3rd Module Upper extremity 2023 - Copy.pptx

Physiotherapy for upper extremity

1. Physiotherapy Department Presented By: Dr. Ahmed Baghdadi PhD in MSK Physical Therapy PT, AWH - OPD Advanced MSK Physiotherapy Program AWH 3 rd Module: Upper Extremity

2. I do not have any conflicts of interest to declare. I do not have an affiliation (financial or otherwise) with a pharmaceutical , medical device, or communications and event planning company.

3. Objectives Identify How to apply different types and grades of mobilization according to our assessment. Understand Anatomy, Biomechanics, path mechanics, and evidence-based practice for upper extremity Understand and apply the assessment rational for upper extremity dysfunctions Understand and apply differential diagnosis for upper extremity dysfunctions Recognize how to tailor treatment plan based on clinical reasoning for upper extremity dysfunctions Identify How to apply different types and grades of mobilization according to our assessment. Demonstrate proper clinical reasoning and practical skills.

4. Biomechanical Difference between Shoulder flexion and abduction Scapulo-Humeral Rhythm Key movements in shoulder dysfunctions Key muscles in shoulder Assessment and Treatment Shoulder Instability. Thoracic, Cervical and Scapular Dominance in shoulder Dysfunction. Distal and Proximal Mechanical Stress Metabolic Stress in shoulder Dysfunction Mobilization technique selection, direction, grade, dose, and when to stop Structure Govern Function and Holistic Approach

5. Functional Anatomy and Arthrokinematics

6. ARTICULATION Articulation is between: The rounded head of the humerus and The shallow, pear-shaped glenoid cavity of the scapula. 6 Head Glenoid cavity

7. The articular surfaces are covered by hyaline cartilage. The glenoid cavity is deepened by the presence of a fibrocartilaginous rim called the glenoid labrum . 7

8. TYPE Synovial Ball-and-socket joint 8

9. FIBROUS CAPSULE The fibrous capsule surrounds the joint and is attached: Medially to the margin of the glenoid cavity outside the labrum; Laterally to the anatomic neck of the humerus. The capsule is thin and lax , allowing a wide range of movement. 9

10. LIGAMENTS 10

11. Extension: Normal extension is about 45° It is performed by the: Posterior fibers of the deltoid, Latissimus dorsi Teres major 11

12. The supraspinatus muscle: initiates the movement of abduction(from 0 to 19) and holds the head of the humerus against the glenoid fossa of the scapula ; This latter function of the supraspinatus allows the deltoid muscle to contract and abduct the humerus at the shoulder joint. 12

13. Lateral rotation: Normal lateral rotation is about 40 to 45°. This is performed by the: infraspinatus teres minor the posterior fibers of the deltoid muscle 13

14. Posteriorly: Infraspinatus Teres minor muscles. 14

15. The long head of the biceps brachii originates from the supraglenoid tubercle of the scapula, It is intracapsular but extrasynovial It's tendon passes through the shoulder joint and emerges beneath the transverse humeral ligament. Inside the joint, the tendon is surrounded by a separate tubular sheath of the synovial capsule . 15

16. MUSCLES IN THE SCAPULAR-HUMERAL MECHANISM 16

17. Abduction involves rotation of the scapula as well as movement at the shoulder joint. For every 3° of abduction of the arm, a 2° abduction occurs in the shoulder joint and a 1° abduction occurs by rotation of the scapula. At about 120° of abduction of the arm, the greater tuberosity of the humerus impinges on lateral border of coraco -acromial arch. Further elevation of the arm above the head accomplished by rotating the scapula. 17

18. STABILITY OF THE SHOULDER JOINT 18

19. ANASTOMOSES AROUND THE SCAPULAR REGIONS

20. BRANCHES FROM THE SUBCLAVIAN ARTERY 20 The suprascapular artery, ( branch from 1 st part of subclavian artery) distributed to the supraspinous and infraspinous fossae of the scapula. The superficial cervical artery, which gives off a deep branch that runs down the medial border of the scapula.

21. BRANCHES FROM THE AXILLARY ARTERY 21 The subscapular artery and its circumflex scapular branch supply the subscapular and infraspinous fossae of the scapula. The anterior & posterior circumflex humeral artery. Both the circumflex arteries form an anastomosing circle around the surgical neck of the humerus.

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23. Capsular pattern of shoulder The capsular pattern described by Cyriax: where external rotation motion loss is proportionally greater than loss of abduction, which is more limited than internal rotation Rundquist et al found varying patterns of restriction in patients with adhesive capsulitis, but the most common pattern was: a. loss of external rotation with the arm at the side followed by a loss of abduction and internal rotation. b. greater loss of internal rotation versus external rotation when the arm was positioned as close as possible to 90° of frontal plane abduction

24. Evaluation/Intervention Component I (Safety and exclude other reasons not MSK)

25. Evaluation/Intervention Component II Complaint Structure I. Differential evaluation of clinical findings suggestive of musculoskeletal impairments of body functioning (ICF) and the associated tissue pathology/disease (ICD) II. Cyriax Concept (Capsular or non-capsular)

26. Evaluation/Intervention Component III I. Diagnosis of Tissue Irritability Level II. Maitland Concept

27. Pain Dominant Pain Physiological Barrier Anatomical Barrier Active ROM Passive ROM P1 P2 Pathological Barrier

28. Pain Dominant (High Irritability) Pain Physiological Barrier Anatomical Barrier Active ROM Passive ROM P2 P1 Pathological Barrier

29. Pain Dominant Pain Physiological Barrier Anatomical Barrier Active ROM Passive ROM P1 P2 Pathological Barrier

30. Resistance Dominant Resistance Physiological Barrier Anatomical Barrier Active ROM Passive ROM P1 R1 R2 Pathological Barrier

31. Resistance Dominant Resistance Physiological Barrier Anatomical Barrier Active ROM Passive ROM R1 P1 R2 Pathological Barrier

32. Resistant Dominant Resistance Physiological Barrier Anatomical Barrier Active ROM Passive ROM R1 R2 P1 Pathological Barrier

33. Evaluation/Intervention Component IV Intervention strategies for shoulder pain and mobility deficits

34. Examination of Outcome Measures Clinicians should use validated functional outcome measures, such as: I. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire II. American Shoulder and Elbow Surgeons (ASES) Score III. SPADI These should be utilized before and after interventions (Strong Evidence)

35. Activity Limitations Measures • Pain during sleep • Pain and difficulty with grooming and dressing activities • Pain and difficulty with reaching activities: to the shoulder level, behind the back, and overhead (Expert Opinion)

36. Physical Impairment Measures Clinicians should measure: I. pain II. AROM III. PROM IV. Glenohumeral joint accessory motion (Theoretical/Foundational Evidence)

37. Differential Diagnosis

38. Adhesive Capsulitis The common shoulder condition characterized by painful and limited active and passive range of motion in a capsular pattern without any radiological insults at the initial stage

39. DISLOCATIONS OF THE SHOULDER JOINT Anterior-Inferior Dislocation Sudden violence applied to the humerus with the joint fully abducted pushes the humeral head downward onto the inferior weak part of the capsule, which tears, and the humeral head comes to lie inferior to the glenoid fossa. 43 The shoulder joint is the most commonly dislocated large joint.

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42. Lesions that are commonly seen with an anterior dislocation include the Hill-Sachs fracture and the Bankart fracture . A Hill-Sachs fracture is a fracture of the humeral head. It occurs along the posterior and superior aspect and is caused by the impaction of the humeral head on the inferior aspect of the glenoid process. A Bankart fracture is caused by the same mechanism, but it is a fracture of the inferior aspect of the glenoid process.

43. ROTATOR CUFF TENDINITIS Lesions of the rotator cuff are a common cause of pain in the shoulder region. Excessive overhead activity of the upper limb may be the cause of tendinitis, although many cases appear spontaneously. During abduction of the shoulder joint, the supraspinatus tendon is exposed to friction against the acromion. Under normal conditions the amount of friction is reduced to a minimum by the large subacromial bursa, which extends laterally beneath the deltoid. 52

44. 53 Scientific Evidence

45. Intervention – Corticosteroid Injections: Intra-articular corticosteroid injections combined with shoulder mobility and stretching exercises are more effective in providing short-term (4-6 weeks) pain relief and improved function compared to shoulder mobility and stretching exercises alone. (Strong evidence)

46. Patient Education: Clinicians should utilize patient education that: (1) describes the natural course of the disease. (2) promotes activity modification to encourage functional, pain-free ROM. (3) matches the intensity of stretching to the patient’s current level of irritability. (Moderate Evidence)

47. Stretching Exercises: Clinicians should instruct patients with adhesive capsulitis in stretching exercises. II. The intensity of the exercises should be determined by the patient’s tissue irritability level. (Moderate Evidence)

48. MODALITIES Clinicians may utilize short-wave diathermy, ultrasound, or electrical stimulation Combined with mobility and stretching exercises to reduce pain and improve shoulder ROM in patients with adhesive capsulitis. (Weak evidence )

49. Joint Mobilization Clinicians may utilize joint mobilization procedures primarily directed to the glenohumeral joint to reduce pain and increase motion and function in patients with adhesive capsulitis. (Weak Evidence )

50. Translational Manipulation Clinicians may utilize translational manipulation under anesthesia directed to the glenohumeral joint in patients with adhesive capsulitis who are not responding to conservative interventions . (Weak Evidence)

51. A reverse total shoulder arthroplasty, or rTSA , refers to a similar procedure in which the prosthetic ball and socket that make up the joint are reversed to treat certain complex shoulder problems. rTSA involves a stemmed-humeral component containing a polyethylene humero -socket replacing the humeral head, and a highly polished metal ball known as a glenosphere replacing the socket, or glenoid. One can think of this as the “ball and socket” components being switched. This allows for better fixation of the prosthetic parts and increased stability of the joint. An rTSA currently is indicated for patients suffering from osteoarthritis or compound fractures of the humerus, in conjunction with a deficiency of the rotator cuff complex.

52. Upper Extremity Trauma

53. Topics Clavicle Shoulder Dislocation Humerus Elbow Forearm Distal Radius

54. Clavicle Fractures

55. Clavicle Fractures Allman Classification of Clavicle Fractures Type I Middle Third (80%) Type II Distal Third (15%) Differentiate whether ligaments attached to lateral or medial fragment Type III Medial Third (5%)

56. Clavicle Fracture Closed Treatment Sling immobilization for usually 3-4 weeks with early ROM encouraged Operative intervention Fractures with neurovascular injury Fractures with severe associated chest injuries Open fractures Group II, type II fractures Cosmetic reasons, uncontrolled deformity Nonunion

57. Associated Injuries Brachial Plexus Injuries Contusions most common, penetrating (rare) Vascular Injury Rib Fractures Scapula Fractures Pneumothorax Clavicle Fractures

58. Shoulder Dislocations

59. Shoulder Dislocations Epidemiology Anterior: Most common Posterior: Uncommon, 10%, Think Electrocutions & Seizures Inferior (Luxatio Erecta): Rare, hyperabduction injury

60. Shoulder Dislocations Clinical Evaluation Examine axillary nerve (deltoid function, not sensation over lateral shoulder) Examine M/C nerve (biceps function and anterolateral forearm sensation) Radiographic Evaluation True AP shoulder Axillary Lateral Scapular Y Stryker Notch View (Bony Bankart)

61. Shoulder Dislocations Anterior Dislocation Recurrence Rate Age 20: 80-92% Age 30: 60% > Age 40: 10-15% Look for Concomitant Injuries Bony: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater Tuberosity Fracture Soft Tissue: Subscapularis Tear, RCT (older pts with dislocation) Vascular: Axillary artery injury (older pts with atherosclerosis) Nerve: Axillary nerve neuropraxia

62. Anterior Dislocation Traumatic Atraumatic (Congenital Laxity) Acquired (Repeated Microtrauma) Shoulder Dislocations

63. Posterior Dislocation Adduction/Flexion/IR at time of injury Electrocution and Seizures cause overpull of subscapularis and latissimus dorsi Look for “lightbulb sign” and “vacant glenoid” sign Reduce with traction and gentle anterior translation (Avoid ER arm  Fx) Shoulder Dislocations

64. Inferior Dislocations Luxatio Erecta Hyperabduction injury Arm presents in a flexed “asking a question” posture High rate of nerve and vascular injury Reduce with in-line traction and gentle adduction Shoulder Dislocations

65. Shoulder Dislocation Treatment Nonoperative treatment Closed reduction should be performed after adequate clinical evaluation and appropriate sedation Reduction Techniques: Traction/countertraction- Generally used with a sheet wrapped around the patient and one wrapped around the reducer. Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial traction Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be used Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral head Scapular manipulation

66. Shoulder Dislocations Postreduction Post reduction films are a must to confirm the position of the humeral head Pain control Immobilization for 7-10 days then begin progressive ROM Operative Indications Irreducible shoulder (soft tissue interposition) Displaced greater tuberosity fractures Glenoid rim fractures bigger than 5 mm Elective repair for younger patients

67. Proximal Humerus Fractures

68. Proximal Humerus Fractures Epidemiology Most common fracture of the humerus Higher incidence in the elderly, thought to be related to osteoporosis Females 2:1 greater incidence than males Mechanism of Injury Most commonly a fall onto an outstretched arm from standing height Younger patient typically present after high energy trauma such as MVA

69. Proximal Humerus Fractures Clinical Evaluation Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

70. Proximal Humerus Fractures Neer Classification Four parts Greater and lesser tuberosities, Humeral shaft Humeral head A part is displaced if >1 cm displacement or >45 degrees of angulation is seen

71. Proximal Humerus Fractures Treatment Minimally displaced fractures- Sling immobilization, early motion Two-part fractures- Anatomic neck fractures likely require ORIF. High incidence of osteonecrosis Surgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF Three-part fractures Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement requires ORIF. Four-part fractures In general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)

72. Humeral Shaft Fractures

73. Humeral Shaft Fractures Mechanism of Injury Direct trauma is the most common especially MVA Indirect trauma such as fall on an outstretched hand Fracture pattern depends on stress applied Compressive- proximal or distal humerus Bending- transverse fracture of the shaft Torsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually associated with a butterfly fragment

74. Humeral Shaft Fractures Clinical evaluation Thorough history and physical Patients typically present with pain, swelling, and deformity of the upper arm Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

75. Humeral Shaft Fractures Radiographic evaluation AP and lateral views of the humerus Traction radiographs may be indicated for hard to classify secondary to severe displacement or a lot of comminution

76. Humeral Shaft Fractures Conservative Treatment Goal of treatment is to establish union with acceptable alignment >90% of humeral shaft fractures heal with nonsurgical management 20 degrees of anterior angulation, 30 degrees of varus angulation and up to 3 cm of shortening are acceptable Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace

77. Humeral Shaft Fractures Treatment Operative Treatment Indications for operative treatment include inadequate reduction, nonunion, associated injuries, open fractures, segmental fractures, associated vascular or nerve injuries Most commonly treated with plates and screws but also IM nails

78. Humeral Shaft Fractures Holstein-Lewis Fractures Distal 1/3 fractures May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

79. Elbow Fracture/Dislocations

80. Elbow Dislocations Epidemiology Accounts for 11-28% of injuries to the elbow Posterior dislocations most common Highest incidence in the young 10-20 years and usually sports injuries Mechanism of injury Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the olecranon from the trochlea Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm supination Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexed

81. Elbow Dislocations Clinical Evaluation Patients typically present guarding the injured extremity Usually has gross deformity and swelling Careful NV exam in important and should be done prior to radiographs or manipulation Repeat after reduction Radiographic Evaluation AP and lateral elbow films should be obtained both pre and post reduction Careful examination for associated fractures

82. Elbow Fracture/Dislocations Treatment Posterior Dislocation Closed reduction under sedation Reduction should be performed with the elbow flexed while providing distal traction Post reduction management includes a posterior splint with the elbow at 90 degrees Open reduciton for severe soft tissue injuries or bony entrapment Anterior Dislocation Closed reduction under sedation Distal traction to the flexed forearm followed by dorsally direct pressure on the volar forearm with anterior pressure on the humerus

83. Elbow Dislocations Associated injuries Radial head fx (5-11%) Treatment Type I- Conservative Type II/III- Attempt ORIF vs. radial head replacement No role for solely excision of radial head in 2006.

84. Elbow Dislocations Associated injuries Coronoid process fractures (5-10%)

85. Elbow Dislocations Associated injuries Medial or lateral epicondylar fx (12-34%)

86. Elbow Dislocations Instability Scale Type I Posterolateral rotary instability, lateral ulnar collateral ligament disrupted Type II Perched condyles, varus instability, ant and post capsule disrupted Type III A: posterior dislocation with valgus instability, medial collateral ligament disruption B: posterior dislocation, grossly unstable, lateral, medial, anterior, and posterior disruption

87. Forearm Fractures

88. Forearm Fractures Epidemiology Highest ratio of open to closed than any other fracture except the tibia More common in males than females, most likely secondary mva, contact sports, altercations, and falls Mechanism of Injury Commonly associated with mva, direct trauma missile projectiles, and falls

89. Forearm Fractures Clinical Evaluation Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome Radiographic Evaluation AP and lateral radiographs of the forearm Don’t forget to examine and x-ray the elbow and wrist

90. Forearm Fractures Ulna Fractures These include nightstick and Monteggia fractures Monteggia denotes a fracture of the proximal ulna with an associated radial head dislocation Monteggia fractures classification- Bado Type I- Anterior Dislocation of the radial head with fracture of ulna at any level- produced by forced pronation Type II- Posterior/posterolateral dislocation of the radial head- produced by axial loading with the forearm flexed Type III- Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced abduction of the elbow Type IV- anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced pronation with radial shaft failure

91. Forearm Fractures Radial Diaphysis Fractures Fractures of the proximal two-thirds can be considered truly isolated Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial ulnar joint A reverse Galeazzi denotes a fracture of the distal ulna with disruption of radioulnar joint Mechanism Usually caused by direct or indirect trauma, such as fall onto outstretched hand Galeazzi fractures may result from direct trauma to the wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronation Reverse Galeazzi results from fall with hand in supination

92. Distal Radius Fractures

93. Distal Radius Fractures Epidemiology Most common fractures of the upper extremity Common in younger and older patients. Usually a result of direct trauma such as fall on out stretched hand Increasing incidence due to aging population Mechanism of Injury Most commonly a fall on an outstretched extremity with the wrist in dorsiflexion High energy injuries may result in significantly displaced, highly unstable fractures

94. Distal Radius Fractures Clinical Evaluation Patients typically present with gross deformity of the wrist with variable displacement of the hand in relation to the wrist. Typically swollen with painful ROM Ipsilateral shoulder and elbow must be examined NV exam including specifically median nerve for acute carpal tunnel compression syndrome

95. Radiographic Evaluation 3 view of the wrist including AP, Lat, and Oblique Normal Relationships 23 Deg 11 mm 11 Deg

96. Distal Radius Fractures Eponyms Colles Fracture Combination of intra and extra articular fractures of the distal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting Most common distal radius fracture caused by fall on outstretched hand Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a flexed wrist Barton Fracture Fracture with dorsal or volar rim displaced with the hand and carpus Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the fragment Mechanism of injury is compression of the scaphoid against the styloid

97. Distal Radius Fractures Treatment Displaced fractures require and attempt at reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine and marcaine in the fracture site Hang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the fracture Place in sugar tong splint Operative Management For the treatment of intraarticular, unstable, malreduced fractures. As always, open fractures must go to the OR.

98. Lateral and Medial Epicondylitis

99. Outline Epidemiology Anatomy Biomechanics Pathophysiology Diagnosis Treatment Research

100. Lateral Epicondylitis Tennis Elbow

101. Anatomy Common Extensors: Extensor Carpi Radialis Brevis* Extensor Carpi Radialis Longus Extensor Digitorum Extensor Carpi Ulnaris Radial  superficial sensory + deep  PIN Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64 Van Hofwegen , C., et al. (2010) Clin Sports Med 29: 577-97

102. Anatomy Radial Collateral Ligament Lateral Ulnar Collateral Ligament Annular Ligament

103. Biomechanics: Extensor Group Eccentric contraction of ECRB Excessive/repetitive use extensors or supinator Tennis, typing, piano, manual work Risk factors in racquet sports: Incorrect technique Extended duration of play Frequency of play Size of handle Racquet weight Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

104. Pathophysiology Paucity of inflammatory cells Gross: Grayish, homogenous, edematous and friable tissue Tendinosis  degenerative process Rate of stretching exceeds tolerance  microtears  tendinosis Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64 Van Hofwegen , C., et al. (2010) Clin Sports Med 29: 577-97

105. Histologic Stages of Microtrauma 1: Acute inflammatory response Sometimes resolves 2: Angiofibroblastic hyperplasia (increased concentration of fibroblasts, vascular hyperplasia, disorganized collagen) Hypercellularity in both organized and unorganized fasion Most common stage of presentation for treatment 3: Structural failure of tendon with partial of complete rupture 4: Features of stage 2 or 3 plus fibrosis, soft calcification within collagen and hard osseous calcification Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

106. Pathophysiology: Microscopy Normal Tendon Kraushaar , BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

107. Pathophysiology: Microscopy Tendinosis of ECRB with some normal tendon and some disorganized tendon Kraushaar , BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

108. Pathophysiology: Microscopy Angiofibroblastic hyperplasia meets normal tendon Kraushaar , BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

109. Pathophysiology: Other Theories Stress shielding certain sections of tendon leading to structural weakening Shear forces leading to fibrocartilaginous composition of ECRB attachment  weak attachment  tendinosis Long muscle contraction rendering tendon avascular  free radicals Hyperthermic injury Protein kinase  apoptosis Altered gene expression and imbalance of matrix metalloproteinases and growth factors Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

110. Pathophysiology: Neurologic Changes High variability of patient’s symptoms Increased concentration neurotransmitters (glutamate), which sensitize pain response and direct irritation by lactate Cascade of changes in PNS neurons, which leads to sensitization of CNS May explain associated neck pain in 56% of patients Could be other overuse or altered biomechanics Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

111. Diagnosis: History Pain at lateral epicondyle Radiates down extensor mass, occasionally proximally Exacerbated by contraction of extensor mass Insidious onset History of repetitive activity or overuse Inability to hold items Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

112. Diagnosis: Physical Examination Tenderness ECRB origin or more diffuse centered about lateral epicondyle Resisted extension Full elbow/wrist ROM Sensation normal Wrist Extensor weakness 2 º pain Decreased grip strength Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

113. Differential Diagnosis Cervical radiculopathy Elbow overuse compensating for frozen shoulder PIN entrapment Radiocapitellar degenerative changes or OCD Inflammation of anconeus Infection Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

114. Diagnosis: Imaging Plain film: 22%-25% calcification within soft tissue Otherwise normal Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

115. Diagnosis: Imaging MRI: Presence of degenerative tissue, tears in tendon More reproducible than US Intra-articular pathology Poor correlation with symptoms Generally not necessary Clinical diagnosis Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

116. Treatment: Nonsurgical 80% + Improve within 1 year Relative rest Ice NSAIDs Steroid Injection: Short-term relief Counterforce Bracing (decrease tension on extensors) and wrist splint PT/Rehab: range of motion, eccentric strengthening Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

117. Treatment: Alternative Ultrasound/Extracorporeal shock waves (ECSW’s) Acupuncture/dry needling Platelet-rich plasma: growth factors Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

118. Treatment: Surgical 4%-11% require surgery Extra-articular extensor tendon debridement Intra-articular: excise synovial fringe and portion of orbicular ligament Tendon excision with origin reattachment

119. Surgical: Open Debridement 8-10 cm incision over lateral epicondyle Subperiosteal detachment of common tendon Tendon debridement Decortication of epicondyle with rongeur Drill 2 v-shaped tunnels with horizontal mattress reattachment Splint 7-10 days with progressive mobilization

120. Surgical: Open Limited Incision Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64 Van Hofwegen , C., et al. (2010) Clin Sports Med 29: 577-97

121. 60 patients Randomized to injection with PRP, steroid or saline Neither PRP no steroid superior to saline Pain at 3 months Steroid decreased pain at 1 month, hypervascularity, and tendon thickness

122. 165 patients Randomized to 1. steroid injection, 2. placebo injection, 3. steroid plus therapy, 4. placebo plus therapy Steroid injection worse than placebo Therapy did no change outcome JAMA 2013

123. PRP vers Placebo PRP versus placebo (AJSM 2013) No change 12 weeks PRP improved 24 weeks Pain

124. Medial Epicondylitis Golfer’s Elbow

125. Epidemiology Prevalence <1% 3.8 – 8.2% occupational settings 10-20% of epicondylitis patients Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

126. Anatomy Pronator Teres* Flexor Carpi Radialis Palmaris Longus Flexor Digitorum Superficialis Flexor Carpi Ulnaris Medial Collateral Ligament Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

127. Anatomy Common flexor tendon attaches to medial humeral epicondyle anteriolrly and attaches proximally to anterior bundle of ulnar collateral ligament, becomes confluent with hyperplastic section of anteromedial joint capsule Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

128. Biomechanics Repetitive eccentric loading Wrist flexion, forearm pronation Valgus stress at elbow Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

129. Pathophysiology Peritendinous inflammation Angiofibroblastic hyperplasia Irreparable fibrosis or calcification Ulnar collateral ligament Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

130. History Sports: overhead throwing, golf, tennis, football, weightlifting, bowling Occupational Forceful grip Loads >44lbs Constant vibratory force at elbow 84% have concomitant work-related disorder Carpal tunnel, lateral epicondylitis, rotator cuff tendinitis Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

131. Diagnosis Pain along medial elbow Radiation to proximal forearm Increased pain with resisted pronation and wrist flexion Tenderness 5-10mm distal and anterior to epicondyle Normal ROM Normal Sensation Resisted wrist flexion, forearm pronation, grip may be weak Valgus Stress  Ligamentous pain X-rays usually normal Concomitant ulnar neuritis Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

132. Imaging MRI is standard of care when imaging needed Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

133. Treatment: Non-surgical Similar to Lateral Epicondylitis Rest 6-12 weeks off throwing NSAIDs Wrist flexor and forearm pronator stretching Night splinting Therapy: ROM, eccentric strengthening Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

134. Treatment: Surgical Nirav , HA, et al. (2015) JAAOS. 23.6: 348-55

135. Research No RCT in last 3 years

136. References Cyriax J. Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions . Baltimore, MD: Williams & Wilkins; 1970. Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petrova DR, Finestone A. Risk factors for idiopathic frozen shoulder. Isr Rundquist PJ, Anderson DD, Guanche CA, Ludewig PM. Shoulder kinematics in subjects with frozen shoulder. Arch Phys Med Rehabil . 2003;84:1473-1479. Med Assoc J . 2008;10:361-364. Zuckerman JD. Definition and classification of frozen shoulder [abstract]. J Shoulder Elbow Surg . 1994;3:S72.

137. QUESTIONS?