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Stressed Out (Elbow and Wrist Syndromes)

Timothy F. Tyler, MS, PT, ATC, Christopher Johnson, DPT,
Steven J. Lee, MD, and Stephen J. Nicholas, MD

Elbows and wrists are the joints of finesse, not force. Their elaborate matrix of muscles, tendons bones facilitate fluid movements and fine motor tasks. But they're poorly suited for feats of brute strength and repetitive loading.
So athletic activities that demand high repetitions and force -- such as golf and racquet sports -- can stress these delicate structures and lead to overuse syndromes. Any sport that requires repetitive elbow or wrist motion can cause microtrauma to tendons, bones and joints. Continuing to stress the area hinders the body's ability to repair the trauma, and an overuse condition is usually the result.
Overuse injuries are subtle and unfold overtime, and they can become chronic. An accurate history and physical exam are important components of diagnosing an overuse syndrome of the elbow or wrist. In some cases, X-rays bone scans and magnetic resonance imaging are necessary to confirm a diagnosis.
Treating overuse disorders of the elbows and wrists is diagnosis-specific. However, several general concepts apply to relieve minor symptoms, such as cutting back the intensity, duration and frequency of activity. Encourage injured athletes to cross train with other activities, which allow them to maintain overall fitness levels during recovery. Many clinicians believe that the earlier you address the symptoms of overuse injuries, the higher the success rates and the sooner patients can get back to pain-free activity.
In addition, athletes should work with a coach or teacher to improve biomechanics and techniques, which lessens strain and reduces damaging forces. Instruct athletes to warm up before an activity, stretch and apply ice afterwards. Over-the-counter nonsteroidal anti-inflammatory medications (NSAIDs) can provider further relief.

Here's a detailed look at four common elbow and wrist overuse syndromes.

Lateral Epicondylitis
Tennis elbow leads the field of elbow diagnoses and sets in when the muscles or tendons surrounding the elbow joint and forearm are damaged. Microtears form in the tendons and muscles that extend the wrist, causing restricted movement, inflammation and pain. These microtears eventually form scar tissue, and can result in calcium deposits. This scar tissue can form within the tendon and lead to chronic tendinosis of the wrist extensors.
The most common cause of tennis elbow is overuse of the muscle groups involved in wrist extension, finger flexion and extension. Actions that place repetitive, prolonged strain on the forearm muscles, coupled with inadequate rest, tend to strain and overwork this muscle group.

Diagnosis. The most common and obvious symptom associated with tennis elbow is pain centered on the outside of the elbow, which may also radiate down toward the wrist. Weakness and stiffness are also common. Tenderness at or just distal to the lateral epicondyle, along with pain with resisted extension of the middle finger, cinch the diagnosis.

Treatment. Tennis elbow is a soft tissue injury of the muscles and tendons around the elbow joint, and should be treated like other soft tissue injuries. After an injury or at the onset of pain, administer the RICE regime -- rest, ice, compression and elevation -- for the first 48 to 72 hours to alleviate an acute bout of tendonitis. Facilitate rest by administrating a wrist splint as well as a tennis elbow brace. This gives the patient the best chance for a complete recovery.
Once the majority of pain and inflammation is reduced, you can move to the next phase of rehab to recapture the strength, power, endurance and flexibility of the injured muscle and tendons.
However, outcomes for chronic tennis elbow and tendinosis are mixed. Because isolated eccentric contractions (the "negative" phase of the strengthening movement) have been shown to be the most effective treatment for Achilles and patellar tendinosis, our clinic has adopted the same approach to treating chronic tennis elbow.
Isolating the wrist extensors for eccentric training can be difficult. We've had success using a flexible rubber exercise bar to isolate these muscles. Patients hold the end of the bar in the involved hand with wrist fully extended (palm facing forward), and the bar in a vertical orientation. Patients maintain wrist extension and move the uninvolved arm across the front of their body and grasp the opposite end of the bar with palm facing away.
While fully flexing the uninvolved wrist, the patient extends both arms forward while maintaining wrist positions. The final step is to slowly release the involved wrist without moving the opposite wrist. At the finish, the bar should be horizontal with the arms straight out in front and palms facing down.
Based on our experience, performing three sets of 15 repetitions per day for 6 weeks can help patients return to their sport. Studies have demonstrated that the ideal intensity level for this form of eccentric training is the threshold that causes discomfort, and that you should increase intensity incrementally to account for rising comfort thresholds as patients improve. The level of discomfort we witness with this program indicates that the contraction intensity is sufficient to induce tendon remodeling.

Medial Epicondylitis
"Golfer's elbow" is an overuse syndrome of the flexor pronator muscles. Inflammation in the early stages can lead to degenerative changes of the proximal origin. However, this disorder can afflict participants of any sport that requires excessive gripping, wrist flexion of forearm pronation.

Diagnosis. Patients report tenderness on the medial epicondyle or just distal to the medial epicondyle at the proximal origin of the flexor pronator mass.
Reproduction of pain occurs with resisted flexion of the wrist and fingers, or with resisted pronation of the extended elbow. Patients may also display concomitant cubital tunnel syndrome (ulnar nerve neuropathy).

Treatment. Treatment hinges on minimizing or stopping activities that worsen the pathology, since proactive treatments may be less successful. Wrist splints and compressive braces for the proximal forearm help shut down the overused muscles and allow them to rest. But make sure you correct poor technique, such as excessive grip tension of a club or racquet.
NSAIDS and corticosteroid injections can decrease inflammation phase. However, use corticosteroids cautiously, and don't exceed two or three injections because of possible degeneration of the tendon.
Emphasize stretching the flexor pronator mass by extending the wrist with the forearm fully supinated and the elbow fully extended. Modalities, such as Iontophoresis, phonophoresis and nitric oxide, can modulate inflammation.
After controlling the initial inflammatory phase, begin eccentric strengthening of the flexor-pronator muscle groups to help return the area to functional, athletic level. Surgery is reserved for athletes who fail nonoperative treatment for at least 2 to 3 months. However, returning to a sport post-surgery typically takes 4 to 6 months.

De Quiervain's Disease
De Quervain's disease is a tenosynovitis that affects the first dorsal compartment of the wrist, and involves the abductor pollicis longus (APL) and extensor pollicis brevis tendons at the radial styloid process.
De Quervain's is traditionally viewed as an inflammatory process caused by friction when tendons are in tight compartments. Treatment involves rest, thumb spica splinting, NSAIDS, corticosteroid injections and modalities.
However, because new evidence suggests that involved tendons often exhibit areas of degeneration and lack inflammatory cells, a component of tendinosis is possible, especially in more chronic conditions. Most likely it's a spectrum of inflammatory and intrinsic degenerative mechanisms. DeQuervain's may also result from blunt trauma to the first dorsal compartment.
Typically, de Quervain's develops from repetitive pinching maneuvers, combined with radial-ulnar deviation. It's six times more common in women than men. There's also a high occurrence of de Quervain's among participants of racquet sports.

Diagnosis. A detailed history is vital. Take note of sport-specific issues, activities of daily living, and occupational demands. Also, patients should bring a racquet to he clinic so you can ensure proper fit.
Video footage can enable you to observe stroke mechanics. Recreational players are more vulnerable to de Quervain's because they lack strength and tend to exhibit poor stroke technique, which places the dominant upper extremity at a mechanical disadvantage.
The exam involves establishing pain levels, palpation, active and passive range of motion measurements, joint mobility testing and strength evaluation.
The two most common ways to confirm de Quervain's are tenderness over the first dorsal compartment in the area of the radial styloid, and the Finkelstein test. This test is performed by adducting the thumb into the fist and ulnarly deviating the wrist approximately 30 degrees. Pain along the radial styloid indicates a positive test.
Other diagnoses to consider include Osteoarthritis (OA) of the trapeziometacarpal joint or radiocarpal joint, Wartenberg's syndrome, intersection syndrome, flexor carpi radialis tendonitis, and carpal tunnel syndrome.

Treatment. Treating a patient diagnosed with de Quervain's who participates in a racquet sport is a unique challenge. You must address the physiologic and mechanical stresses a sport exerts on the dominant upper extremity and the relationship to links in the kinetic chain.
A therapy program for de Quervain's should encompass modulating inflammation, stretching, strength, endurance, balance and flexibility of the muscles in the kinetic chain. Observe the scapulothoracic articulation to ensure proximal stability.
Tailor a treatment program to the chronic nature of symptoms. The prognosis is good for patients with minor symptoms and early intervention. You can incorporate eccentric training and use noxious electrical stimulation to produce favorable outcomes.
Surgery to free involved tendons from adhesions and compression yields excellent results, but it's reserved for those who fail nonoperative treatment.

Wrist Tendinitis
The wrist is a prime site for tendonitis, as repetitive loads cause micro-trauma faster than the body can heal them. Wrist tendonitis can strike the wrist extensors and flexors, especially the extensor carpi ulnaris (ECU), flexor carpi ulnaris (FCU), and flexor carpi radialis (FCR).

Diagnosis. A history of repetitive injuries can indicate wrist tendonitis. A physical exam reveals tenderness at the insertion of the tendon or just proximal to the insertion. Pain with resisted flexion or extension -- depending on the tendon involved -- supports the diagnosis.

Treatment. Rest is the name of the game. Decrease or halt activity and use wrist splints liberally. NSAIDs can decrease pain and inflammation.
Corticosteroid injections can help reduce inflammation, but use them cautiously. Oral steroids -- another anti-inflammatory agent, are rarely used because of serious side effects that can occur outside the affected area. Use modalities to decrease pain and inflammation, introduce stretching and design a progressive strengthening program.
Sports injuries are minor and heal with rest and physical therapy. But athletes need to know that they shouldn't "work through the pain" and believe that talent and superior fitness create invincibility. Don't let overuse injuries bring an early end to your patients' athletic careers.



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