Medical

The elbow is prone to painful maladaptive degeneration of the tendon attachments. These are typically of insidious onset but precipitating factors may be identified from a careful history. Lateral epicondylitis Medial epicondylitis Distal biceps tendinopathy Baseball pitcher’s elbow Lateral Epicondylitis Also known as tennis elbow This is the most common tendinopathy Pain originates from the origin of ECRB (extensor carpi radialis brevis) at the lateral epicondyle Most cases occur in those with a history of racquet use Sudden traumatic onset of pain -> tendon rupture -> often requires repair Usually occurs in active person aged 40-55 years Clinical features Lateral elbow pain Often after a period of unaccustomed activity Radiation down the forearm Elbow stiffness in the morning Pain is aggravated by lifting objects ROM - full Tenderness Palpation over the front of the lateral epicondyle Maudsley’s test -> resisted middle finger extension Mill’s sign -> elbow extension in pronation with a flexed wrist Diagnosis Imaging is not required except At the extremes of age History of trauma History of mechanical symptoms e.g. locking USG / MRI In patients with long-standing symptoms, not responding to treatment To exclude radial tunnel syndrome, radiocapitellar plica or PLRI (postero-lateral rotator instability) Treatment It spontaneously resolves within 12 months in 90% cases. ...

Also known as Stenosing tenosynovitis A flexor tendon becomes trapped by thickening at the entrance to its sheath Forced extension -> tendon passes the constriction by snapping/triggering Secondary nodule can develop on the tendon Unknown etiology, more common in diabetic patients Rheumatoid arthritis -> synovial thickening, intra-tendinous nodules -> triggering Thumb, ring and middle fingers are most commonly affected Anatomy Flexor pulley system (fingers except thumb) Annular pulleys (A1 - A5) -> prevent bowstringing Cruciate pulleys (C1 - C3) -> prevent sheath collapse and expansion Palmar aponeurosis pulley (PA) Flexor pulley system (thumb) Annular pulleys (A1, Av, A2) -> prevent bowstringing Oblique pulley -> same as cruciate pulleys in other fingers Clinical features Inability to extend the flexed digit and/or flex the extended digit Patient notices click during flexion. While extending, the finger remains bent at the PIP joint -> with further effort it suddenly extends with a snap Patient may notice a tender lump/knot/nodule in the palm in front of the MCP joint. It may be Thickened area in the pulley Nodular/fusiform swelling of the flexor tendon e.g. by healing of a partially lacerated tendon. The tendon nodule is usually proximal to the pulley, it may be distal in patients with rheumatoid arthritis Triggering after surgical release may occur due to catching of the tendon in the palmar aponeurosis. This resolves over time. Treatment Stretching, night splinting, combination of heat and ice Corticosteroid injection at the mouth of the sheath Recurrence within 6 months occurs in 30% cases, especially younger and diabetic ones. A second injection may be given. Refractory cases need surgery Release of the pulley Thumb -> only A1, other fingers -> A1 + A0 (PA) Care should be taken to avoid injury to the digital neurovascular bundles, risk is greatest in the thumb (nerves are close to midline) and the index (radial digital nerve crosses the tendon) Flexor synovectomy with excision of one slip of flexor digitorum superficialis (in rheumatoid arthritis patient) In babies, wait until 3 years of age. If no spontaneous recovery -> A1 pulley release

repetitive compression or rubbing of the tendons (mainly supraspinatus) under coraco-acromial arch i.e. subacromial space during abduction -> conjoint tendon slides under coraco-acromial arch abduction approaches 90 deg -> subacromial space narrows internal rotation -> narrower, external rotation -> wider naturally, at 90 deg abduction -> arm externally rotates to increase the space activities with repeated int. and ext. rotation (window cleaning, wall painting) -> compression, rubbing, friction of the tendon -> impingement syndrome Impingement Position -> abduction, slight flexion, internal rotation Site of impingment -> critical area of diminished vascularity in the supraspinatus tendon about 1 cm proximal to its insertion into the greater tuberosity Intrinsic factors degeneration of the tendon (age-related, cell-mediated) changes in the presence of highly sulphated glycosaminoglycans changes in the collagen composition with loading. Changes in vascularity All these changes -> rotator cuff dysfunction -> upward displacement of the humeral head -> subsequent extrinsic compression. Extrinsic factors spurs growing down the coracoacromial ligament a laterally sloping acromion osteoarthritic thickening of the acromioclavicular joint Effects friction -> tendinitis (edema, swelling) -> usually self-limiting prolonged / repetitive -> minute tears -> scarring, fibrocartilaginous metaplasia, calcification in the tendon healing -> vascular reaction -> local congestion -> narrowing of the space -> further impingement slow healing / sudden strain -> microscopic tear extends -> partial / full thickness tear -> loss of abduction large tears -> disturbed shoulder mechanics -> osteoarthritis of the glenohumeral joint Clinical features typically those of a Rotator Cuff Syndrome Subsequent progress depends on the stage of the disorder, the age of the patient and the vigour of the healing response 3 patterns subacute tendinitis chronic tendinitis cuff disruption Subacute tendinitis (painful arc syndrome) anterior shoulder pain after vigorous/unaccustomed activity tenderness along the anterior edge of acromion (easily elicited on extension) often reversible, relieves spontaneously by activity modification Chronic tendinitis recurrent attacks of subacute tendinitis pain relieves with rest, anti-inflammatory treatment recurs with more demanding activity pain is worse at night, patient cannot lie on the affected side pain restricts even simple activities like hair grooming, dressing signs of bicipital tendinitis (tenderness in the bicipital groove, crepitus on moving tendon) Most advanced stage is progressive fibrosis and cuff disruption. Patient gives history of refractory shoulder pain, increasing stiffness and weakness. ...

Phase I (1-2 weeks) passive of active-assisted ROM exercises in pain-free ranges improve or maintain motion provide gentle stress for healing collagen tissue optimize subacromial gliding mechanism phase I ROM -> forward elevation and external rotation, hold for 10 seconds, 10 times each, 2 times daily. both exercises should be pain free phase II ROM -> extension, internal rotation, cross-body adduction, hold for 10 seconds, 10 times each, 2-4 times daily phase I strengthening exercises (using elastic bands / free weights) -> external rotation, internal rotation, flexion, extension Phase II (2-4 weeks) pain and inflammation has resolved, ROM & strength improved sleeper stretch -> hold for 10 seconds, 5 times wall stretch & stretch behind the head phase II strengthening (after reaching level 3 resistance in all phase I strengthening exercises) -> abduction and forward elevation to 45 degrees & external rotation at 45 degrees total arm strengthening with biceps and triceps exercises scapular strengthening exercises -> horizontal abduction with scapular retraction, external rotation with elastic resistance Phase III ROM should be full and pain-free athletes will progress to higher-level exercises involving functional combination movements in more provocative positions Phase IV Athletes should continue with the rotator cuff, deltoid, and scapular exercises with a bias toward sport-specific positions

This comprises of at least four conditions supraspinatus impingement and tendinitis tears of the rotator cuff acute calcific tendinitis biceps tendinitis and/or rupture. Symptoms pain and/or weakness during certain movements of the shoulder. Pain may have started recently, sometimes quite suddenly, after a particular type of exertion; the patient may know precisely which movements now reignite the pain and which to avoid. Rotator cuff pain over the front and lateral aspect of the shoulder during activities with the arm abducted and medially rotated may be present even with the arm at rest tenderness is felt at the anterior edge of the acromion. site association in front along the delto-pectoral boundary biceps tendon over the top of the shoulder acromio-clavicular pathology at the back along the scapular border cervical spine Rotator Cuff Anatomy The rotator cuff comprises the lateral portions of the infraspinatus, teres minor, supraspinatus and subscapularis muscles and their conjoint tendon which is inserted into the greater and lesser tuberosity of the humerus. ...