​Kembara Xtra - Medicine - Epicondylitis

​Kembara Xtra - Medicine - Epicondylitis 
Introduction 

Tendinopathy of the elbow is characterized by pain and tenderness at the myotendinous junctions or tendinous insertions of the wrist flexors/extensors at the humeral epicondyles. Although commonly known as medial and lateral epicondylitis, without microscopic histologic examination, the more appropriate term is medial epicondyle tendinopathy (MET) and lateral epicondyle tendinopathy (LET).
Occurs most frequently as a result of chronic (overuse) disease; but, acute (traumatic) etiology can also play a role. There are two forms.
– MET (also known as "golfer's elbow"): This condition involves the wrist flexors and pronators, which originate at the medial epicondyle. – LET (also known as "tennis elbow"): This condition involves the wrist extensors and supinators, which originate at the lateral epicondyle. 75% of cases involve the dominant arm. Most usually affects the extensor carpi radialis brevis (ERCB) tendon. May be caused by a variety of different sports or occupational activity. Common in carpenters, plumbers, gardeners, and athletes who perform overhead movements.

Prevalence and Incidence 
Predominant age: over forty years old Predominant sex: males and females equally represented Estimates place the incidence of this common overuse injury laterally more than medially and place it somewhere between 1 and 3 percent.
Prevalence
● LET: 1.3%
● MET: 0.4%


Causes and effects: etiology and pathophysiology 

Acute tendinitis is a rare and unusual form of the illness.
- Inflammatory response to either an injury or a rapid, severe contraction
Chronic (tendinosis) - Overuse injury – Repetitive wrist flexion or extension exerts strain throughout the enthesis of the group that flexes and extends the wrist.
- Decay, calcium deposit, proliferation of fibroblasts and microvascular cells, loss of hyaline cartilage, and a reduced restorative inflammatory response 
Activities that make the condition worse, such as gripping tools or racquets and shaking one's hands
– Professions (such as painters, mechanics, and chefs); – Sports (such as golf, tennis, archery, and pitchers);

factors of danger 
Repetitive movements of the wrist
- Flexion and pronation toward the middle; extension and supination toward the sides
● Smoking

• Obesity • Strenuous exercises involving the upper extremities

Prevention 

It is important to avoid overusing the flexors, extensors, pronators, and supinators of the wrist and to practice correct form if working with hand tools or participating in racquet sports.
It is recommended to make use of lighter instruments with smaller grips.

Insidious onset, discomfort confined to the lateral or medial elbow, aching pain that frequently extends from the epicondyle to the forearm or wrist, pain experienced when grasping, and a feeling of slight weakening in the forearm are the presenting characteristics of this condition.

Clinical Examination Localized pain just distal to the affected epicondyle Tenderness at the origin of wrist flexor tendons Increased pain with resisted wrist flexion and pronation Normal elbow range of motion Increased pain when gripping

Differential Diagnosis Arthritis, including posterior osteophytes Arthritic fractures of the epicondyle Posterior interosseous nerve entrapment Ulnar neuropathy Medial elbow pain Synovitis

referred discomfort from the shoulder or neck thoracic outlet syndrome medial collateral ligament damage thoracic outlet syndrome

Results From the Laboratory 
Initial Tests (laboratory, imaging) There is no need for imaging to be performed during the initial examination and treatment of a classic overuse injury.

Additional Examinations, as well as Other Important Factors
Anteroposterior and lateral radiographs in cases when there is a decreased range of motion, trauma, or if there is no improvement with initial conservative therapy. Examine the patient for any evidence of arthritis or fractures.
Musculoskeletal ultrasound (US) indicates aberrant tendon appearance in recalcitrant situations (such as hypoechoic, tendon thickening, partial rip at tendon origin, and calcifications).
Injections of steroid and/or anesthesia can also be guided using ultrasound.
– The presence of peritendinous soft tissue edema or intermediate or high T2 signal intensity within the common flexor or extensor tendon can be shown by MRI.
Diagnostic Methods and Other Procedures
Infiltration of local anesthetic followed by relief of symptoms provides evidence for the diagnosis if clinical uncertainty exists regarding the condition.

Management 

Activity modification, counterforce bracing, oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), ice, and physical therapy are the initial treatments.
Symptoms often continue for a period of time ranging from six months to two years if treatment is not received. Patients who have good function and minimal pain may benefit from conservative care, which entails taking a "wait and see" attitude and catering treatment to the preferences of the individual patient.
Changes should be made to the level of activity, relative rest should be encouraged, and improper biomechanics should be fixed.
Bracing - Wrist extensor splints (WESs) restrict contraction of extensor muscle and diminish tendon mobility, which ultimately results in a reduction in stress at the common extensor origin in LET.
– A simple and low-cost counterforce bracing option is to use a strap around the forearm. The results of systematic reviews are inconclusive about the efficacy of the treatment as a whole; however, initial bracing may enhance the patient's capacity to do day-to-day activities within the first six weeks.
– If counterforce bracing is unsuccessful, think about using cock-up wrist splinting for your repetitious daily chores; you can also wear it at night to provide relative rest for your wrist.
Frequently apply ice after strenuous activities.
Physical treatment - Infiltration of a local anesthetic might help relieve discomfort, which in turn may make it possible for patients to participate more actively in physical therapy.
– A strength training and stretching program based on eccentric contractions – Ultrasound therapy – Corticosteroid iontophoresis – Dry needling

Medication 

First-Line Treatment: Topical NSAIDs There is some data, albeit of low quality, that suggests topical NSAIDs are significantly more effective than placebo in terms of pain and the number needed to treat (NNT = 7) to benefit in the short term (up to 4 weeks), with minimal adverse effects.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) have a questionable impact on pain and function, but they may provide temporary pain relief. However, they are linked to gastrointestinal (GI) side effects.
Injections of Corticosteroids in the Second Line: reduction in pain for the short term (less than eight weeks), but no advantages were reported for the intermediate or long-term outcomes.

Referral 

The ineffectiveness of conservative treatment


Extra Medical Interventions 
Given the nature of the damage, a significant number of recently developed treatments concentrate on tendon regeneration.

Nitric oxide (NO) is a type of tiny free radical that is produced during the creation of nitric oxide (NO). Glyceryl trinitrate (GTN) transdermal patches contain NO. It is believed that NO has a role in the production of collagen, as it is expressed by fibroblasts. Through this method, topical use of GTN should, in theory, aid the healing process. A transdermal patch containing five milligrams of glycated transdermal nicotine is applied once per day for a maximum of twenty-four weeks. – When compared to the placebo patch, those using the real thing experience significantly less discomfort after three weeks and six months.
Extracorporeal shock wave therapy, often known as ESWT, is a form of treatment that is noninvasive and does not include the use of electricity. According to some research, ESWT is 89% as successful as WES in the treatment of LET.

In prolotherapy, a dextrose solution is injected into and around the tendon attachment in order to generate a localized inflammatory reaction. This leads to increased blood flow, which in turn encourages the body's natural healing processes.
Platelet-rich plasma (PRP) injections cause a local inflammatory reaction because they include the injection of supraphysiologic levels of autologous PRP. Platelets, when activated, will degranulate, which will cause them to release growth factors and initiate the physiologic healing cascade. The use of PRP therapy for patients with chronic LET results in a considerable reduction in pain and a gain in function. Even after a follow-up period of one year, the benefits of this treatment outweigh those of corticosteroid injections.

Injection of a local anesthetic is followed by US-guided tendon fenestration, aspiration, and abrasion of the underlying bone. This procedure is supposed to break apart scar tissue and encourage inflammation and healing. US-guided percutaneous needle tenotomy entails these steps: — In most cases, a referral to a specialist in sports medicine or orthopedic medicine who has specialized equipment and training is required.
Autologous tenocyte injection (ATI) is a two-step method that involves harvesting a small number of tenocytes, most commonly from the patellar tendon, and then cultivating those tenocytes. Following this step, cultured tenocytes are introduced into the tendon in an effort to encourage regeneration.
● Botulinum toxin A for chronic LET
Outpatient treatment is an option for administering injections into the forearm extensor muscles at a dose of sixty units.

Surgical Procedures Surgical intervention is required in only 2.8% of patients; elbow surgery may be indicated in refractory instances when other treatment options have failed to alleviate symptoms: – Consists of debridement and tendon release – May be carried out either open or arthroscopically
— A five-year study found significant increases in subjects' VAS, DASH scores, and grip strength.

Denervation of the lateral humeral epicondyle, which involves the transection of the posterior cutaneous nerve of the forearm and its subsequent implantation into the triceps, may be helpful in relieving persistent symptoms and pain.

Alternative Medicine 

Acupuncture is an excellent method for the temporary alleviation of pain associated with lateral epicondyle pain.

The prognosis is favorable; the majority of cases improve with conservative treatment.

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