979).

More recently, arthroscopic techniques in the management of lateral epicondylitis have been reported (Szabo et al, 2006).

Short-term results after arthroscopic treatment of lateral epicondylitis have high rates of success with pain relief and return to activities (Baker, 2008).

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MEDIAL EPICONDYLITISMedial epicondylitis, often called golfer’s elbow, can affect any human who repetitively contract the flexor-pronator mass. (Gabel, 1995).

The flexor-pronator muscles originate from the medial epicondyle and include the pronator teres, Flexor carpi radialis FCR, palmaris longus, flexor digitorum superficialis (FDS), and flexor carpi ulnaris FCU.

The FCU has both humeral and ulnar heads. The pronator teres and FCR are anatomic structures most commonly involved in medial epicondylitis, and they originate from the medial supracondylar ridge (Jobe, 1994).

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CAUSESMedial epicondylitis results from the pathologic combination of intrinsic muscle contraction of the flexor-pronator muscles added to the extrinsic valgus force of swinging or throwing. (Ciccotti et al., 2004).

Repetitive exposure of the medial aspect of the elbow to this combined force in the context of bad mechanics, inadequate warm up, poor conditioning, or overuse can overcome the tensile strength of the muscles’ origins causing microtearing. (Glousman et al., 1992).

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CAUSESThe flexor carpi radialis (FCR) and pronator teres have been the most consistently implicated sites for development of medial epicondylitis. (Glousman et al., 1992).

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CLINICAL PRESENTATIONPatients who have medial epicondylitis tend to report a gradual onset and increase of medial symptoms without a particular inciting event. (Van Hofwegen et al., 2010).

Pain from medial epicondylitis most often can be elicited on examination by palpating the medial epicondyle and slightly distally into the flexor pronator mass. (Gabel, 1995).

Pain during resisted pronation has been reported to be the most sensitive physical examination finding ( Gabel, 1995).

Pain during resisted wrist flexion can also indicate medial epicondylitis (Van Hofwegen et al., 2010).

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NON- SURGICAL TREATMENT

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There are three phases involved in the non surgical treatment; Phase 1 Phase 2 Phase 3

The protocol of rest, ice, and nonsteroidal anti-inflammatory medication is believed to be useful for relief of epicondylitis symptoms in about 90% of patients (Gabel, Morrey; 1995).

Nonsurgical treatment is usually successful and remains the mainstay of treatment.

SURGICAL TREATMENTSurgical treatment of medial epicondylitis is reserved for those patients who do not show significant improvement with rest and a supervised course of prolonged rehabilitation; a period of about 6 to 12 months (Jobe, 1994).

Surgical options include; open detachment of the flexor muscle origin without debridement (Kruvers, 1995),

open detachment of the flexor origin with debridement of pathologic tendinosis tissue followed by secure common flexor repair (Vangsness, 1991),

open resection of pathologic tendinosis tissue. (Ollivierre, 1995).

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CONCLUSION

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In conclusion, it is important to state that the leading cause of epicondylitis is the continuous overstretching of the tendons over the elbow region.

The relevance is not limited to sports science but also to occupations that involve repetitive arm movements and strenuous arm exercises such as carpentry, archery, waiting(as a chef), weightlifting amidst many others.

RECOMMENDATION

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As a recommendation, all jobs or exercises that may involve the utilization of arms; carpenters, typists, painters, chefs and waiters amidst other jobs that involve the repetitive arm movements are advised to sufficiently relax from time to time.

Strengthening exercises and counterforce bracing, as well as technique enhancement and equipment modification should have full attention, if a sport or occupation is causative.

REFERENCESCiccotti MG. Epicondylitis in the athlete. Instr Course Lect 1999;49:375– 81.

Coel M, Yamada CY, Ko J. MR imaging of patients with lateral epicondylitis of the elbow (tennis elbow): importance of increase signal of the anconeus muscle. AJR Am J Roentgenol 1993;161:1019–21.

Field LD, Savoie FH. Common elbow injuries in sport. Sports Med 1988;26:1936.

Gabel GT, Morrey BT. Operative treatment of medial epicondylitis: the influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77:1065–9

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REFERENCES

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Kurvers H, Verhaar J. The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am 1995;77:1374–9.

Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1– 8.

Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop 1985;201: 84– 90.

Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med 1988;7:289– 94.

REFERENCESNirschl RP. Muscle and tendon trauma: tennis elbow. In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders; 1985. p. 489– 96.

Stafford H, Sakr M, Ditto A. lateral epicondylitis. Sports med. 2010.

Szabo SJ, Savoie FH 3rd, Field LD, et al. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg 2006;15:721–7.

Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI interpretation. Clin Sports Med 2006.

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REFERENCE.

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Van Hofwegen et al. Epicondylitis in the Athlete’s elbow 2010

Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br 1991;73:409–11.