Outpatient practice requires the need to have a large amount of knowledge. Sometimes it seems that the information baggage here is many times greater than that of colleagues from the hospital. This is not an infringement on inpatient doctors, but rather a statement of fact arising from several key provisions:
- time limit;
- restrictions on the availability and timeliness of laboratory and instrumental diagnostics;
- a large flow of patients from different areas of the same profile or different profiles;
- lack of consultation with highly specialized specialists on demand in an outpatient setting.
In this regard, the same outpatient surgeon must understand both the nosologies of his level and “inpatient” diseases. Since most residents and specialists who trained in the specialty “General Surgery” do not have such knowledge, we decided to talk about what outpatient surgeons face and how they cope.
The first fairly common outpatient surgical nosology that we will talk about today is epicondylitis. What is it and how to deal with it - read on.
Epicondylitis is a type of musculoskeletal disorder in which the epicondyle of the humerus becomes inflamed. Considering that there are two epicondyles, epicondylitis itself is divided into:
- medial, or “golfer’s elbow”;
- lateral, or “tennis elbow.”
Based on the classification above, we will analyze both of these options.
What is lateral epicondylitis of the elbow joint?
Your elbow joint is made up of 3 bones: the humerus and two forearm bones (the radius and ulna). At the bottom of the humerus there are bony tubercles called epicondyles, where several muscles of the forearm begin their movement. The bump on the outside of the elbow is called the lateral epicondyle. Adjacent to this epicondyle of the humerus is a tendon that continues with the muscle of the outer surface of the elbow and its main task is to raise the hand.
Epicondylitis of the elbow is an inflammation, or in some cases, a microtear, of the tendons that connect to the muscles of the forearm on the outside of the elbow. Inflammation can be acute and chronic, lateral and medial.
Causes
The muscles and tendons of the forearm become damaged from overuse - repeating the same movements over and over for 2 hours or moving loads of more than 20 kg at least 10 times a day. Direct elbow strikes or sharp jerks can also be unsuccessful. All this can lead to inflammation and microcracks in the tendon and, as a result, to epicondylitis.
Disease frequency
Tennis elbow is one of the most common hand diseases. The incidence ranges from 3 to 11 patients per 1000 per year. Prevalence ranges from 1% to 3% in the general population and can be as high as 23% in workers and athletes. People in the following professions are especially prone to developing epicondylitis: painters, plumbers, carpenters, butchers, cooks. The peak prevalence of tennis elbow is estimated to be 1.3% in individuals aged 45 to 54 years.
Symptoms
Symptoms of lateral epicondylitis (LE) of the elbow develop gradually.
In most cases, the pain starts mild and slowly gets worse over weeks and months. The dominant hand is most often affected, but both hands can be affected. There is usually no specific injury occurring when symptoms appear. More often, patients complain of lateral pain in the elbow joint, which often radiates to the muscles of the proximal extensor of the forearm:
- Pain or burning in the outer part of the elbow;
- Weak grip strength;
- Pain at night;
- Sharp pain when forearm is active: holding a racket, turning a wrench, or shaking hands.
With severe inflammation, the pain can be so severe that even holding a cup of coffee will be a challenge.
Diagnostics
The diagnosis is made based on complaints and external examination. X-rays for epicondylitis are informative only in the case of a long-term chronic course, when structural changes become noticeable in the affected joint: a decrease in bone density (osteoporosis), pathological growths (osteophytes).
MRI and biochemical blood tests are performed when it is necessary to differentiate epicondylitis from other diseases or injuries (fracture, carpal tunnel syndrome or GHS).
Treatment of epicondylitis
When making a diagnosis, your doctor will take many factors into account: how your symptoms developed, how active you are, what sports you play, how old you are, and whether you have had any elbow injuries.
To make the diagnosis more accurate, the doctor may order additional tests: ultrasound of the elbow joint, x-rays to clearly image dense structures, magnetic resonance imaging (MRI) to image the soft tissues of the body, including muscles and tendons.
If your doctor thinks your symptoms may be related to a neck problem, an MRI of your neck may be ordered to see if you have a herniated disc or arthritic changes. Both of these conditions can cause arm pain. The most common methods for treating tennis elbow are:
- Limitation of movements, rest and peace
. These are the first steps towards relieving inflammation. You will need to stop/reduce exercise, heavy work, and other activities that cause painful symptoms for several weeks. - Cold compresses
. - Medicines
. You can take an anti-inflammatory drug, acetaminophen or ibuprofen, to reduce pain and swelling. Non-steroidal anti-inflammatory drugs (NSAIDs) containing diclofenac, ketoprofen or others that act symptomatically and do not cause tissue regeneration can also be prescribed. - Physiotherapy
. Special exercises help strengthen the muscles of the forearm. Massage, iontophoresis and laser therapy are effective to improve muscle healing. - Wearing bandages and orthoses
. Using a bandage placed in the center of the back of the forearm promotes rapid recovery. The orthosis massages the tissues during exercise, stimulates metabolism and blood circulation and helps relieve swelling. - Steroid injections
. Steroids (cortisone) are very effective anti-inflammatory drugs. They are injected into the area around the lateral epicondyle to relieve symptoms. - Plasmolifting
. Blood is taken from the patient, then the resulting material is centrifuged to obtain plasma. Platelet-rich plasma (PRP) injections are intended to improve the biological environment of the tissue. Platelets are known for their high concentration of growth factors, which can be injected into the affected area. - ESWT
(Extracorporeal Shock Wave Therapy) - shock wave therapy. Sound waves of different frequencies create “microtraumas” that promote the body’s natural healing processes. Many doctors consider shock wave therapy experimental, but numerous studies confirm the effectiveness of the method.
Approximately 80% to 95% of patients achieve success with conservative treatment. If symptoms do not disappear after 6-12 months of conservative treatment, surgical intervention will be required. Author: Serdyuchenko Sergey Nikolaevich Orthopedic traumatologist of the highest category
causes
causes
The most common provoking factor leading to the formation of microdamages in the tissues of the external meniscus area, as well as the development of inflammation, is playing sports associated with a fairly high functional load on the muscles of the forearm and hand. External epicondylitis is called “tennis elbow” because the disease is most common in tennis players.
Also, the development of epicondylitis may be associated with exposure to provoking causative factors not related to sports, these include:
- Professional human activity associated with constant high dynamic and static loads on the forearm and hand (painters, mechanics, artists, carpenters).
- Age - the older the person, the higher the likelihood of developing degenerative-dystrophic processes in the tissues and structures of the area of the external epicondyle, leading to their destruction and the development of the inflammatory process. In this case, the pathological process mainly develops against the background of normal functional loads.
- Previous injuries leading to the formation of scars in the area of the tendons and bone base, which can then become inflamed.
- A long-term inflammatory process in the area of the structures of the elbow joint, caused by a specific infectious or autoimmune (formation of antibodies to the body’s own tissues) process.
- A congenital change in the properties and strength of connective and bone tissue, caused by disturbances in the genome, while the inflammatory process in the area of the external epicondyle develops already in childhood.
During the diagnosis, the reasons that led to the development of the disease are necessarily clarified. This is necessary to select the most optimal therapeutic tactics, as well as to prevent the recurrence of a pathology such as external epicondylitis of the shoulder.
Types of fasteners
For joint damage, four main types of fixators are used:
- elastic bandages;
- bandages;
- plaster casts;
- orthoses.
Each of these options has its own advantages and disadvantages. You will not be able to choose a suitable product on your own: you must first consult with your doctor.
Despite the fact that orthoses are easy to put on and take off, the first fixation must be carried out by a doctor. After that, he will tell you in detail how to use the product and when it can be removed.
ORTHOPEDIST-TRAUMOTOLOGIST
The mechanism of action of shock waves in epicondylitis
The use of shock wave therapy for epicondylitis helps relieve pain and reduce the intensity of inflammatory and degenerative processes in tissues.
Pain relief
The analgesic effect when using shockwave therapy is due to the stimulation and activation of nerve fibers, which leads to an increase in the pain threshold. Shock waves also help reduce the concentration of a protein involved in the transmission of pain impulses.
Strengthening tissue regeneration
Tissue restoration and regeneration is carried out by dilating blood vessels, forming new capillaries, improving the permeability of cell membranes, restoring cellular and tissue metabolism and removing inflammatory products from tissues. Oxygen and nutrients enter the pathological focus, and stem cells migrate. The production of elastin and collagen is stimulated, as a result of which the tendon tissue is restored.
Literature review
A group of Turkish scientists conducted a comparative study of the effectiveness of shock wave therapy and ultrasound treatment in patients with lateral epicondylitis. They divided all patients into 2 groups:
- Group 1, consisting of 25 people, received shockwave therapy - a total of 3 procedures per course with an interval of 1 week.
- Group 2, also consisting of 25 patients, received ultrasound therapy (UT) - a total of 10 procedures per course for 2 weeks.
After completion of treatment, all patients noted significant improvement. When comparing the two groups immediately after the end of the course of therapy and after a month of observation, the scientists did not find any differences - pain scores on the VAS scale and joint mobility were the same.
Based on their study, the authors concluded that shockwave therapy and ultrasound therapy are equally effective in the treatment of lateral epicondylitis. The advantage of UST treatment was the time factor - the course of treatment required only 3 procedures versus 10 when performing UST.
Another group of Turkish scientists compared the effectiveness of shock wave therapy and corticosteroid hormone injections for lateral epicondylitis. 64 patients were divided equally into two groups:
- Group 1 received shockwave therapy - 3 procedures per course of therapy with an interval of 1 week.
- Group 2 received corticosteroid injections into the most painful point - a total of 3 injections, also with an interval of 1 week.
After completing the course, patients in both groups noted a significant decrease in pain, as well as an increase in compression strength. However, after 1 and 3 months of observation, a number of patients from the second group experienced a relapse of pain, while no relapses were found in the group of patients receiving shockwave therapy.
Based on their study, the authors concluded that shockwave therapy is more effective in the long-term treatment of lateral epicondylitis.
conclusions
Epicondylitis is a common disease that occurs in people of working age and in athletes. The recurrent nature of the course associated with professional or sports activities not only reduces the quality of life of patients, but can also lead to a forced change of profession.
Conservative methods of treating the disease do not always achieve the desired results. In some cases, patients are forced to undergo surgical treatment and undergo rehabilitation courses after surgery.
According to various authors, the UVT method causes virtually no side effects. It can be considered an alternative to traditional conservative treatment and surgery. And long-term observations show no relapse of the disease. Overall, researchers recommend widespread use of shockwave therapy for epicondylitis in outpatient settings.