La epicondilitis medial en los lanzadores de la Isla de la Juventud / Epicondilite medial em lançadores da Ilha da Juventude / Medial epicondylitis in pitchers of La Isla de la Juventud

Resumen La tendinopatía es una causa importante de morbilidad musculo-esquelética. Tiene una alta incidencia en el ámbito deportivo de 30 a 50 % de las lesiones, en atletas profesionales y recreativos, que pueden comprometer el rendimiento deportivo y causar discapacidad. En gran medida, es causada por una alteración en los orígenes músculo-tendinosos, en los cóndilos humerales. En la mayoría de los casos, se encuentra en población laboralmente activa, por lo cual tiene alto impacto en la reducción de la productividad por ausencias laborales, que de acuerdo con la severidad pueden ser días o semanas. El objetivo general de la investigación consiste en proponer un complejo de ejercicios físicos que contribuyan a la recuperación de dicha lesión en lanzadores de béisbol. Se emplearon los métodos teóricos, empíricos y se determinaron los fundamentos teóricos que componen la rehabilitación de la epicondilitis medial. Se analizó la información obtenida luego de aplicar una entrevista a los entrenadores, con la finalidad de caracterizar el estado actual del proceso de rehabilitación de esta lesión. A partir de los resultados obtenidos, se diseñó un conjunto de ejercicios físicos para rehabilitar dicha lesión en el área de entrenamiento. Los ejercicios diseñados se clasifican en pasivos, activos asistidos, activos libres, activos resistidos; este último dividido en dos grupos. Para facilitar la labor de los entrenadores, se describen la forma de ejecución de los ejercicios, así como las indicaciones metodológicas, músculos implicados, organización y variantes.

Resumo A Tendinopatia é uma das principais causas de morbidade músculo-esquelética. Tem uma alta incidência no ambiente desportivo de 30-50% das lesões em atletas profissionais e recreativos, o que pode comprometer o desempenho desportivo e causar incapacidade. Em grande medida, é causada por uma alteração na origem músculo-tendão nos côndilos umerais. Na maioria dos casos, encontra-se na população ativa, pelo que tem um elevado impacto na redução da produtividade por faltas ao trabalho, que de acordo com a gravidade pode variar de dias a semanas. O objetivo geral da pesquisa é propor um complexo de exercícios físicos que contribuam para a recuperação desta lesão em arremessadores de beisebol. Os métodos teóricos e empíricos foram utilizados e os fundamentos teóricos que compõem a reabilitação da Epicondilite medial foram determinados. As informações obtidas após a entrevista com os treinadores foram analisadas a fim de caracterizar o estado atual do processo de reabilitação para esta lesão. Com base nos resultados obtidos, um conjunto de exercícios físicos foi concebido para reabilitar esta lesão na área de treino. Os exercícios concebidos são classificados em passivos, ativos assistidos, ativos livres e ativos resistidos; sendo estes últimos divididos em dois grupos. Para facilitar o trabalho dos treinadores, é descrita a forma de execução dos exercícios, assim como as indicações metodológicas, músculos envolvidos, organização e variantes.

Abstract Tendinopathy is a major cause of musculoskeletal morbidity. A high incidence of sports-related injuries of 30-50 % in professional and recreational athletes, which can compromise sports performance and cause disability. Mostly, it is caused by an alteration in the muscle-tendontium origins in the humeral condyles. In most cases, it is in the working population, so it has a high impact on reducing productivity due to absences from work, which, depending on the severity, can range from days to weeks. The general objective of the research is to propose a complex of physical exercises that will contribute to the recovery of such injury in baseball pitchers. Theoretical and empirical methods were used and the theoretical foundations for the rehabilitation of medial epicondylitis were determined. The information obtained after interviewing the coaches was analyzed in order to characterize the current state of the rehabilitation process for this injury. Based on the results obtained, a set of physical exercises was designed to rehabilitate this injury in the training area. The exercises designed are classified into passive, assisted active, free active, and resisted active; the latter being divided into two groups. In order to facilitate the work of the trainers, the form of execution of the exercises is described, as well as the methodological indications, muscles involved, organization and variants.

Lesión del nervio cubital secundario a terapia de ondas de choque extracorpóreas radiales identificada con ultrasonografía de alta resolución: Reporte de caso / Ulnar Nerve Injury After Radial Extracorporeal Shock Wave Therapy Identified With High­Resolution Ultrasonography: Case Report

Mujer de 49 años fue evaluada por desarrollar dolor súbito a nivel de los epicóndilos mediales conjuntamente con entumecimiento y sensación de hormigueo en el cuarto y quinto dedos después de recibir terapia de ondas de choque extracorpóreas radiales (rESWT) como tratamiento para epicondilitis medial bilateral. El examen neurológico reveló signo de Tinel positivo, parestesia y una prueba de discriminación de dos puntos alterada sobre la región cubital del cuarto y quinto dedos. La ultrasonografía de alta resolución demostró hallazgos de lesión nerviosa periférica tales como hipoecogenicidad y aumento del diámetro de ambos nervios cubitales. La paciente mejoró únicamente tras recibir tratamiento conservador, demostrando así una aparente neuropatía compresiva bilateral aguda como resultado de la terapia. ESWT se utiliza como una alternativa prometedora para el tratamiento de diversos trastornos musculoesqueléticos; sin embargo, existe evidencia limitada con respecto a sus efectos secundarios, en particular la mononeuropatía periférica. Según el conocimiento de los autores, este es el primer reporte que demuestra un daño nervioso estructural después de rESWT con el uso de ultrasonografía de alta resolución.

A 49-year old woman was evaluated for developing bilateral acute medial elbow pain, numbness, and tingling sensation in the fourth and fifth fingers after receiving radial extracorporeal shock wave therapy (rESWT) for bilateral medial epicondylitis. Neurologic examination revealed the presence of Tinel's sign, paresthesia and impaired two-point discrimination testing over the ulnar side of the fourth and fifth fingers bilaterally. High-resolution ultrasonography demonstrated findings of nerve injury, such as hypoechogenicity and increased diameter of both ulnar nerves. After conservative treatment, the patient improved her condition demonstrating an apparently acute compressive nerve injury as a result of the therapy. ESWT is used as a promising alternative for the treatment of various musculoskeletal disorders; however, there is limited evidence regarding its side effects, in particular peripheral mononeuropathy. To the authors' knowledge, this is the first report demonstrating structural damage of a nerve after rESWT with the use of high-resolution ultrasonography.

Ulnar Collateral Ligament Tear Combined with Medial Epicondylitis of the Elbow / 대한스포츠의학회지

Medial epicondylitis, also known as “golfer's elbow,” is a common overuse syndrome of the elbow and predominantly affects the origin of the common flexor tendon. We report two unique cases of medial epicondylitis complicated by chronic complete tear of the ulnar collateral ligament and common flexor tendon origin. Physical examination showed a focal huge swelling of medial epicondylar region of the dominant elbow and magnetic resonance imaging revealed complete tear of the ulnar collateral ligament and common flexor tendon and extravasation of intra-articular effusion. Satisfactory results were achieved with ulnar collateral ligament reconstruction and simultaneous repair of the common flexor tendon origin.

Heterotopic Ossification of the Elbow after Medial Epicondylectomy / 대한정형외과학회잡지

Postoperative heterotopic ossification of the elbow after surgery for treatment of acute trauma such as fractures and ligament/tendon ruptures has been well-documented. However, literature concerning heterotopic ossification after medial epicondylectomy is scarce. We report on two cases of heterotopic ossification that occurred following medial epicondylectomy for medial epicondylitis and for cubital tunnel syndrome. Preoperatively, calcifications around the medial epicondyle were observed in both patients. These cases suggest that medial epicondylectomy, in the presence of pre-existing calcifications, may pose an increased risk of postoperative heterotopic ossification of the elbow.

Operative Treatment of Medial Epicondylitis: A Comparative Analysis of the Clinical Outcomes between the Suture Anchor Group and the Non-suture Anchor Group

BACKGROUND: The purpose of this study was to make a comparative analysis of the clinical outcomes after the operative treatment of refractory medial epicondylitis between the suture anchor group and the non-suture anchor group. METHODS: We enrolled 20 patients (7 men and 13 women) with recalcitrant medial epicondylitis who were able to receive operative treatment in a minimum of an 18-month follow-up. The mean age was 48.6 years (range, 36-59 years). The patients were allocated into either the suture anchor group (7 patients) or the non-suture anchor group (13 patients). We evaluated clinical outcomes using the visual analog scale (VAS), the pain grading system of Nirschl and Pettrone, and postoperative grip strength. RESULTS: The VAS score decreased from 8.8 to 2.0 for the suture anchor group and from 8.6 to 1.3 for the non-suture anchor group (p=0.16). The postoperative grip strength was 95%, 93% of the non-treated arm in both groups (p=0.32). The postoperative satisfaction level was good in 5 patients and fair in 2 for the suture anchor group and excellent in 5 patients, good, in 4, and fair, in 4 for the nonsuture anchor group (p=0.43). The clinical outcomes did not show a statistically significant difference between the two groups. CONCLUSIONS: We found that patients with recalcitrant medial epicondylitis were treated reliably with satisfactory clinical outcomes whether or not suture anchors were used. We believe the use of suture anchors when more than 50% of the tendon origin is affected provides an effective and favorable treatment modality.

Operative Treatment of Medial Epicondylitis: A Comparative Analysis of the Clinical Outcomes between the Suture Anchor Group and the Non-suture Anchor Group

BACKGROUND: The purpose of this study was to make a comparative analysis of the clinical outcomes after the operative treatment of refractory medial epicondylitis between the suture anchor group and the non-suture anchor group. METHODS: We enrolled 20 patients (7 men and 13 women) with recalcitrant medial epicondylitis who were able to receive operative treatment in a minimum of an 18-month follow-up. The mean age was 48.6 years (range, 36-59 years). The patients were allocated into either the suture anchor group (7 patients) or the non-suture anchor group (13 patients). We evaluated clinical outcomes using the visual analog scale (VAS), the pain grading system of Nirschl and Pettrone, and postoperative grip strength. RESULTS: The VAS score decreased from 8.8 to 2.0 for the suture anchor group and from 8.6 to 1.3 for the non-suture anchor group (p=0.16). The postoperative grip strength was 95%, 93% of the non-treated arm in both groups (p=0.32). The postoperative satisfaction level was good in 5 patients and fair in 2 for the suture anchor group and excellent in 5 patients, good, in 4, and fair, in 4 for the nonsuture anchor group (p=0.43). The clinical outcomes did not show a statistically significant difference between the two groups. CONCLUSIONS: We found that patients with recalcitrant medial epicondylitis were treated reliably with satisfactory clinical outcomes whether or not suture anchors were used. We believe the use of suture anchors when more than 50% of the tendon origin is affected provides an effective and favorable treatment modality.

Effectiveness of Initial Extracorporeal Shock Wave Therapy on the Newly Diagnosed Lateral or Medial Epicondylitis

OBJECTIVE: To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection. METHOD: An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm2, 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments. RESULTS: Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week. CONCLUSION: The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.

Epicondilitis medial. Revisión del estado actual de la enfermedad / Medial epicondylitis. Current concepts

La epicondilitis medial tiene menor incidencia que la lateral, patología que ha sido principalmente descrita en estudios anatómicos y clínicos. La información sobre la epicondilitis lateral ha sido extrapolada a la epicondilitis medial. Se ha denominado a la epicondilitis medial como "codo de golfista", debido a la asociación con este deporte; sin embargo, se asocia mucho más a actividades laborales específicas. Es una patología que compromete el origen de los músculos de la parte medial del codo, conocidos como músculos flexopronadores, organizados así: pronator teres, flexor carpiradialis, palmarislongus, flexordigitorumsuperficialis y flexor carpiulnaris. El diagnóstico principalmente es clínico y se puede apoyar mediante imágenes diagnósticas. El manejo conservador es el más frecuente (85-90%), y los objetivos son mejoría del dolor y rehabilitación para una reincorporación a las actividades. En casos resistentes a tratamiento conservador, la cirugía es el último paso, preferiblemente resecando la zona afectada.

The medial epicondylitis has a smaller impact that the lateral, pathology that has mainly been described in anatomical study and clinical trials. The information on the lateral epicondylitis has been extrapolated to the medial epicondylitis. It has been called to the medial epicondylitis as "golfer's elbow", due to the association with this sport, however joins much more to labor activities. It is a pathology that commits the origin of the muscles of the medial elbow, known as flexopronator muscles, organized like this: pronator teres, flexor carpi radialis, palmarislongus, flexordigitorumsuperficialis, flexor carpi ulnaris. The diagnosis is mainly clinical and can be supported by diagnostic images. The treatment conservative is more frequent (85-90%) and the objectives are: improvement of the pain and rehabilitation for a return to the activities, if not achieved the improvement is performed surgery preferably with resection the affected area.

Mini-open Muscle Resection Procedure under Local Anesthesia for Lateral and Medial Epicondylitis

BACKGROUND: This study examined the clinical results of surgical treatment using a mini-open muscle resection procedure under local anesthesia for intractable lateral or medial epicondylitis. METHODS: Forty two elbows (41 patients) were treated surgically for lateral or medial epicondylitis. The indication for surgery was refractory pain after six months of conservative treatment, or a history of more than three local injections of steroid, or severe functional impairment in the occupational activities. The treatment results were assessed in terms of the pain using the visual analogue scale (VAS), Roles & Maudsley score, and Nirschl & Pettrone grade. RESULTS: The preoperative VAS scores of pain were an average of 5.36 at rest, 6.44 at daily activities, and 8.2 at sports or occupational activities. After surgery, the VAS scores improved significantly (p < 0.01): 0.3 at rest, 1.46 at daily activities, and 2.21 at sports or occupational activities. The preoperative Roles & Maudsley score was acceptable in 6 cases, and poor in 36 cases, which was changed to excellent in 23 cases, good in 16 cases, acceptable in 3 cases after surgery. According to the grading system by Nirschl & Pettrone, 23 cases were excellent, 18 cases were good, and the remaining 1 case was fair. Overall, 41 cases (97.6%) achieved satisfactory results. Postoperative complications were encountered in three cases. Subcutaneous seroma due to the leakage of joint fluid in two patients was managed by additional surgery and suction drainage, and resulted in a satisfactory outcome. One patient complained of continuous pain on occupational activity, but her pain at rest was improved greatly. CONCLUSIONS: The mini-open muscle resection procedure under local anesthesia appears to be one of effective methods for intractable lateral or medial epicondylitis.

Low-energy Extracorporeal Shock Wave Therapy on Chronic Epicondylitis of the Elbow: Clinical and Sonographic Study

OBJECTIVE: To evaluate the effect of extracorporeal shock wave therapy (ESWT) and the improvement of ultrasonographic findings in refractory chronic epicondylitis of the elbow. METHOD: Twenty seven patients (7 men, 20 women, mean age 47) with minimum 1 year history of chronic epicondylitis of the elbow that was unresponsive to conventional therapy were included. Each patient was treated with 3~4 sessions of low-energy (0.06~0.12 mJ/mm2, 2000 impulses) ESWT. A 100-point scoring system, Nirschl score and Roles and Maudsley score were evaluated before treatment and at the 3- and 6-month follow-up. Ultrasonography was performed before treatment and at the 3-month follow-up. RESULTS: Total score of a 100-point scoring system and Nirschl score were significantly improved at the 3- and 6-month follow-up compared to before treatment (p<0.05). Follow up ultrasonography was performed in twenty one patients. Eighteen of 21 patients (85.7%) showed improvement of tendinosis and 4 of 6 patients (66.7%) showed improvement of tear and 3 of 10 patients (30.0%) showed improvement of calcification on ultrasonography. CONCLUSION: ESWT is safe and effective modality in the treatment of refractory chronic epicondylitis of the elbow. And ultrasonography can be a useful method to evaluate the therapeutic effect of ESWT.

Effect of Low-energy Extracorporeal Shock Wave Therapy on Calcifying Epicondylitis: Sonographic Follow-up

OBJECTIVE: To evaluate the effect of low-energy extracorporeal shock wave therapy (ESWT) in refractory calcifying epicondylitis. METHOD: Twelve patients (1 man, 11 women, mean age 49), who suffered from refractory medial or lateral epicondylitis (mean duration 22 months) with sonographically verified calcification, were included. Subjects were classified according to radiologic and sonographic findings of calcification. Visual analogue scale (VAS) at rest and activities of daily living (ADL) as well as Nirschl score were evaluated before and 3 months after low-energy (0.06~0.12 mJ/mm2, 1,500~2,000 shocks) extracorporeal shock wave therapy (ESWT). Sonographic changes and Roles and Maudsley score were assessed 3 months after ESWT. RESULTS: VAS at rest and ADL as well as Nirschl score were significantly decreased (p<0.05) after ESWT. Roles and Maudsley score was "Good" in six patients (50%), "Acceptable" in 3 (25%) and "Poor" in 3 (25%) after 3 months. In sonographic classification, "Fragmented type" was observed in five (42%), "Nodular" in 3 (25%), "Small" in 4 (33%). All of eight radiologically positive patients (67%) showed sonographic changes of calcification including one complete resorption (8%), 3 disintegration (25%) and 4 decrease of size or number (33%). All of four radiologically negative patients (33%) were "Small type" and did not show any change of calcification on sonography. CONCLUSION: Low-energy ESWT can help the clinical improvement and resorption of calcification in refractory calcifying medial or lateral epicondylitis. Radio-opaque calcification may be a good indicator of resorption of calcification on sonography after low-energy ESWT.