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

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.

Prevalence of incidental distal biceps signal changes on magnetic resonance imaging

BACKGROUND

Knowledge of the base rate of signal changes consistent with distal biceps tendinopathy on magnetic resonance imaging (MRI) has the potential to influence strategies for diagnosis and treatment of people that present with elbow pain. The aim of this study is to measure the prevalence of distal biceps tendon signal changes on MRIs of the elbow by indication for imaging.

METHODS

MRI data for 1,306 elbows were retrospectively reviewed for mention of signal change in distal biceps tendon. The reports were sorted by indication.

RESULTS

Signal changes consistent with distal biceps tendinopathy were noted in 197 of 1,306 (15%) patients, including 34% of patients with biceps pain, 14% of patients with unspecified pain, and 8% of patients with a specific non-biceps indication. Distal biceps tendon changes noted on radiology reports were associated with older age, male sex, and radiologists with musculoskeletal fellowship training.

CONCLUSIONS

The finding that distal biceps MRI signal changes consistent with tendinopathy are common even in asymptomatic elbows reduces the probability that symptoms correlate with pathology on imaging. The accumulation of signal changes with age, also independent of symptoms, suggests that tendon pathology persists after symptoms resolve, that some degree of distal biceps tendinopathy is common in a human lifetime, and that tendinopathy may often be accommodated without seeking care. Level of evidence: IV.

The Acute Effect of Tissue Flossing on Pain, Function, and Perception of Movement: A Pilot Study

Tissue flossing (TF) is a novel device that has been shown to cause peripheral compression and concurrent change in joint range of motion, perception of mobility and muscular performance. However, the effect of tissue flossing on pain, perception of mobility and function at the elbow joint has not been thoroughly investigated. The purpose of this pilot study was to examine the acute effect of TF on pain and upper extremity functional performance in subjects with musculoskeletal-related complaints of pain surrounding the elbow joint. We utilized a randomized crossover design. Nine resistance trained participants (8 men/1 woman) mean age 35.6 ± 10.7 took part in this study. We measured the following outcome measures; Pain Visual Analog Scale, Short Form McGill Pain Questionnaire II, pain-pressure threshold and hand grip dynamometry (HHD) pre and post and a Likert scale for movement ability questionnaire, posttest only, following a TF and placebo condition for each participant. TF resulted in significant improvement in all test measures, except HHD, pre to post (p ≤ 0.05). All pre to post changes were associated with large effect sizes for TF compared to the placebo condition applied to the elbow improves pain quality and intensity, perception of mobility and pain-pressure threshold in resistance trained individuals with a history of musculoskeletal pain for greater than 1 month. The results of this pilot study suggest that TF may function as an adjunct to treatment in the management of musculoskeletal pathologies at the elbow joint.

Clinical Outcomes of Surgical Repair for Partial Distal Biceps Tendon Tears

PURPOSE

The purpose of this study was to describe the outcomes of patients treated with surgical repair of partial tears of the distal biceps tendon.

METHODS

The study was a retrospective review of repairs of partial tears of the distal biceps tendon performed by multiple surgeons from January 1, 2015 to October 15, 2020. Inclusion criteria consisted of preoperative magnetic resonance imaging indicative of distal biceps pathology without a complete tear and surgical treatment with intraoperative confirmation of a partial tear. The presence of preceding trauma, duration of symptoms, and postoperative complications were documented. Patients were contacted for outcome assessment using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Elbow Evaluation outcome measures. Clinical outcomes were obtained from 56 of 74 (76%) eligible patients with an average follow-up of 46 months (range: 15-85 months).

RESULTS

After surgery, the median QuickDASH was 2.3 (interquartile range, 0-9.7), and the median Patient-Reported Elbow Evaluation score was 1 (interquartile range, 0-12). Postoperative QuickDASH scores were significantly lower than the preoperative scores. Known traumas preceding the symptoms and duration of symptoms before surgery were not significantly associated with the outcome. Of all eligible patients, 30 complications were reported in 25 (34%) patients and included 2 reruptures, 2 cases of heterotopic ossification, 1 deep infection, 1 case of implant irritation, 21 neuropraxias, and 3 hematomas. Five (7%) patients underwent 6 reoperations including 1 revision for a rerupture, 1 irrigation and debridement, 2 heterotopic ossification excisions, 1 hematoma evacuation, and 1 implant removal.

CONCLUSIONS

The results suggest that the repair of partial distal biceps tendon tears is a viable treatment option with significant improvement in QuickDASH. There was no significant relationship between the postoperative outcome and duration of symptoms or known traumas preceding the symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Conservative management of distal bicipital tendinopathy with lateral antebrachial nerve entrapment: A case report

INTRODUCTION

Kettlebell snatches are an efficient and effective exercise. If the kettlebell being utilized is too heavy or too many repetitions are executed, this can lead to an overuse injury such as a tendinopathy. Multiple orthopedic tests exist to evaluate for a distal biceps tendon rupture. At present, there are no publications utilizing shockwave and active rehabilitation to treat distal bicipital tendinopathy with Lateral Antebrachial Cutaneous Nerve (LABCN) entrapment. Currently, no published manuscripts are reporting distal bicipital tendinopathy with LABCN nerve entrapment being treated successfully with shockwave and active rehabilitation over the course of 5 weeks.

METHODS

The objective of this case report is to examine the conservative management of a 37-year-old male with a diagnosis of distal bicipital tendinopathy and LABCN entrapment. The patient presents with discomfort originated weeks prior after an intense block of kettlebell training. The patient was diagnosed with brachioradialis tendinopathy due to the specifics of his injury. Following the initial evaluation, the patient was unable to supinate the forearm past 45° actively, yet he can passively achieve 90°, although this is done with minor discomfort.

DISCUSSION

The patient's rehab began with the execution of wrist, elbow, and shoulder controlled articular rotation (CARS). The concept of CARs is to train the joint and soft tissues to respond to full range activity. A progressive approach utilizing isometric to eccentric exercise with extracorporeal shockwave was used. The authors studied forty-eight patients with chronic distal biceps tendinopathy. After five shockwave therapy treatments over three months, there was a significant decrease in symptomology without complications (Furia et al., 2017).

CONCLUSION

This case report demonstrates that active rehabilitation and shockwave therapy effectively resolved the patient's symptoms with no adverse reactions. Additionally, the case report can be a suggested management protocol for successful conservative management for patients with suspected distal bicipital tendinopathy with LABCN entrapment going forward.

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.

Distal biceps tendon ruptures occur with the almost extended elbow and supinated forearm - an online video analytic study

Background

Distal biceps tendon ruptures can lead to significant restrictions in affected patients. The mechanisms of injury described in scientific literature are based exclusively on case reports and theoretical models. This study aimed to determine the position of the upper extremities and forces involved in tendon rupture through analyzing video recordings.

Methods

The public YouTube.com database was queried for videos capturing a clear view of a distal biceps tendon rupture. Two orthopedic surgeons independently assessed the videos for the activity that led to the rupture, the arm position at the time of injury and the forces imposed on the elbow joint.

Results

Fifty-six video segments of a distal biceps rupture were included (55 male). In 96.4%, the distal biceps tendon ruptured with the forearm supinated and the elbow isometrically extended (non-dynamic muscle engagement) (71.4%) or slightly flexed (24%). The most common shoulder positions were adduction (85.7%) and neutral position with respect to rotation (92.9%). Most frequently a tensile force was enacted on the elbow (92.9%) and the most common activity observed was deadlifting (71.4%).

Conclusion

Distal biceps tendon ruptures were most commonly observed in weightlifting with a slightly flexed or isometrically extended elbow and forearm supination. These observations may provide useful information for sports specific evidence-based injury prevention, particularly in high performing athletes and individuals engaged in resistance training.

Level of evidence

Observational study.

Cell-based therapy of the elbow: evidence for lateral tendinopathy-a review on current treatments

PURPOSE

Cell-based therapies are on the rise in treating intra and extraarticular pathologies, trying to avoid surgical intervention and support local repair processes. Therefore, the aim was to summarize current evidence-based treatment options for a cell-based therapy around the elbow.

METHODS

Through a literature review up-to date treatment algorithms and therapies have been identified and have been rated according to their evidence level for clinical recommendation.

RESULTS

Regarding the four extraarticular anatomical regions of the elbow (anterior, medial, posterior and lateral) and the joint itself, the lateral elbow and its´ tendinopathies as well as the use of cell-based treatment options have been extensively studied and, therefore, allow for clear and evidence-based recommendations. The remaining three regions as wells as the intraarticular application do not show enough evidence for a clinical recommendation.

CONCLUSION

In conclusion the cell-based approach for treating elbow pathologies can only be recommended for the lateral elbow, as there has been shown sufficient evidence for the extraarticular application. It has to be mentioned, that the results from the lateral elbow maybe transferred to other extra-articular tendinopathies, as the lack of evidence may be due to the rare appearance of posterior, medial and anterior tendon affection. No recommendation can be given for intra-articular use.

LEVEL OF EVIDENCE

IV.

Clinical Assessments and MRI Findings Suggesting Early Surgical Treatment for Patients with Medial Epicondylitis

Purpose

To evaluate the MRI findings and clinical factors that are characteristic of patients who ultimately undergo surgery for medial epicondylitis.

Materials and Methods

Fifty-two consecutive patients who were diagnosed with medial epicondylitis and underwent an elbow MRI between March 2010 and December 2018 were included in this retrospective study. The patients' demographic information, clinical data, and MRI findings were evaluated. All variables were compared between the conservative treatment and surgical treatment groups. Logistic regression analyses were conducted to identify which factors were associated with surgical treatment.

Results

Common flexor tear (CFT) tear size showed a statistically significant difference in both the transverse and longitudinal planes (p < 0.001, p = 0.013). The CFT abnormality grade significantly differed in both the transverse and longitudinal planes (p = 0.022, p = 0.003). A significant difference was also found in the medial collateral ligament abnormality (p = 0.025). Logistic regression analyses showed that only the transverse diameter of the CFT tear size (odds ratio: 1.864; 95% confidence interval: 1.264-2.750) was correlated with surgical treatment.

Conclusion

Of patients diagnosed with medial epicondylitis, patients with a larger transverse CFT tear size tend to undergo surgical treatment ultimately.

Triceps Tendon Injuries

Triceps tendon injuries are an uncommon clinical entity poorly described in the literature. This review discusses the spectrum of pathology, effective diagnosis, nonsurgical treatment, surgical treatment, rehabilitation, and surgical complications of triceps tendon injuries. Management of triceps tendinopathies depends on the mechanism of injury and the patient's motor examination. Triceps tendinopathies and partial tendon tears with intact strength can be managed conservatively with rest, ice, immobilization, nonsteroidal anti-inflammatory drugs, and physical therapy. If conservative management fails for 6 months or there are strength deficits on examination, surgery should be considered. Based on the current evidence, there are no clear guidelines for "best" surgical approach. Although rare, the most significant surgical complication to be concerned about is rerupture. Rerupture rate is 4.62% among the articles we reviewed.

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.

Orthobiologics in Elbow Injuries

Orthobiologics are exciting tools providing promising results for difficult orthopedic conditions. In the elbow there is high-level evidence for their use in lateral epicondylopathy and encouraging evidence for other elbow pathologies. This article provides an in-depth review of the current literature for the use of orthobiologics in elbow injuries.

Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review

BACKGROUND

Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up.

METHODS

Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation [SD], 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up.

RESULTS

Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate.

CONCLUSION

Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy.

Distal biceps section and reinsertion for chronic distal biceps tendinopathy

BACKGROUND

Surgical reinsertion of the distal biceps tendon for acute and chronic tears is a widely accepted procedure, but little is known about surgical treatment of distal biceps tendinopathy.

METHODS

Twenty patients underwent a surgical procedure for distal biceps tendinopathy after failure of conservative treatment. The surgery was performed through a single incision. The biceps tendon was detached, debrided and reinserted using a ToggleLoc (Zimmer Biomet) device. Clinical and radiologic evaluation was performed after a minimum follow-up of 1 year. Quick-Dash score, Liverpool Elbow Score, Mayo Elbow Performance Index, Broberg and Morrey Score and Short HSS Scoring System were used, and isokinetic testing was performed.

RESULTS

The outcome of these five clinical elbow scores showed no clinically relevant differences between the affected and non-affected side. Isokinetic testing of peak torque in flexion and supination showed equal strength between both sides. These results indicate good functional outcome and recovery of flexion and supination, compared to the non-operated side and the normal population.

CONCLUSION

This study demonstrates that distal biceps tendon debridement and reinsertion is a safe and valid option for patients with distal biceps tendinopathy after failure of conservative treatment.

LEVEL OF EVIDENCE

Level 3 retrospective cohort study.

Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature

PURPOSE OF REVIEW

Platelet-rich plasma is used in many orthopedic pathologies such as tendinopathies and ligament injuries. The clinical results reported in the scientific literature are, however, confusing. The aim of this manuscript is to provide a narrative literature review regarding the role of PRP in the most common elbow soft tissue pathologies.

RECENT FINDINGS

The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears. Only a few manuscripts comparing the results of PRP treatment with either extracorporeal shockwave (ESW), dry needling, or even surgical treatments in lateral epicondylitis exist. The use of PRP in other elbow pathologies such as golfer's elbow, ulnar collateral ligament injury, and distal biceps and triceps pathology is examined in few studies, with unclear recommendations. Regarding elbow pathologies, PRP injections in tennis elbow seems to be the best-studied intervention. A major limitation in these studies is the significant heterogeneity in the methods used for preparing PRP, for example employing leukocyte-rich, leukocyte-poor preparations, PRP with or without activation, which makes the results of the studies difficult to compare. Results of this review show that more studies on larger cohorts, with comparable formulations, and with longer follow-up are required to give optimal suggestions concerning the use of PRP in elbow pathologies.

Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy

BACKGROUND

Distal biceps tendinopathy is an uncommon cause of elbow pain. The optimum treatment for cases refractory to conservative treatment is unclear. Platelet-rich plasma has been used successfully for other tendinopathies around the elbow.

METHODS

Six patients with clinical and radiological evidence of distal biceps tendinopathy underwent ultrasound-guided platelet-rich plasma (PRP) injection. Clinical examination findings, visual analogue score (VAS) for pain and Mayo Elbow Performance scores were recorded.

RESULTS

The Mayo Elbow Performance Score improved from 68.3 (range 65 to 85) (fair function) to 95 (range 85 to 100) (excellent function). The VAS at rest improved from a mean of 2.25 (range 2 to 5) pre-injection to 0. The VAS with movement improved from a mean of 7.25 (range 5 to 8) pre-injection to 1.3 (range 0 to 2). No complications were noted.

DISCUSSION

Ultrasound-guided PRP injection appears to be a safe and effective treatment for recalcitrant cases of distal biceps tendinopathy. Further investigation with a randomized controlled trial is needed to fully assess its efficacy.