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X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as fracture or arthritis. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle. Medical ultrasonography and magnetic resonance imaging (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost. MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.
If severe pain persists after the first 24hours it is recommended that an individual consult with a professional who can make a diagnosis and implement a treatment plan so the patient can return to everyday activities (Flegel, 2004). These are some of the tools that a professional can use to help make a full diagnosis;
Nerve conduction studies may also be used to localize nerve dysfunction ("e.g.", carpal tunnel syndrome), assess severity, and help with prognosis.
Electrodiagnosis also helps differentiate between myopathy and neuropathy.
Ultimately, the best method of imaging soft tissue is magnetic resonance imaging (MRI), though it is cost-prohibitive and carries a high false positive rate.
CMC OA is diagnosed based on clinical findings and radiologic imaging.
Ultrasound imaging can be used to evaluate tissue strain, as well as other mechanical properties.
Ultrasound-based techniques are becoming more popular because of its affordability, safety, and speed. Ultrasound can be used for imaging tissues, and the sound waves can also provide information about the mechanical state of the tissue.
Increased water content and disorganized collagen matrix in tendon lesions may be detected by ultrasonography or magnetic resonance imaging.
To diagnose tennis elbow, physicians perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin), 1cm distal and slightly anterior to the lateral epicondyle. There is also pain with passive wrist flexion and resistive wrist extension (Cozen's test).
As the symptoms become prominent, the child will visit their pediatrician or family doctor to confirm whether or not the child has Panner Disease. When the child visits the doctor, the doctor will seek information about the child’s age, sports participation, activity level, and what the child’s dominant arm is. The affected elbow will be compared to the healthy elbow and any differences between the two will be noted. The location of where the pain is in the elbow, and the child’s range of motion and extension will also be determined to make an accurate diagnosis. To check the child’s range of motion and extension limitation the child will be asked to move the arm of the affected elbow in various directions. The movement of the arm in various directions will allow the doctor to conclude how good the child is able to move the arm and the doctor will be able to determine if there is pain caused by the various directions of movement.
To confirm the diagnosis, an x-ray or MRI scan will be done. The radiograph will enable the doctor to visualize irregularities and see the shape of the capitellum and also visualize the growth plate. In Panner Disease, the capitellum may appear flat and the bone growth plate will look irregular and fragmented. The areas where bone breakdown has occurred can also be visualized on the radiograph. When the patient undergoes a MRI scan any irregularities of the capitellum will able to be visualized, and the bone will be able to be visualized in more detail to determine the extent of swelling, if any. In the MRI results for Panner disease, there will be a decreased signal intensity of the capitellum on a T1 series and increased signal intensity on a T2 series.
As of July 2000, hypermobility was diagnosed using the Brighton criteria. The Brighton criteria do not replace the Beighton score but instead use the previous score in conjunction with other symptoms and criteria. HMS is diagnosed in the presence of either two major criteria, one major and two minor criteria, or four minor criteria. The criteria are:
Being an extremely rare disease, it is unknown as to what exactly causes Panner Disease. It is believed that the disease may be brought on by continuous overuse of the elbow and that puts pressure on the elbow and also strains the elbow in children during the period of rapid bone growth. The overuse of the elbow can be due to the involvement in sports such as baseball, handball, and gymnastics where these sports involve throwing or putting a lot of pressure on the joints. These repeated activities cause microtraumas and results in the affected elbow being swollen, irritated, and in pain. Panner Disease results when the blood supply to the capitellum is disrupted and therefore the cells within the growth plate of the capitellum die and it becomes flat due to the softening and collapsing of the surrounding bone. To prevent future instances of Panner Disease the child is instructed to cease all physical and sports activities that involve the use of the affected elbow until the symptoms are relieved.
Percutaneous ultrasonic tenotomy provided continued pain relief and functional improvement for recalcitrant tennis elbow at a 3-year follow-up.
The diagnosis is based on symptoms and signs alone and objective testing is expected to be normal. This syndrome may be clinically tested by flexing the patients long finger while the patient extends the wrist and fingers. Pain is a positive finding.
The chief complaint of this disease is usually pain in the dorsal aspect of the upper forearm, and any weakness described is secondary to the pain. Tenderness to palpation occurs over the area of the radial neck. Also, the disease can be diagnosed by a positive "middle finger test", where resisted middle finger extension produces pain. Radiographic evaluation of the elbow should be performed to rule out other diagnoses.
In most cases, a physician will diagnose an ulnar collateral ligament injury using a patient’s medical history and a physical examination that includes a valgus stress test. The valgus stress test is performed on both arms and a positive test is indicated by pain on the affected arm that is not present on the uninvolved side. Physicians often utilize imaging techniques such as ultrasound, x-rays and magnetic resonance imaging or arthroscopic surgery to aid with making a proper diagnosis.
This method should be used within the first 48–72 hours after the injury in order to speed up the recovery process.
Heat: Applying heat to the injured area can cause blood flow and swelling to increase.
Alcohol: Alcohol can inhibit your ability to feel if your injury is becoming more aggravated, as well as increase blood flow and swelling.
Re-injury: Avoid any activities that could aggravate the injury and cause further damage.
Massage: Massaging an injured area can promote blood flow and swelling, and ultimately do more damage if done too early.
A cubitus varus deformity is more cosmetic than limiting of any function, however internal rotation of the radius over the ulna may be limited due to the overgrowth of the humerus. This may be noticeable during an activity such as using a computer mouse.
One way to prevent this injury from occurring is to be informed and educated about the risks involved in hurting your wrist and hand. If patients do suffer from median nerve palsy, occupational therapy or wearing a splint can help reduce the pain and further damage. Wearing a dynamic splint, which pulls the thumb into opposition, will help prevent an excess in deformity. This splint can also assist in function and help the fingers flex towards the thumb. Stretching and the use of C-splints can also assist in prevention of further damage and deformity. These two methods can help in the degree of movement the thumb can have. While it is impossible to prevent trauma to your arms and wrist, patients can reduce the amount of compression by maintaining proper form during repetitive activities. Furthermore, strengthening and increasing flexibility reduces the risk of nerve compression.
Non-specific treatments include:
- Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
- Heat or ice
- A counter-force brace or "elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.
Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as the common rest, ice, compression and elevation (R.I.C.E.) will typically be used. This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The patient can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm. The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
Therapy will include a variety of exercises for muscle/tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly begin with isometrics and progresses to eccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the patient to ice the area.
Simple analgesic medication has a place, as does more specific treatment with oral anti-inflammatory medications (NSAIDs). These will help control pain and any inflammation. A more invasive treatment is the injection into and around the inflamed and tender area of a long-acting glucocorticoid (steroid) agent. After causing an initial exacerbation of symptoms lasting 24 to 48 hours, this may produce an improvement of the condition in some five to seven days.
The ulnar nerve runs in the groove between the medial humeral epicondyle and the olecranon process of the ulna. It is most important that this nerve should not be damaged accidentally in the process of injecting a golfer's elbow.
If all else fails, epicondylar debridement (a surgery) may be effective. The ulnar nerve may also be decompressed surgically.
If the appropriate remediation steps are taken - rest, ice, and rehabilitative exercise and stretching - recovery may follow. Few patients will need to progress to steroid injection, and less than 10% will require surgical intervention.
The Beighton score is an edited version of the Carter/Wilkinson scoring system which was used for many years as an indicator of widespread hyper-mobility. Medical professionals varied in their interpretations of the results; some accepting as low as 1/9 and some 4/9 as a diagnosis of HMS. Therefore, it was incorporated, with clearer guidelines, into the Brighton Criteria. The Beighton score is measured by adding 1 point for each of the following:
- Placing flat hands on the floor with straight legs
- Left knee bending backward
- Right knee bending backward
- Left elbow bending backward
- Right elbow bending backward
- Left thumb touching the forearm
- Right thumb touching the forearm
- Left little finger bending backward past 90 degrees
- Right little finger bending backward past 90 degrees
Diagnosis is confirmed by x-ray imaging. Displaced fractures are readily apparent. A non-displaced fracture can be difficult to identify and a fracture line may not be visible on the X-rays. However, the presence of a joint effusion is highly suggestive of a non-displaced fracture. Bleeding from the fracture expands the joint capsule and is visualized on the lateral view as a darker area anteriorly and posteriorly, and is known as the sail sign. Depending on the child's age, parts of the bone will still be developing and if not yet calcified, will not show up on the X-rays. At times, X-rays of the opposite elbow may be obtained for comparison. There are landmarks on the X-rays that can be used to assess displacement, including the "anterior humeral line", which is a line drawn down along the front of the humerus on the lateral view and it should pass through the middle third of the capitulum of the humerus.
RSIs are assessed using a number of objective clinical measures. These include effort-based tests such as grip and pinch strength, diagnostic tests such as Finkelstein's test for De Quervain's tendinitis, Phalen's Contortion, Tinel's Percussion for carpal tunnel syndrome, and nerve conduction velocity tests that show nerve compression in the wrist. Various imaging techniques can also be used to show nerve compression such as x-ray for the wrist, and MRI for the thoracic outlet and cervico-brachial areas.
Conservative management of minor cases involves icing, a firm compression bandage, and avoidance of the aggravating activity. This can also be augmented with oral or topical anti-inflammatory medications such as NSAIDs. Elbow padding can also be used for symptomatic relief. Treatment for more severe cases may include the excess bursa fluid with a syringe (draining of the bursa), or injecting into the bursa a hydrocortisone type medication which is aimed at relieving the inflammation and preventing further accumulation of fluid.
In case of infection, the bursitis should be treated with an antibiotic.
To assess an olecranon fracture, a careful skin exam is performed to ensure there is no open fracture. Then a complete neurological exam of the upper limb should be documented. Frontal and lateral X-ray views of the elbow are typically done to investigate the possibility of an olecranon fracture. A true lateral x-ray is essential to determine the fracture pattern, degree of displacement, comminution, and the degree of articular involvement.
Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.
Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly. There is insufficient evidence on the routine use of injection therapies (Autologous blood, Platelet-rich plasma, Deproteinised haemodialysate, Aprotinin, Polysulphated glycosaminoglycan, Corticosteroid, Skin derived fibroblasts etc.) for treating Achilles tendinopathy. As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies.
If the fluid continues to return after multiple drainings or the bursa is constantly causing pain to the patient, surgery to remove the bursa is an option. The minor operation removes the bursa from the elbow and is left to regrow but at a normal size over a period of ten to fourteen days. It is usually done under general anesthetic and has minimal risks. The surgery does not disturb any muscle, ligament, or joint structures. To recover from surgical removal, a splint will be applied to the arm to protect the skin. Exercises will be prescribed to improve range of motion.
Tendon injury and resulting tendinopathy are responsible for up to 30% of consultations to sports doctors and other musculoskeletal health providers. Tendinopathy is most often seen in tendons of athletes either before or after an injury but is becoming more common in non-athletes and sedentary populations. For example, the majority of patients with Achilles tendinopathy in a general population-based study did not associate their condition with a sporting activity. In another study the population incidence of Achilles tendinopathy increased sixfold from 1979-1986 to 1987-1994. The incidence of rotator cuff tendinopathy ranges from 0.3% to 5.5% and annual prevalence from 0.5% to 7.4%.
Because lesions to different areas of the median nerve produce similar symptoms, clinicians perform a complete motor and sensory diagnosis along the nerve course. Decreased values of nerve conduction studies are used as indicators of nerve compression and may aid in determining the localization of compression.
Palpation above the elbow joint may reveal a bony consistency. Radiography images may show an abnormal bony spur outgrowth (supracondyloid process) just proximal to the elbow joint. Attached fibrous tissue (Struthers' ligament) may compress the median nerve as it passes underneath the process. This is also known as supracondylar process syndrome. Compression at this point may also occur without the bony spur; in this case, aponeurotic tissue found at the location of where Struthers' ligament should be is responsible for the compression.
If patients mention reproduction of symptoms to the forearm during elbow flexion of 120–130 degrees with the forearm in maximal supination, then the lesion may be localized to the area underneath the lacertus fibrosus (also known as bicipital aponeurosis). This is sometimes misdiagnosed as elbow strain and medial or lateral epicondylitis.
A lesion to the upper arm area, just proximal to where motor branches of forearm flexors originate, is diagnosed if the patient is unable to make a fist. More specifically, the patient's index and middle finger cannot flex at the MCP joint, while the thumb usually is unable to oppose. This is known as hand of benediction or Pope’s blessing hand. Another test is the bottle sign—the patient is unable to close all their fingers around a cylindrical object.
Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it passes under the carpal tunnel. Nerve conduction velocity tests through the hand are used to diagnosis CTS. Physical diagnostic tests include the Phalen maneuver or Phalen test and Tinel's sign. To relieve symptoms, patients may describe a motion similar to "shaking a thermometer", another indication of CTS.
Pronator teres syndrome (also known as pronator syndrome) is compression of the median nerve between the two heads of the pronator teres muscle. The Pronator teres test is an indication of the syndrome—the patient reports pain when attempting to pronate the forearm against resistance while extending the elbow simultaneously. The physician may notice an enlarged pronator teres muscle. Tinel's sign the area around the pronator teres heads should be positive. The key to discerning this syndrome from carpal tunnel syndrome is the absence of pain while sleeping. More recent literature collectively diagnose median nerve palsy occurring from the elbow to the forearm as pronator teres syndrome.
In uncooperative patients, the skin wrinkle test offers a pain-free way to identify denervation of the fingers. After submersion in water for 5 minutes, normal fingers will become wrinkled, whereas denervated fingers will not.
In "Ape hand deformity", the thenar muscles become paralyzed due to impingement and are subsequently flattened. This hand deformity is not by itself an individual diagnosis; it is seen only after the thenar muscles have atrophied. While the adductor pollicis remains intact, the flattening of the muscles causes the thumb to become adducted and laterally rotated. The opponens pollicis causes the thumb to flex and rotate medially, leaving the thumb unable to oppose. Carpal tunnel syndrome can result in thenar muscle paralysis which can then lead to ape hand deformity if left untreated. Ape hand deformity can also be seen in the hand of benediction deformity.
The Anterior Interosseus Nerve (AIN), a branch of the median nerve, only accounts for the movement of the fingers in hand and does not have any sensory capabilities. Therefore, the AIN syndrome is purely neuropathic. AINS is considered as an extremely rare condition because it accounts for less than 1% of neuropathies in the upper limb. Patients suffering from this syndrome have impaired distal interphalangeal joint, because of which they are unable to pinch anything or make and "OK" sign with their index finger and thumb. The syndrome can either happen from pinched nerve, or even dislocation of the elbow.
It is important to differentiate between infected and non-infected bursitis. People may have surrounding cellulitis and systemic symptoms include a fever. The bursa should be aspirated to rule out an infectious process.
Bursae that are not infected can be treated symptomatically with rest, ice, elevation, physiotherapy, anti-inflammatory drugs and pain medication. Since bursitis is caused by increased friction from the adjacent structures, a compression bandage is not suggested because compression would create more friction around the joint. Chronic bursitis can be amenable to bursectomy and aspiration.
Bursae that are infected require further investigation and antibiotic therapy. Steroid therapy may also be considered. In cases when all conservative treatment fails, surgical therapy may be necessary. In a bursectomy the bursa is cut out either endoscopically or with open surgery. The bursa grows back in place after a couple of weeks but without any inflammatory component.