Flexor carpi ulnaris tendinopathy

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Case report: Flexor carpi ulnaris tendinopathy in a lure-coursing dog treated with three platelet-rich plasma and platelet lysate injections

In the present case report a 7-year-old male Whippet competing in lure-coursing presented with third-degree recurrent lameness of the right forelimb, pain on palpation of the caudal aspect of the carpus and swelling of the forearm proximally to the accessory carpal bone. Clinical, radiographic, and ultrasonographic evaluation diagnosed a flexor carpi ulnaris (FCU) chronic tendinopathy unresponsive to previously attempted conservative treatments such as oral non-steroidal anti-inflammatory drugs (NSAIDs) administration along with padded palmar splint application and rest. The dog was subjected to one injection of autologous platelet-rich plasma (PRP) obtained using a double centrifugation tube method, followed by two platelet lysate (PL) injections. Treatment was administered at three-week intervals. The healing process was assessed through clinical and ultrasonographic imaging (US) on the day of the first injection (T0), and at week three (T1), six (T2), twelve (T3), fifty-two (T4), and one-hundred-and-four (T5). Fiber alignment score (FAS) and echogenicity score (ES) were developed by modifying a previously published US assessment scale. At T1, ES, and FAS improvement was detected, and at T2, further improvements in ES and FAS were observed. Ultrasonographic results were clinically consistent with the improvement in lameness: lameness grade 3/4 was detected at T0 and grade 2/4 at T1. A lameness grade of 1/4 was detected at T2, and grade 0/4 was observed at T3, T4, and T5. Moreover, at T5, the dog returned to competition, and no history of re-injury was reported. Our results suggest that the treatment of FCU tendinopathy in lure-coursing dogs with a combination of consecutive injections of autologous PRP and PL could be feasible. Additionally, no adverse reactions were observed.

Anatomical variations of the flexor carpi ulnaris in the fetal period

Introduction: The Flexor Carpi Ulnaris (FCU) is a part of the palmar the forearm muscle group and one of the most important muscles for upper limb functioning - is responsible for flexion and adduc­tion of the hand at the radio-carpal joint. There are clinically significant but rare anatomical variations of FCU. The variability of the FCU has not been described up to now, and no typology of the muscle based on its more variable terminal attachment has been created. Aim of the study: Determination of FCU muscle typology based on available fetal material. Material and methods: A total of 114 human fetuses (53 female, 61 male) between 117 and 197 days of fetal life were eligible for the study. Preparations were carried out using classical anatomical techniques based on a previously published procedure. Thanks to that significant anthropometric landmarks were vis­ible for the gathering of metric measurements. Metric measurements were taken and statistically analysed using R-Project software. Results: A new typology was created based on variable muscle insertions. Additionally, the presence of an atypically located, additional, separated muscle belly was described. A comparison of measurements of the left upper limb in relation to the right upper limb showed significant differences for forearm length to the anthropometric point of the stylion radiale, limb length, total FCU length and FCU length which means that the left limb is longer than the right limb. A comparison of FCU insertion types between left and right upper limb showed there’s no significant difference between counts of each type. Conclusion: The FCU is a muscle that is easy to palpate and may therefore act as a topographical marker for healthcare professionals. Knowledge of its variability is not only of theoretical importance but also has clinical sig­nificance. The current publication demonstrates presence of variability in FCU terminal attachment. Certainly, this topic requires further research and continued work on a detailed understanding of forearm anatomy in the fetal period.

Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BACKGROUND

Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine.

PURPOSE

Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint.

CONCLUSION

Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.

An Evidence-Based Review of Overuse Wrist Injuries in Athletes

Overuse wrist injuries are a common problem in athletes and can be related to tendinopathies or osteoarticular pathology. Fortunately, athletes rarely miss time from their sport due to these conditions because many can be treated nonoperatively. For refractory cases, there often is a curative surgical procedure that can be done during the off-season.

Sonography of Non-neoplastic Disorders of the Hand and Wrist Tendons

Tendon disorders commonly cause hand and wrist disability and curtail the performance of work-related duties or routine tasks. Imaging is often needed for diagnosis, but it requires knowledge of the complex anatomic structures of the tendons of the hand and wrist as well as familiarity with related disorders. This review article aims to provide medical professionals with guidelines for the sonographic assessment of the tendons of hand and wrist and related disorders. Sonographic features of tendon disorders affecting the hand and wrist are described here, specifically: infectious tenosynovitis; tendon rupture or tearing; stenosing forms of tenosynovitis such as De Quervain disease and trigger finger; intersection syndrome; insertional tendinopathy; several forms of tendinous instability such as extensor carpi ulnaris instability, climber finger, and boxer knuckle; and tendinopathy in inflammatory rheumatic diseases. Postsurgical evaluation of the hand and wrist tendons is also discussed, including the healthy and pathologic appearances of operated tendons as well as impingement from orthopedic hardware. In conclusion, sonography is effective in assessing the tendons of the hand and wrist and related disorders and represents a valuable tool for diagnosis.

Hand and Wrist Injuries in Golfers and Their Treatment

A thorough understanding of the swing phases and mechanisms of injury in golf allows accurate diagnosis, treatment, and future prevention of injuries. Recommended initial treatment starts with cessation of practice to rest the wrist, a splint or orthotic brace, and nonsteroidal antiinflammatory drug medication with corticosteroid injection and swing modification. Pisiform excision is the best treatment of the most severe chronic cases of pisiform ligament complex syndrome. Delayed diagnosis of hook of hamate fracture may lead to complications, including flexor tendon rupture. Prompt surgical resection is recommended to hasten return to sport and to prevent further complications.

The pisotriquetral joint: osteoarthritis and enthesopathy

Pisotriquetral (PT) osteoarthritis (OA) and enthesopathy of the flexor carpi ulnaris (FCU) are pathologies of the hypothenar eminence which both often remain undiagnosed, but can cause ulnar wrist pain. This study determined the prevalence of these pathologies in an older donor population. Twenty wrists were obtained from 10 cadavers with an age ranging from 65 to 94 years. Radiographs were taken of all wrists with the hand in pisotriquetral view and were assessed for osteoarthritic changes of the PT joint and signs of enthesopathy of the FCU. Ten wrists were grossly dissected and the other ten wrists were sagitally sectioned at a thickness of 10 μm. The wrists were analyzed for type and grade of osteoarthritis and signs of enthesopathy. On radiology, 2 out of 20 wrists showed no signs of osteoarthritis, 5 wrists showed severe changes. One wrist showed signs of enthesopathy. On macroscopy, 9 out of 10 wrists showed osteoartritic changes; 5 of these were severely osteoarthritic. On microscopy, all wrists showed some degree of osteoarthritis of which five showed severe changes. Signs of enthesopathy were seen in seven wrists. Pisotriquetral osteoarthritis has a high prevalence in the older donor population and may therefore be a cause of ulnar sided wrist pain. It should therefore always be considered in the differential diagnosis of ulnar sided wrist pain. By performing clinical examination with these pathologies in mind, diagnosis could be a lot faster. Furthermore, based on our results, radiographs seem to be not accurate in diagnosing osteoarthritis of the PT joint and enthesopathy of the FCU.

Platelet-rich plasma for the treatment of lateral epicondylitis: sonographic assessment of tendon morphology and vascularity (pilot study)

OBJECTIVE

To investigate the efficacy of using contrast-enhanced ultrasound to assess the relationship of altered vascularity and tendon morphology following injection of platelet-rich plasma (PRP) for lateral epicondylitis.

MATERIALS AND METHODS

This study prospectively evaluated six patients who had a baseline ultrasound confirming tendinosis of the common extensor tendon. Patients received a single 3-ml PRP injection under ultrasound guidance. Grayscale images of the injected elbow were obtained at baseline and were repeated at 1 and 6 months after injection. DEFINITY® contrast was also injected after by 2 sets of wrist-extension exercises in order to obtain contrast-enhanced images of the elbow. Qualitative and quantitative analyses of the level of enhancement to the regions of interest were performed using off-line quantitative analysis software.

RESULTS

All patients had either moderate or severe common extensor tendinosis as determined on clinical examination and baseline imaging. Five patients demonstrated improved tendon morphology using ultrasound imaging 6 months after PRP injection (one patient was lost to follow-up). At baseline, there was evidence of increased vascularity at the myotendinous junction (MT) of the common extensor tendon when compared to its footprint (FP). There was a trend towards no change in FP vascularity between baseline and 6 months (p = 0.062) and between 1 and 6 months (p = 0.288). There was a trend for increased vascularity to the MT region from baseline to 6 months (p = 0.433) and from 1 to 6 months (p = 0.783).

CONCLUSIONS

Contrast-enhanced ultrasound provides a sensitive method the display alterations in vascularity in the common extensor tendon of the elbow. PRP therapy for lateral epicondylitis can improve extensor tendon morphology. Corresponding increased extensor tendon FP vascularity, however, was not seen. There is a trend for increased vascularity at the MT up to 6 months following PRP injection, based on limited pilot data.

Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations

This article reviews the current opinion of the histopathological findings of common elbow, wrist, and hand tendinopathies. Implications for client management including examination, diagnosis, prognosis, intervention, and outcomes are addressed. Concepts for further research regarding common therapeutic interventions are discussed.

[Chronic ulnar wrist pain in adults: diagnosis and treatment principles]

Adult patients with chronic ulnar wrist pain often seek medical advice. There are a number of diagnoses for chronic ulnar-sided wrist pain. A sound diagnostic strategy is therefore of paramount importance. Patient's history, clinical examination and high quality standard radiographs are the most important part of this strategy. Sophisticated investigations should only be performed to focus on solid clinical hypotheses. The palmar and dorsal aetiologies of ulnar wrist pain are considered as well as their treatment principles.

Tendon disorders of the hand and wrist

The terminology used to describe most common tendon disorders in the hand and wrist suggests that they are inflammatory in nature, although current evidence indicates that mechanical and degenerative factors are more important. Corticosteroid injections provide relief in 60% or more of cases; however, the duration of their effectiveness remains uncertain. Surgical release of the stenotic pulley or sheath is curative in well over 90% of cases; complications of surgery are rare, and relief is long-lasting. Enlightened management of these common problems demands evidence-based guidelines defining indications for surgery that will maximize outcomes and minimize costs.

Ulnar-sided wrist pain. II. Clinical imaging and treatment

Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.

Neovascularisation in flexor carpi ulnaris tendinopathy: novel combined sclerosing therapy and eccentric training of the forearms in athletics' wrist pain

Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform bone. Sclerosing therapy using polidocanol under power and laser Doppler guidance was initiated, with immediate decrease of capillary blood flow by 25% with resolution of the neovascularisation in power Doppler. Immediately following sclerosing, the patient's reported pain level on the VAS was reduced from 9/10 to 4/10. Following a short period of rest, eccentric training of the forearm muscle was initiated over 12 weeks with functional complete recovery and complete resolution of wrist pain.

Neuropeptides in tendinopathy

Overuse tendinopathy remains a major clinical burden for sports medicine and general practitioners. Recent studies have highlighted the role of sensory and autonomic nerves in generating or perpetuating the symptoms and tissue abnormalities associated with tendinopathy. We outline the neuroanatomy and potential roles of nerves and associated neuropeptides in tendinopathy. In addition, intriguing new data is reviewed which suggests that there may be a substantial intrinsic source of neuropeptides within tendons - namely, the tenocytes themselves. The potential roles of Substance P and mast cells are highlighted in particular. We discuss the implications for conservative management including sclerosing injections and exercise training.

VEGF expression in patellar tendinopathy: a preliminary study

Vascular function and angiogenesis are regulated by vascular endothelial growth factor-A (VEGF). The purpose of this preliminary study was to address the following questions: Is VEGF expression in the patellar tendon more prevalent in patients with patellar tendinopathy than in individuals with normal, pain-free patellar tendons? Which cell populations express VEGF in normal and tendinopathic tendon? Is there a difference in symptom duration between VEGF+ and VEGF- tendons? We collected patellar tendon tissue from 22 patients undergoing open débridement of the patellar tendon and from 10 patients undergoing intramedullary nailing of the tibia. VEGF expression was assessed immunohistochemically. Relevant inflammatory and repair cell types were immunolabeled. VEGF expression was absent from control tendons, but was present in a subset of patients with histopathological evidence of angiofibroblastic tendinosis. VEGF was expressed in the intimal layer of tendon vessels, but was absent in other cell types. Patients demonstrating VEGF expression in the patellar tendon had a shorter symptom duration (12 +/- 7.8 months) than patients with no detectable VEGF (32.8 +/- 23.5 months). VEGF may contribute to the vascular hyperplasia that is a cardinal feature of symptomatic tendinosis, particularly in cases with more recent onset.

The reliability of the "Scratch test"

The "Scratch Test" uses a sharp scalpel to scrape areas of suspected tendinosis in the management of lateral and medial epicondylitis. As claimed in the literature, this tissue is friable and peels off, whereas normal tendon does not. The purpose of this study was to determine whether, or not, the "Scratch Test" is able to differentiate between tendinosis and more normal adjacent tendon. Nineteen specimens from patients treated for tendinosis about the elbow were examined histologically. Three groups of specimens were compared: (1) grossly abnormal tendon, (2) tendon that was scraped out using the "Scratch Test" and (3) tendon that remained behind following the "Scratch Test". There was no significant histological difference between visibly degenerated tendon (group 1) and that which was scraped out using the "Scratch Test" (group 2). There was, however, a significant histological difference between both these groups and the more normal tendon tissue that the "Scratch Test" left behind (group 3).

Sclerosing therapy and eccentric training in flexor carpi radialis tendinopathy in a tennis player

BACKGROUND

Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. Recent research revealed the role of a neurovascular ingrowth at the point of pain in various tendinopathic locations, such as at the Achilles and patellar tendon, in plantar fasciitis as well as in supraspinatus and tennis elbow tendinopathy. However, beyond the elbow no such neovascularisation has been reported to date.

METHODS

We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform bone. The patient was assessed with power Doppler and laser Doppler quantification of neovascularisation at the point of pain.

RESULTS

Power Doppler and laser Doppler quantification of neovascularisation at the point of pain identified higher capillary blood flow at three points over the painful vs the non-painful tendon (146/240/232rU vs 93/74/70rU at the non-affected side). Sclerosing therapy using polidocanol under power and laser Doppler guidance was initiated, with immediate decrease of capillary blood flow by 25% with resolution of the neovascularisation in power Doppler. Immediately following sclerosing, the patient's reported pain level on the VAS was reduced from 9/10 to 4/10. Following a short period of rest, eccentric training of the forearm muscle was initiated over 12 weeks with functional complete recovery and complete resolution of wrist pain.

CONCLUSION

Sclerosing therapy using polidocanol under power- and laser-Doppler guidance can decrease capillary blood flow by 25% with resolution of the neovascularisation. Subsequent eccentric training of the forearm muscle over 12 weeks can result in complete resolution of wrist pain.