Diagnostic Value of Ultrasonography for Clinical Medial Epicondylitis

Ultrasonographic differential diagnosis of medial elbow pain

Medial elbow pain is a common musculoskeletal problem among individuals engaging in repetitive activities. Medial epicondylitis is the predominant cause of this pain. However, other potential causes must be considered as part of the differential diagnosis. This article discusses several etiologies of medial elbow pain, including medial epicondylitis, ulnar neuropathy, snapping triceps syndrome, ulnar collateral ligament injury, medial antebrachial cutaneous neuropathy, and diseases of the elbow joint, with an emphasis on ultrasound (US) findings. Awareness of possible diagnoses and their US features can assist radiologists in establishing a comprehensive diagnosis for medial elbow pain.

Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis-a randomised controlled trial

PURPOSE

To assess whether Ultrasound guided dry needling is adequate for both common extensor tendon tears and tendinosis or whether ultrasound guided platelet rich plasma (PRP) has a superior outcome when compared to dry needling when there are tears of the common extensor tendon.

MATERIALS AND METHODS

This is a single-centre, single-blinded, randomised controlled trial conducted between November 2018 and April 2020. 40 patients diagnosed with lateral epicondylitis based on clinical and sonographic features and having comparable baseline characteristics were randomly assigned to the two study groups (dry needling and PRP). Inclusion criteria were patients aged 20 years or more who were symptomatic for at least 3 months with sonographic evidence of lateral epicondylitis. Exclusion criteria were complete tear of common extensor tendon confirmed on ultrasound and presence of other associated diseases like osteoarthritis of shoulder and elbow.

RESULTS

There was significant improvement in the visual analogue scale pain score in PRP group compared to the dry needling group at 9 months. However, this difference was not evident at 3 and 6 months follow-up. Mean improvement in common extensor tendon thickness in PRP group (5.1 mm at 3 months and 4.3 mm at 6 months) was slightly better than dry needling (4.4 mm at 3 months and 4.0 mm at 6 months). There was no difference in tear (if present) healing between both groups at 3 months. However at 6 months follow up, PRP demonstrated significant (mean-2.5) healing in tear compared to dry needling (mean-3.1).

CONCLUSION

Two injections of Ultrasound guided PRP are more beneficial non operative treatment compared to ultrasound guided dry needling, in lateral epicondylitis.

Shoulder and Elbow Injuries in Adult Overhead Throwers: Imaging Review

Overhead throwing, particularly in baseball, subjects the shoulder and elbow to various unique injuries. Capsular contracture following repetitive external rotation shifts the humeral head posterosuperiorly, predisposing to glenohumeral internal rotation deficit (GIRD), Bennett, posterosuperior internal impingement (PSI), and superior labrum anterior-posterior (SLAP) lesions. GIRD represents loss of internal rotation at the expense of external rotation. Bennett lesion represents ossification of the posteroinferior glenohumeral ligament due to repetitive traction. PSI manifests with humeral head cysts and "kissing" tears of the posterosuperior cuff and labrum. Scapular dysfunction contributes to symptoms of PSI and predisposes to labral or rotator cuff disease. "Peel-back" or SLAP lesions occur when torsional forces detach the biceps-labral anchor from the glenoid. Finally, disorders of the anterior capsule, latissimus dorsi, teres major, and subscapularis are well recognized in overhead throwers. At the elbow, injuries typically involve the medial-sided structures. The ulnar collateral ligament (UCL) is the primary static restraint to valgus stress and can be thickened, attenuated, ossified, and/or partially or completely torn. Medial epicondylitis can occur with tendinosis, partial tear, or complete rupture of the flexor-pronator mass and can accompany UCL tears and ulnar neuropathy. Posteromedial impingement (PMI) and valgus extension overload syndrome are related entities that follow abundant valgus forces during late cocking or acceleration, and deceleration. These valgus stresses wedge the olecranon into the olecranon fossa, leading to PMI, osteophytes, and intra-articular bodies. Other osseous manifestations include olecranon stress fracture and cortical thickening of the humeral shaft. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Current concepts of natural course and in management of medial epicondylitis: a clinical overview

Medial epicondylitis (ME), called "golfer's elbow", is not frequent or serious disease but can cause symptoms that are bothersome in everyday life. Therefore knowledge about this condition may improve diagnostic-therapeutic process. In this article detailed information concerning pathophysiology and symptomatology of ME was described. Great attention was paid to issues related to the diagnosis of the disease both in terms of differentiation with other elbow disorders as well as examination techniques. Finally, current therapeutic options were presented in detail and their efficacy was discussed based on the available data.

Open procedure vs. arthroscopic débridement for chronic medial epicondylitis

BACKGROUND

This retrospective study compared the outcomes after open and arthroscopic treatment of chronic medial epicondylitis (ME).

METHODS

The study included 44 elbows in 38 patients: 25 (29-72 years) in the open group and 19 (27-70 years) in the arthroscopy group. The indications for ME surgery were failed conservative therapy for more than 3 months, symptom duration exceeding 6 months, and persistent severe pain. We used radiography, ultrasonography, and magnetic resonance imaging assessments. The clinical assessment included operating time, range of motion, grip strength, visual analog scale (VAS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications.

RESULTS

The mean follow-up was 20.2 (12-58) months. The mean operating time was significantly longer in the arthroscopy group (32.5 vs. 23.5 minutes; P = .029). In both groups, all outcome measures improved significantly after surgery and there were no significant differences between the DASH scores (preoperative 44.8 vs. 43.9, postoperative 12.5 vs. 13.2), grip strength (preoperative 72.2 vs. 66.8, postoperative 84.8 vs. 83.6), and VAS scores (preoperative 8.5 vs. 8.2, postoperative 1.0 vs. 1.1) in the open and arthroscopy groups. The outcomes were excellent or good in 20 patients (80%) in the open group and 16 (84%) in the arthroscopy group. The only complication was 1 case of transient ulnar neuropathy in the open group.

CONCLUSION

Open and arthroscopic techniques were very effective and comparable for treating chronic ME. The surgeon can choose either technique for treating chronic ME.

Forearm Flexor Tendon Injury in Adolescent Athletes: Risk Factors, Treatment, and Prevention

ABSTRACT

Injury to the flexor pronator mass is a common condition that is especially prevalent in overhead throwing athletes. The increasing incidence of these injuries has promoted considerable efforts in research to better understand the pathology, risk factors, and potential mechanisms to prevent injury in these athletes. While there are numerous intrinsic and extrinsic factors associated with injury, a common theme involves chronic overuse and microtrauma with inadequate resting intervals between performances. The purpose of this review is to discuss medial elbow injuries in young athletes with a particular focus on the flexor pronator mass.

Ultrasound in the Differential Diagnosis of Medial Epicondylalgia and Medial Elbow Pain-Imaging Findings and Narrative Literature Review

Medial epicondylalgia (ME), commonly known as “the golfer’s elbow”, typically develops in individuals who perform repetitive forearm movements and weight-bearing activities. It accounts for up to 20% of all epicondylitis cases and is most prevalent in particular sports and occupations. Though the diagnosis can be made based on sole clinical examination, additional imaging might be essential for confirmation of medial epicondylitis and excluding other pathologies of the medial epicondyle region. US imaging, with a sensitivity and specificity of 95% and 92%, respectively, remains a practical and accessible alternative to MRI. However, its diagnostic efficacy highly depends on the operator’s experience and requires proper technique. This article describes the ultrasound examination and technique for adequate visualization of elbow joint structures. It also discusses the differential diagnosis of other common and less-known pathologies of the medial compartment of the elbow, including snapping triceps, medial collateral ligament injury, and cubital tunnel neuropathy.

Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

Tennis overuse injuries in the upper extremity

OBJECTIVE

Tennis is a popular sport with high levels of participation. This article aims to describe how upper extremity overuse injuries occur in relation to tennis biomechanics and to review their imaging characteristics and implications for management. In particular, we will review the imaging patterns of internal impingement, scapular dyskinesis, lateral and medial epicondylitis, ulnar collateral ligament insufficiency, valgus extension overload, capitellar osteochondritis dissecans, extensor carpi ulnaris tendinosis and instability, tenosynovitis, triangular fibrocartilage complex injuries, and carpal stress injuries.

CONCLUSION

Tennis is a complex and physically demanding sport with a wide range of associated injuries. Repetitive overloading commonly leads to injuries of the upper extremity. An understanding of the underlying mechanisms of injury and knowledge of these injury patterns will aid the radiologist in generating the correct diagnosis in both the professional and recreational tennis athlete.

Ultrasound Examination Techniques for Elbow Injuries in Overhead Athletes

Elbow pain is a frequent complaint among overhead athletes. Standard evaluation of the elbow uses history and physical examination, with radiographic imaging and MRI aiding in the confirmation of diagnosis. Musculoskeletal ultrasonography (US) provides dynamic, functional assessment of tendons and ligaments in the elbow, allowing the visualization of structures under stress and motion. Stress US offers the ability to detect injuries to the ulnar collateral ligament by measuring changes in joint space under stress. The freedom of dynamic imaging means results are dependent on the skill of the US operator to obtain the most accurate and complete evaluation. US is cost efficient and portable, allowing for quick examination at the point of care. This article provides a technique guide for sports medicine specialists performing US examination of the elbow.

Clinical applicability of shear wave elastography for the evaluation of medial epicondylitis

OBJECTIVES

To evaluate the ability of shear wave elastography (SWE) in diagnosing medial epicondylitis and to compare the diagnostic performance of SWE with that of grey-scale ultrasound (GSU) and strain elastography (SE).

METHODS

GSU, SE, and SWE were performed on 61 elbows of 54 patients from March 2018 to April 2019. An experienced radiologist evaluated the GSU findings (swelling, cortical irregularity, hypoechogenicity, calcification, and tear), colour Doppler findings (hyperaemia), SE findings (strain ratio [SR]), and SWE findings (stiffness and shear wave velocity [SWV]). Participants were divided in two groups: patients with clinically diagnosed medial epicondylitis and patients without medial elbow pain. Findings from the two groups were compared, and the receiver operating characteristic (ROC) curves were calculated for significant features.

RESULTS

Of the 54 patients, 25 patients with 28 imaged elbows were clinically diagnosed with medial epicondylitis and 29 patients with 33 imaged elbows had no medial elbow pain. Cortical irregularity, hypoechogenicity, calcification, hyperaemia, SR, stiffness, and SWV were significantly different between the two groups. The areas under the ROC curves were 0.838 for hypoechogenicity, 0.948 for SR, 0.999 for stiffness, and 0.999 for SWV. The diagnostic performances of SR, stiffness, and SWV were significantly superior compared to that of hypoechogenicity. However, there were no significant differences among SR, stiffness, and SWV.

CONCLUSIONS

SWE can obtain both stiffness and SWV, which are valuable diagnostic tools in the diagnosis of medial epicondylitis. The diagnostic performance of SWE and SE is similar in detecting medial epicondylitis.

KEY POINTS

• Shear wave elastography providing stiffness and shear wave velocity showed excellent performance in the diagnosis of medial epicondylitis. • There was no significant difference in the ability of SE and SWE for diagnosing medial epicondylitis.

Practical ultrasonographic technique to precisely identify and differentiate tendons and ligaments of the elbow at the level of the humeral epicondyles: anatomical study

OBJECTIVES

To develop a practical step-by-step technique to precisely identify and differentiate tendons and ligaments attaching to the humeral epicondyles, to confirm through gross anatomical study the accurate structure identification provided by this technique and to determine the frequency at which each structure can be identified in healthy volunteers.

MATERIALS AND METHODS

First, ten fresh frozen cadavers (6 men, age at death = 58-92 years) were examined by two musculoskeletal radiologists and a step-by-step technique for the identification of tendons and ligaments at the level of humeral epicondyles was developed. Second, the accurate identification of structures was confirmed through gross anatomical study including anatomical sections on five specimens and layer-by-layer dissection technique on five others. Finally, 12 healthy volunteers (6 men, average age = 36, range = 28-52) were scanned by two radiologists following the same technique.

RESULTS

An ultrasonographic technique based on the recognition of bony landmarks and the use of ultrasonographic signs to differentiate overlapping structures was developed and validated through gross anatomical study. In healthy volunteers, most tendons and ligaments were identified and well-defined in ≥ 80% of cases, except for the extensor carpi radialis brevis and extensor digiti minimi tendons on the lateral epicondyle (having common attachments with the extensor digitorum communis) and the palmaris longus tendon on the medial epicondyle (absent, or common attachment with the flexor carpi radialis).

CONCLUSION

A step-by-step approach to the ultrasonographic assessment of tendons and ligaments at the humeral epicondyles allowed accurate identification of and differentiation among these structures, in particular those relevant to pathological conditions.

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries

Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.

Injuries and Conditions Affecting the Elbow Flexor/Pronator Tendons

Common flexor-pronator tendon injuries and medial epicondylitis can be successfully treated nonoperatively in most cases. Operative treatment is reserved for patients with continued symptoms despite adequate nonoperative treatment or in high-level athletes with complete rupture of the common flexor-pronator tendon. The physical examination and workup of patients with flexor-pronator tendon injuries should focus on related or concomitant pathologies of the medial elbow. The gold standard for surgical treatment of flexor-pronator tendon ruptures or medial epicondylitis includes tendon debridement and reattachment.

Clinical Application of Real-Time Sonoelastography for Evaluation of Medial Epicondylitis: A Pilot Study

The aim of this study was to evaluate the diagnostic potential of real-time sonoelastography (RSE) in medial epicondylitis by comparing clinically diagnosed patients and patients without medial elbow pain. From July 2016 to December 2017, gray-scale sonographic findings (swelling, cortical irregularity, hypo-echogenicity, calcification and tear), color Doppler findings (hyperemia) and sonoelastographic findings (elastographic grade on a 3-point visual scale and strain ratio from two regions of interest) for 63 elbows of 56 patients were compared. Twenty-four patients with 29 imaged elbows were clinically diagnosed with medial epicondylitis, and 32 patients with 34 imaged elbows had no medial elbow pain. Cortical irregularity, hypo-echogenicity, calcification, elastographic grade and strain ratio revealed significant differences (p < 0.05). Among these, strain ratio had the highest diagnostic performance (area under the curve: 0.985). Real-time sonoelastography, which can obtain both elastographic grade and strain ratio, is valuable as a supplementary tool in the diagnosis of medial epicondylitis.

The use of gadolinium-containing medium dilutions in evaluations of pathological changes in magnetic resonance images of the canine elbow

The aim of this study was to evaluate the usefulness of the paramagnetic gadolinium-containing contrast agent, diluted 1:800, in evaluations of pathological changes in the canine elbow joint. The experiment was performed on 6 large breed dogs of both sexes with a body weight of 25 to 40 kg. Thoracic limb lameness and pain in the elbow joint area were observed in all patients. The animals were subjected to standard physical examinations, radiography and low-field magnetic resonance imaging scans with the use of a contrast agent. The Spin Echo T1 dorsal sequence as well as 3D SST1 transverse and XBONE T1 transverse sequences were highly effective in diagnosing osteochondritis dissecans (OCD) of the medial humeral condyle. Degenerative changes and the fragmented coronoid process (FCP) of the ulna were very well visualized by High Resolution Gradient Echo, XBONE T2 and Spin Echo T1 sequences in the sagittal plane. The administration of the gadolinium contrast agent, diluted 1:800, to the elbow joint cavity enhances the diagnostic value of magnetic resonance images in evaluations of medial compartment disease, in particular fragmentation of the medial coronoid process.

Clinical Applications of Ultrasonography in the Shoulder and Elbow

In the past 30 years, the use of ultrasonography in the field of orthopaedics has evolved. As ultrasonography has been refined, smaller machines with higher fidelity and better transducers have become available at a lower cost. Diagnostic and therapeutic applications of ultrasonography in the shoulder and elbow have expanded imaging options and provided alternatives to surgical management. Ultrasonography is a dynamic tool that affords immediate diagnostic assessment for clinical correlation and can be used for serial examinations and image guidance during therapeutic procedures. This imaging modality is highly reliable and accurate and may limit the need for costly imaging referrals, particularly in geographic areas where advanced imaging is not readily available. However, clinical expertise is paramount for ultrasonography, which is an operator-dependent modality. Ultrasonography is an effective educational resource; therefore, the curriculum in orthopaedic residency training programs should include education on this modality as the use of ultrasonography increases among orthopaedic surgeons.

Sonoelastography of the Common Flexor Tendon of the Elbow with Histologic Agreement: A Cadaveric Study

Purpose To determine the correlation of the results of conventional B-mode ultrasonography (US) and compression sonoelastography with histologic results in common flexor tendons of the elbow in human cadavers. Materials and Methods Twenty-five common flexor tendons were evaluated in 16 fresh, unembalmed cadavers of 11 women with a median age of 85 years (range, 71-101 years) and five men with a median age of 78 years (range, 70-88 years). Informed consent was provided according to the last will of the donors. B-mode US results were classified as grade 1, normal tendon with homogeneous fibrillar pattern; grade 2, tendon thickening or hypoechoic areas and/or calcifications in less than 30% of the tendon; or grade 3, hypoechoic areas and/or calcifications greater than 30% of the tendon. Sonoelastographic results were grade 1, blue (hardest) to green (hard); grade 2, yellow (soft); and grade 3, red (softest). The intraclass correlation coefficient was calculated to determine agreement with histologic findings for each B-mode US, sonoelastographic, and combined B-mode US and sonoelastographic examination. Histologic results were grade 1, normal, with parallel fibrillar pattern; grade 2, mild tendinopathy, with cellular infiltration, angiogenesis, or fatty vacuoles; or grade 3, severe tendinopathy, with loss of parallel collagen structure and necrosis. Results Histologic alterations were detected in 44% (11 of 25) of biopsy specimens. Intraclass correlation with histologic results was 0.57 for B-mode US, 0.68 for sonoelastography, and 0.84 for the combination of the two approaches. Conclusion The addition of sonoelastography to B-mode US provided statistically significant improvement in correlation with histologic results compared with the use of B-mode US alone (P < .02). ^© RSNA, 2016 Online supplemental material is available for this article.

The accuracy of diagnostic ultrasound imaging for musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature

Musculoskeletal diagnostic ultrasound imaging (MSK-DUSI) has been growing outside the traditional radiology speciality. Increased use of this technology has been reported in several healthcare settings, however an apparent gap in the knowledge of the accuracy of this diagnostic technology indicated a review was warranted. We undertook a structured review of the literature to assess the accuracy of MSK-DUSI for the diagnosis of musculoskeletal soft tissue pathology of the extremities. An electronic search of the National Library of Medicine’s PubMed database (1972 to mid-2014) was conducted. All relevant systematic reviews of diagnostic studies, all diagnostic studies published after the date of the latest systematic reviews and relevant diagnostic studies outside the scope the systematic reviews that directly compared the accuracy of MSK-DUSI (the index test) to an appropriate reference standard for the target condition were included. A fundamental appraisal of the methodological quality of studies was completed. The individual sensitivity, specificity and likelihood ratio data were extracted and entered into diagnostic accuracy tables. A total of 207 individual studies were included. The results show that MSK-DUSI has acceptable diagnostic accuracy for a wide spectrum of musculoskeletal conditions of the extremities. However, there is a lack of high quality prospective experimental studies in this area and as such clinicians should interpret the results with some caution due to the potential for overestimation of diagnostic accuracy.

An effective approach to diagnosis and surgical repair of refractory medial epicondylitis

BACKGROUND

Medial epicondylitis of the elbow, an overuse injury characterized by angiofibroblastic tendinosis of the common flexor-pronator origin, generally responds to nonoperative treatment. Refractory cases may require surgical débridement and repair. This study discusses physical examination and imaging findings and an updated surgical technique used in patients with recalcitrant medial epicondylitis.

METHODS

The surgical records of 60 patients with refractory medial epicondylitis were reviewed. All received a course of nonoperative care. After 3 to 6 months of failed therapy, imaging was obtained, and surgical intervention was offered when indicated. This open procedure consisted of thorough débridement with repair and restoration of the flexor-pronator origin, using a suture anchor. Accelerated rehabilitation, emphasizing early motion, was used. One-year follow-ups were obtained. The Mayo Elbow Performance Score was calculated preoperatively and postoperatively.

RESULTS

Pronation weakness at 90° was a critical physical examination finding. Preoperative magnetic resonance images demonstrated pathologic partial tearing at the flexor-pronator origin. Ulnar neuritis was addressed in 20%. Postoperatively, the Mayo Elbow Performance Score significantly increased (preoperatively, 58 ± 7.7; postoperatively, 88 ± 7.8; P = 5.6E-34), and pain significantly decreased (preoperatively, 2.2 ± 0.3; postoperatively, 0.6 ± 0.5; P = 3.8E-33). There was one retear in a patient noncompliant with the postoperative protocol. He responded positively to reoperation.

CONCLUSION

Identification of weakness on pronation is a reliable physical examination finding for determining clinically significant pathologic changes in patients with medial epicondylitis. Débridement with restoration of the flexor-pronator origin is an efficacious procedure. In this large series of patients, surgical repair with aggressive rehabilitation was shown to be reliable and safe in restoring function and relieving pain in recalcitrant cases of medial epicondylitis.

Medial epicondylitis: evaluation and management

Medial epicondylitis, often referred to as "golfer's elbow," is a common pathology. Flexor-pronator tendon degeneration occurs with repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation. A staged process of pathologic change in the tendon can result in structural breakdown and irreparable fibrosis or calcification. Patients typically report persistent medial-sided elbow pain that is exacerbated by daily activities. Athletes may be particularly symptomatic during the late cocking or early acceleration phases of the throwing motion. Nonsurgical supportive care includes activity modification, NSAIDs, and corticosteroid injections. Once the acute symptomology is alleviated, focus is turned to flexor-pronator mass rehabilitation and injury prevention. Surgical treatment via open techniques is typically reserved for patients with persistent symptoms.

Treatment of medial epicondylar tendinopathy in athletes

Medial epicondylar tendinopathy, also known as golfer's elbow, is less common than lateral elbow tendinopathy. Overhead throwing athletes and those participating in sports that require repeated forearm pronation and wrist flexion are most commonly affected by this disorder. This problem predominates in amateur as opposed to professional athletes and is also seen more commonly in patients over 40 years of age. This review will begin by outlining the incidence, history, and physical examination of medial epicondylar tendinopathy, including a new clinical test. Imaging modalities, nonoperative, and operative treatments will then be outlined. Finally, future directions will be explored including emerging biological therapies.

Assessment of neuromuscular conditions using ultrasound

Upper extremity pain in persons with spinal cord injury is a common cause of morbidity. Ultrasound of nerve, muscle, and tendon has the potential to become a valuable modality in assessing this population, and has the advantage of reduced health care costs, portability, and use in populations that cannot tolerate MRI. It has the potential to detect issues before the onset of significant morbidity, and preserve patient independence. Upper extremity ultrasound already has many studies showing its utility in diagnosis, and newer techniques have the potential to enhance its use in the diagnosis and management of musculoskeletal conditions.

The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis

BACKGROUND

Medial epicondylitis is a tendinopathy of the common flexor-pronator origin, and surgical treatment is required when this condition fails to respond to nonoperative methods. This study details the development of a new technique, termed fascial elevation and tendon origin resection (FETOR), which facilitates the complete visualization and resection of the CFPO with limited soft tissue dissection.

PURPOSE

To evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The electronic medical records of patients who underwent FETOR from January 2008 to July 2011 were retrospectively reviewed. Outcome assessments included the visual analog scale (VAS) for average pain, pain at rest, and pain experienced during hard work or heavy lifting; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and pain-free grip strength. Preoperative and postoperative data were compared.

RESULTS

A total of 22 elbows in 20 patients with a mean age of 48.8 years (range, 29-58 years) were included. At a mean follow-up of 35.6 months (range, 16-77 months), the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P < .001). The patients' perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 ± 18.0 to 8.0 ± 11.1; P < .001). The mean pain-free grip strength improved significantly from 53.7% ± 30.3% to 97.3% ± 19.8% of the uninvolved arm (P < .001). Eighteen (90%) patients were satisfied with the surgical outcomes, while 2 patients changed their jobs because of decreased elbow function. No major complications occurred.

CONCLUSION

The FETOR technique is an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.

Magnetic resonance imaging of primary and concomitant flexor enthesopathy in the canine elbow

Flexor enthesopathy is a recently recognized elbow disorder in dogs and considered to be an important differential diagnosis for elbow lameness. Primary and concomitant forms of the disease have been previously described and treatments differ for the two forms. The goal of this prospective study was to compare magnetic resonance imaging (MRI) findings for dogs with primary flexor enthesopathy (n = 17), concomitant flexor enthesopathy (n = 23), elbow dysplasia alone (n = 13), and normal elbows (n = 7). Each elbow joint underwent MRI using the same low-field scanner. Sequences included transverse and sagittal T1-weighted (before and after IV contrast), transverse and sagittal T2-weighted, and dorsal STIR. For each elbow, MRI lesions were recorded based on a consensus of two observers unaware of group status. Magnetic resonance imaging lesions involving flexor tendons were found in 100% of clinically affected joints with primary flexor enthesopathy and 96% of clinically affected joints with concomitant flexor enthesopathy. Thickened flexor muscles were the most common lesions, followed by hyperintense tendon signal and contrast enhancement. Irregular, thickened medial humeral epicondyle, edema, and calcified body lesions were less frequently observed. Magnetic resonance imaging characteristics of flexor enthesopathy were not found in normal joints or those affected by elbow dysplasia alone. No significant differences in frequencies and details of individual MRI characteristics were found between primary and concomitant flexor enthesopathy groups. Findings indicated that MRI is a sensitive technique for detection of flexor enthesopathy lesions in dogs, however, MRI characteristics do not allow differentiation of primary versus concomitant forms of the disease.

Computed tomography of canine elbow joints affected by primary and concomitant flexor enthesopathy

Flexor enthesopathy is an important differential diagnosis for elbow lameness in dogs. The disorder can be a primary cause of elbow lameness or concomitant with other elbow pathology. Since treatment differs for primary and concomitant forms of flexor enthesopathy, a noninvasive method for distinguishing between them is needed. In the current prospective study, computed tomographic (CT) examination was performed before and after IV injection of contrast in 17 dogs with primary flexor enthesopathy, 24 dogs with concomitant flexor enthesopathy, 13 dogs with elbow dysplasia, and seven normal dogs. Dogs were assigned to groups based on results of clinical examination and at least three other imaging modalities. Computed tomographic lesions consistent with flexor enthesopathy were found in all clinically affected joints with primary flexor enthesopathy and in 29 of the 30 clinically affected joints with concomitant flexor enthesopathy. Those lesions were not found in sound elbows or joints affected by elbow dysplasia. Flexor lesions detected in dogs with primary flexor enthesopathy were not significantly different from those detected in dogs with the concomitant form. Findings indicated that CT can be applied to detect flexor enthesopathy, but a distinction between the primary and concomitant forms was not always possible. Authors recommend the use of multiple diagnostic techniques for treatment planning in affected dogs.

Value of ultrasound in rheumatologic diseases

The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly increased over the past decade. Ultrasound has enabled rheumatologists to diagnose, prognosticate and monitor disease outcome. Although international standardization remains a concern still, the use of ultrasound in rheumatology is expected to grow further as costs fall and the opportunity to train in the technique improves. We present a review of value of ultrasound, focusing on major applications of ultrasound in rheumatologic diseases.

Role of diagnostic ultrasound in the assessment of musculoskeletal diseases

The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.

Magnetic resonance imaging of the elbow in athletes

Acute and chronic elbow pain is common, particularly in athletes. Although plain radiographs, ultrasound, and computed tomography all have a role to play in the investigation of elbow pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for diagnosis of soft tissue disease and osteochondral injury around the elbow. The high spatial resolution, excellent soft-tissue contrast, and multiplanar imaging capabilities of MRI make it ideal for evaluating the complex joint anatomy of the elbow. This article reviews imaging of common disease conditions occurring around the elbow in athletes, with an emphasis on MRI.

The prevalence of medial epicondylitis among patients with c6 and c7 radiculopathy

Background:

Medial epicondylitis, or golfer’s/pitcher’s elbow, develops as a result of medial stress overload on the flexor muscles at the elbow and presents as pain at the medial epicondyle. Cervical radiculopathy has been associated with lateral epicondylitis, but few associations between the cervical spine and medial epicondylitis have been made. Researchers propose that there is an association, suggesting that the weakness and imbalance in the elbow flexor and extensor muscles from C6 and C7 radiculopathy allow for easy onset of medial epicondylitis.

Hypothesis:

Medial epicondylitis will present in over half the patients diagnosed with C6 and C7 radiculopathy.

Methodology:

A total of 102 patients initially presenting with upper extremity or neck symptoms were diagnosed with cervical radiculopathy. They were then examined for medial epicondylitis. Data were collected by referring to patient charts from February 2008 until June 2009.

Results:

Fifty-five patients were diagnosed with medial epicondylitis. Of these, 44 had C6 and C7 radiculopathy whereas 11 presented with just C6 radiculopathy.

Conclusion:

Medial epicondylitis presented with cervical radiculopathy in slightly more than half the patients. Weakening of the flexor carpi radialis and pronator teres and imbalance of the flexor and extensor muscles from the C6 and C7 radiculopathy allow for easy onset of medial epicondylitis. Patients with medial epicondylitis should be examined for C6 and C7 radiculopathy to ensure proper treatment. Physicians dealing with golfers, pitchers, or other patients with medial epicondylitis should be aware of the association between these 2 diagnoses to optimize care.

A musculoskeletal ultrasound course for physical medicine and rehabilitation residents

Musculoskeletal ultrasound is an imaging modality that can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures. A growing proportion of physiatrists are interested in musculoskeletal ultrasound as demonstrated by the increasing number of musculoskeletal ultrasound articles published in physical medicine and rehabilitation journals and quantity of musculoskeletal ultrasound courses and workshops at physical medicine and rehabilitation conferences. The Mayo Clinic (Rochester, MN) Physical Medicine and Rehabilitation residency program developed a musculoskeletal ultrasound course for their physical medicine and rehabilitation residents, which was implemented in 2008. A detailed description of the course is provided in this article. In addition, results from a premusculoskeletal ultrasound course and postmusculoskeletal ultrasound course practical and written test are presented, and the results of a postmusculoskeletal ultrasound course resident survey are discussed. This information can be used by other physical medicine and rehabilitation residency programs to assist in the creation of their own musculoskeletal ultrasound course.

Diagnostic ultrasound in sports medicine: current concepts and advances

Diagnostic ultrasound is a valuable imaging tool that is slowly gaining in popularity among sports medicine clinicians. Commonly referred to as "musculoskeletal ultrasound," its valuable role in assisting with sports medicine diagnoses has been to date underused for a variety of reasons. Effective clinical usage for sports medicine diagnoses includes commonly seen conditions such as rotator cuff disease, ulnar collateral ligament of the elbow injury, and internal derangement of the knee, among many others. Limitation of clinical usage has been deterred by the cost of the unit, perception of time associated with assessment procedures, and the lack of formal training associated with diagnostic implementation. However, when properly used, musculoskeletal ultrasound can increase the accuracy of diagnosis and treatment, improve time to treatment intervention, and improve patient satisfaction. The purpose of this paper is to review the fundamentals of musculoskeletal ultrasound and present its specific diagnostic uses.

Associations between work-related factors and specific disorders at the elbow: a systematic literature review

OBJECTIVES

To assess the exposure-response relationships between work-related physical and psychosocial factors and lateral epicondylitis, medial epicondylitis, cubital tunnel syndrome and radial tunnel syndrome in occupational populations.

METHODS

A systematic review of the literature was conducted on the associations between type of work, physical load and psychosocial aspects at work and the occurrence of specific elbow disorders. Associations between work factors and these elbow disorders were expressed in quantitative measures: odds ratio (OR) or relative risk (RR).

RESULTS

Handling tools >1 kg (ORs of 2.1-3.0), handling loads >20 kg at least 10 times/day (OR 2.6) and repetitive movements >2 h/day (ORs of 2.8-4.7) were associated with lateral epicondylitis. Psychosocial factors associated with lateral epicondylitis were low job control (OR 2.2) and low social support (OR 1.8). Handling loads >5 kg (2 times/min at minimum of 2 h/day), handling loads >20 kg at least 10 times/day, high hand grip forces for >1 h/day, repetitive movements for >2 h/day (ORs of 2.2-3.6) and working with vibrating tools >2 h/day (OR 2.2) were associated with medial epicondylitis. The occurrence of cubital tunnel syndrome was associated with the factor 'holding a tool in position' (OR 3.53). Handling loads >1 kg (OR 9.0; 95% CI 1.4, 56.9), static work of the hand during the majority of the cycle time (OR 5.9) and full extension (0-45 degrees ) of the elbow (OR 4.9) were associated with radial tunnel syndrome.

CONCLUSIONS

Several physical and psychosocial factors at work may result in an increased occurrence of specific disorders at the elbow.