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?