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Key Clinical Updates in Upper Extremity Musculoskeletal Injuries

Some evidence suggests superior clinical outcomes of percutaneous needle aponeurotomy compared with collagenase Clostridium histolyticum (CCH) injections and a higher minor complication rate with CCH.

Hirase T et al. J Hand Microsurg. [PMID: 34511831]

1. LATERAL & MEDIAL EPICONDYLOSIS (TENDINOPATHY)

ESSENTIALS OF DIAGNOSIS

  • Tenderness over the lateral or medial epicondyle.

  • Diagnosis of tendinopathy is confirmed by pain with resisted strength testing and passive stretching of the affected tendon and muscle unit.

  • Physical therapy and activity modification are more successful than anti-inflammatory treatments.

General Considerations

Tendinopathies involving the wrist extensors, flexors, and pronators are very common concerns. The underlying mechanism is chronic repetitive overuse causing microtrauma at the tendon insertion, although acute injuries can occur as well if the tendon is strained due to excessive loading. The traditional term “epicondylitis” is a misnomer because histologically tendinosis or degeneration in the tendon is seen rather than acute inflammation. Therefore, these entities should be referred to as “tendinopathy” or “tendinosis.” Lateral epicondylosis involves the wrist extensors, especially the extensor carpi radialis brevis. This is usually caused be lifting with the wrist and the elbow extended. Medial epicondylosis involves the wrist flexors and most commonly the pronator teres tendon. Ulnar neuropathy and cervical radiculopathy should be considered in the differential diagnosis.

Clinical Findings

A. Symptoms and Signs

For lateral epicondylosis, the patient describes pain with the arm and wrist extended. For example, common concerns include pain while shaking hands, lifting objects, using a computer mouse, or hitting a backhand in tennis (“tennis elbow”). Medial epicondylosis presents with pain during motions in which the arm is repetitively pronated or the wrist is flexed. This is also known as “golfer’s elbow” due to the motion of turning the hands over during the golf swing. For either, tenderness directly over the epicondyle is present, especially over the posterior aspect where the tendon insertion occurs. The proximal tendon and musculotendinous junction can also be sore. To confirm that the pain is due to tendinopathy, pain can be reproduced over the epicondyle with resisted wrist extension and third digit extension for lateral epicondylosis and resisted wrist pronation and wrist flexion for medial epicondylosis. The pain is also often reproduced with passive stretching of the affected muscle groups, which can be performed with the arm in extension. It is useful to check the ulnar nerve (located in a groove at the posteromedial elbow) for tenderness as well as to perform a Spurling test for cervical radiculopathy (see Neck Pain, above).

B. Imaging

Radiographs are often normal, although a small traction spur may be present in chronic cases (enthesopathy). Diagnostic investigations are usually unnecessary, unless the patient does not improve after up to 3 months of conservative treatment. At that ...

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