- Posterior elbow associated abnormalities may include
extra-articular olecrenon bursitis and intra-articular
olecrenon fossa issues (synovitis, chondromalacia,
and loose fragments). - The mesenchymal syndrome, coined by Nirschl, has
been used to describe a subset of patients with appar-
ent decreased tissue durability who present with mul-
tiple affected areas that are often bilateral, including
rotator cuffs, medial and lateral elbow tendinosis,
carpal tunnel syndrome, trigger finger, deQuervain’s
disease, plantar neuromaplantar fasciosis, Achilles’
insertional tendinosis, and hip trochanteric bursitis
(Nirschl, 1992).
TREATMENT CONCEPTS
- Anti-inflammatory medications can be helpful in con-
trolling pain and can be first line therapy allowing
patients to comfortably proceed with curative rehabil-
itative exercises. - Cortisone injections, when done correctly under the
origin of the extensor carpi radialis brevis(ECRB) or
flexor pronator mass can also be effective in relieving
pain; however, cortisone injections are not without
risks including fat atrophy, skin pigmentation
changes, and infection, especially if injected superfi-
cially. Recently, injection of autologous blood has
shown promising results (Edwards and Calandruccio,
2003).
•Physical modalities such as high voltage electrical
stimulation, ultrasound, heat/cold, and dexametha-
sone iontophoresis (Nirschl et al, 2003) also are useful
in relieving pain. - Promotion of a tendon healing response (neovascu-
larization, fibroblastic infiltration with collagen depo-
sition and maturation) can be accomplished by the
following:- Rehabilitative exercise
- High-voltage electrical stimulation
3.General/aerobic conditioning that provides
increased regional blood perfusion and minimiza-
tion of loss of strength of adjacent tissue - Rest from inciting trauma
- Control of force loads
1.Counter-force strap bracing to constrain key
muscle groups while maintaining muscle balance
2.Improved sports technique, such as improved
backhand stroke in tennis (lateral tendinosis) and
less trailing arm activity in the golf swing (medial
tendinosis)
3. Equipment changes in sports, such as low string
tension on tennis racquets and perimeter weighting
in golf clubs
INDICATIONS FOR SURGERY- Chronic symptoms usually exceeding one year dura-
tion
•Failure of response to a good quality rehabilitation
program
•Failed permanent response to cortisone injections (up
to three) - Unacceptable quality of life as determined by the
patient
SURGICAL PRINCIPLES•Historically, elbow tendinosis was treated by the total
release of the origin of the combined tendon groups
from the epicondyle.- Currently, surgical treatment is directed at resecting
only the pathologic tissue, protecting all normal tis-
sues and attachments, followed by quality postopera-
tive rehabilitation.
•Surgical goals can be accomplished through a small
incision (3 cm or less). - Associated lesions, when present, such as OCD, loose
bodies, and synovitis can be addressed with a
miniarthrotomy at the time of the tendinosis resection
(Kraushaar, Nirschl, and Cox, 1999). - Recently, interest has risen in arthroscopic treatment
of lateral elbow tendinosis with encouraging early
results (Owens, Murphy, and Kuklo, 2001); however,
at this time we feel the arthroscopic approach does not
afford the visualization necessary to resect all the
pathologic tissue. - Ulnar nerve entrapment can be addressed along with
medial tendinosis resection through the same inci-
sion.
TREATMENT RESULTS- The vast majority of patients with elbow tendinosis
respond to nonoperative intervention. - Of those that do require surgery, 97% will experience
significant or total pain relief and return of strength
with minimal complications (Nirschl and Ashman).
REFERENCES
Edwards SG, Calandruccio JH: Autologous blood injections for
refractory lateral epicondylitis. J Hand Surg Am28:272–278,
2003.298 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE