Evaluation of overuse elbow injuries.

The evaluation of elbow pain can be challenging because of the complexity of the joint and its central location in the upper extremity. Diagnosing the injury correctly requires an understanding of the anatomy of the elbow, which includes three articulations, two ligament complexes, four muscle groups and three major nerves. The history should be directed at pinpointing the location of symptoms and the activities that cause the patient's pain. It is important to identify the specific musculotendinous structures that are at risk for overuse or have been injured through overuse. Mechanical symptoms are indicative of intra-articular pathology, whereas neurologic symptoms are characteristic of nerve entrapment syndromes. Physical examination of the elbow and related structures should confirm the diagnosis. Only a minority of patients require diagnostic studies. Basic treatment principles are described by the acronym PRICEMM: protection, rest, ice, compression, elevation, medication and modalities (physical therapy). Surgical consultation is warranted in selected patients.

A modified lateral approach for release of posttraumatic elbow flexion contracture.

A modified lateral approach for release of posttraumatic flexion contracture of the elbow is described. The approach is a modification of the procedure described by Nirschl for resection and repair of lateral elbow tendinosis (tennis elbow). The modified approach allows visualization of the entire anterior elbow joint without disturbing the common extensor origin or the collateral ligaments. If necessary, a second, posterior triceps-splitting incision is used to access the olecranon fossa. Twelve consecutive patients were treated from 1988 to 1992. Mean flexion/deformity, which measured 41 degrees before operation, measured 8 degrees immediately after operation. The mean flexion/extension arc measured 70 degrees before operation and improved to 117 degrees after operation. With an average follow-up of 36.5 months, mean flexion contracture was 11 degrees and the mean flexion/extension arc of motion was 114 degrees. In no case was a medial approach or transhumeral perforation required. All patients were treated after operation with the elbow splinted in extension for 3 days, after which they were started on an aggressive physical therapy regimen. There were no wound complications, no neurovascular injuries, and no formations of heterotopic bone.

Salvage surgery for lateral tennis elbow.

We undertook a retrospective analysis of 34 patients (35 elbows) who had prior failed surgical intervention for lateral tennis elbow. Revision surgeries were performed between 1979 and 1994. Each patient's non-operative and operative history was recorded before our salvage revision surgery. At revision surgery, findings included residual tendinosis of the extensor carpi radialis brevis tendon in 34 of 35 elbows. In 27 elbows, the pathologic changes in the extensor carpi radialis brevis tendon had not been previously addressed at all, and in 7 elbows the damaged tissue had not been completely excised. Salvage surgery included excision of pathologic tissue in the extensor carpi radialis brevis tendon origin combined with excision of excessive scar tissue and repair of the extensor aponeurosis when necessary. Based on a 40-point functional rating scale proposed here, 83% of the elbows (29 of 35) had good or excellent results at an average followup of 64 months (range, 17 months to 17 years). To prevent failure of surgical treatment for tennis elbow, the pathologic tissue usually present in the extensor carpi radialis brevis tendon should be resected. Release operations, which weaken the extensor aponeurosis but fail to address the pathoanatomic changes, are not recommended.

Arthroscopic transglenoid suture capsulolabral repair. Five-year followup.

The preliminary results of our arthroscopic transglenoid suture capsulolabral repair demonstrated a failure rate of only 10%, with no postoperative dislocations. The purpose of this study was to reevaluate a patient population with a 5-year minimum followup similar to the one previously reported with a 2-year followup. We performed a retrospective analysis of 38 shoulders in 37 consecutive patients who underwent arthroscopic transglenoid suture capsulolabral repair between January 1989 and June 1990. Thirty shoulders in 29 patients were available for followup. The patient population for the current study consisted of 19 men and 10 women. The patients' ages at the time of surgery ranged from 14 to 44, with an average of 24.7 years. Thirteen patients were evaluated in the office and 16 by telephone. The current followup demonstrated a redislocation rate of 17% (5 shoulders). Twenty-seven percent of the patients (N = 8) required a second open stabilization procedure. Only 40% of shoulders (N = 12) had no episodes of instability at this extended followup. Higher failure rates were noted in patients with generalized ligamentous laxity or an absent labrum at the time of surgery and in those participating in contact sports.

Managing overuse injuries: a systematic approach.

Cumulative, repetitive microtrauma can cause tissue damage that leads to overuse injuries, which constitute a large share of sports-related disorders. The authors explain their five-step approach to treating overuse injuries: establishing a pathoanatomic diagnosis, controlling inflammation, promoting healing, increasing fitness, and controlling tissue abuse. The case of a 28-year-old male runner with heel pain demonstrates their management of overuse injuries.

Tennis elbow. Current concepts of treatment and rehabilitation.

Tennis elbow occurs as a result of repetitive microtrauma to the musculotendinous unit causing inflammatory and degenerative tissue damage. A good understanding of the aetiology and pathoanatomy will aid the clinician in preventing and recognising this condition. Early recognition with a quality rehabilitative programme, and the judicious use of surgical intervention usually results in full recovery and excellent functional outcomes.

Shoulder pain: the role of diagnostic injections.

Many different shoulder disorders cause similar symptoms and pain patterns. An accurate diagnosis can generally be made by obtaining a detailed history, performing a comprehensive, directed physical examination and obtaining selected radiographs. Occasionally, shoulder injections can be of great assistance in establishing a clear diagnosis and providing relief of symptoms. Subacromial space injection, acromioclavicular joint injection, intra-articular injection and injection of the biceps tendon are helpful in identifying such disorders as subacromial bursitis, acromioclavicular arthritis, injury to the glenohumeral joint and bicipital tendinitis.

Assessment and treatment guidelines for elbow injuries.

Acute elbow injuries are often collision related; chronic elbow injuries typically stem from overuse and valgus stress. What seems a purely traumatic injury, though, may actually represent an acute-on-chronic process, so a detailed history and physical exam are essential in pinpointing the injury process and making a specific diagnosis. Important details in the history are the quality, intensity, and onset of pain and the location of symptoms and their effect on function. The exam should include visual inspection, palpation, range of motion, and key tests such as applying valgus stress. Treatment can often be conservative, with emphasis on strength-building rehabilitation.