Elbow Update Dr. Neil Dilworth CCFP (EM, SEM), MScCH HPTE University of Toronto Primary Care Sports Medicine Conference May 26, 2017

Disclosures Grant from Canadian Academy of Sports and Exercise Medicine for Pediatric Sport-related Concussion Study No other disclosures

Case 1

Case 2

Objectives To expand differential considerations for elbow complaints To understand importance of mechanism of injury To be able to describe neurological considerations

Lateral Epicondylitis Aka Tennis elbow,Tendinopathy/enthesopathy of the extensor carpi tendons Duration 12-18 months OE: Tender over lateral epicondyle, pain with activation v. resistance extensors Ix: Clinical (Xray, US, MRI may be helpful in ruling out other conditions) Variety of differentials (including radicular pain) Mgt: Variety of treatments (See next slide)

Lateral Epicondylitis Treatments …. PRP +- Per. Radiofrequency thermal + Cortisone Botulinum Leeches? Surgery + Activity Modification + Physiotherapy + Accupuncture + Extracorporeal shockwave Bracing Laser GTN + PRP – 2 level 1 studies v. cortisone showed favourable results – RCT however of PRP v. Saline v. Cortisone – no difference GTN favourable results up to 6 months, Botulinum – inconclusive and potenial weakness …. Leeches – 1 application better than diclofenac. (n=40),

Lateral Elbow Differentials!

Radial Tunnel Syndrome Radial nerve branch (Posterior Interosseous Nerve) entrapped in tunnel Motor innervation to extensors OE – Weak Extensors 2o Pain, tender supinator Pain with supination v. resistance, passive pronation & flexion of wrist Ix: Diagnostic injection (NCS, EMG not helpful) Mgt – avoid extension, wrist pronation/flexion, cortisone injection US- guided, failure at 1 year – consider surgery NCS,EMG not particularly useful as pain sensation with syndrome no motor weakness, MRI not useful.

Capitellar osteochondral injury Occurs in pitchers, overhead sports – tennis, ping poing Repetitive valgus stress, MCL/UCL may be involved OE: Loss of range of motion, effusion posterior and anterior capitellar pain Ix: MR Arthrogram to assess for stability Rx: Rest, protection, UCL tear (consider surgical reconstruction), Therapy – focus on flexor strengthening, ROM

Capitellar osteochondral injury

Elbow Osteoarthritis Arthritis of elbow, could be idiopathic, secondary to trauma or prolonged immobilization. Associated with pain and crepitus. OE: Loss of range of motion, effusion, pain over radiocapitellar joint line Ix: Xray Mgt: Physio, ROM, sleeve, NSAIDs, cortisone, arthroscopy, arthroplasty

Medial Epicondylitis Gofler’s elbow, tendinopathy/enthesopathy of flexor carpi origin OE: Tender over medial epicondyle, pain with activation v. resistance of flexor carpi muscles Ix: Clinical (Xray, US, MRI may be helpful in ruling out other conditions (see following slides) Mgt: Variety of treatments (See lateral epicondylitis)

Snapping Triceps Syndrome Rare, may be associated with ulnar subluxation Medial triceps tendinous insertion snaps over medial epicondyle ~115 degrees of flexion Treatment: ART/Graston/Roller, avoid hyperextension, if still persists consider surgeon In flexion tendon becomes thinner and broader allowing it to snap over medial epicondyle

Ulnar Nerve Subluxation www.orthobullets.com

Ulnar Nerve Subluxation Rare, shallow ulnar groove May also occur in patients with rapid muscle atrophy OE: Ulnar nerve subluxes out of groove and over medial epicondyle ~70-90 deg of flexion, +ve Tinel’s, weakness in D4,5 may exists (incl. grip strength) Ix: Dynamic US Mgt: Wt resistance training (if atrophy), surgical fixation

Ulnar Collateral Ligament - injuries Valgus overload – traumatic, or more commonly repetitive valgus stress – throwing, overhead sports Associated with radio-capitellar osteochondral injuries OE: +ve milk test, pain on palpation, gapping +- pain with valgus stressing at 30deg flexion Ix: Xray (R/O avulsion), US, MRI, MRA (if suspicious of OCD) Mgt: Partial tears treat conservatively – rehab geared at ROM, flexor strengthening. PRP may be considered. Bracing consideration. Complete tears in overhead athletes (includes climbing) consider surgical opinion for reconstruction.

Case 3

Triceps Rupture Eccentric overload of tendon, associated with anabolic steroid use OE: Swelling, bruising, pain with flexion of elbow and supination. Ix: Xray – avulsion fracture, US, MRI (extent of tear +- associated ligamentous injuries) Mgt: Immobilization, Surgical repair

Distal Biceps Rupture Eccentric overload of biceps tendon, associated with anabolic steroid use OE: Hook test, weakness/pain on supination, proximal migration of biceps muscle bulk Ix: Xray (Radial tuberosity avulsion), US, MRI Mgt: Sling, Surgical repair

Summary Always consider differential for lateral and medial elbow presentations Exam should include palpation, ROM (active and passive), neurovascular Other common issues of elbow olecranon bursitis, posterior impingement may be considered