Epicondylitis of the shoulder is an inflammatory lesion of tissue in the shoulder area, which is expressed by pain in the area of the elbow joint on the outer surface.
The bones of the shoulder have condyles at the edges - thickenings; on their surface there are epicondyles, they are intended for attaching muscles.
Systematic overstrain of the forearm muscles is the main factor in this disease. According to statistics, brachial epicondylitis accounts for 21% of arm diseases that arise as a result of professional activities - for example, the second name for epicondylitis is “tennis elbow.”
Treatment
Most often, treatment involves restricting arm movements. In acute epicondylitis, the limb must be secured with a bandage.
The disease is highly treatable. The treatment regimen is determined by the attending physician. As a rule, a set of procedures is recommended - drug therapy:
- Use of ointments and gels;
- Injections into the area of inflammation (hydrocortisone or methylprednisolone);
- Vitamin B injections.
As well as folk remedies and physiotherapy:
- Shock wave therapy;
- Acupuncture;
- Magnetotherapy;
- Phonophoresis and electrophoresis;
- Laser therapy;
- Currents Bernard;
- Paraffin treatment;
- Cryotherapy.
After an exacerbation of the disease, therapeutic exercises help restore the functionality of the joint.
Medial epicondylitis
Medial epicondylitis refers to chronic tendinosis of the flexor and pronator muscles of the wrist, which attach to the medial epicondyle. Medial epicondylitis most often occurs due to repetitive pronation of the forearm or flexion of the wrist.
Although it is called epicondylitis, a more appropriate description, especially in chronic conditions, would be epicondylosis or epicondylalgia. Current literature shows that the main process appears to be degeneration and formation of granulation tissue, which is referred to as angiofibroblastic hyperplasia or tendinosis without a definitive inflammatory process. However, it should be noted that there is no clear evidence that there is no inflammatory component in the early stages of the disease.
Medial epicondylitis is primarily caused by repetitive strain associated with frequent weight-bearing grips, forearm pronation, and/or wrist flexion. In the sports world, it can be seen in throwing athletes (baseball pitchers, javelin throwers), golfers, tennis players, bowlers, rock climbers, archers and weightlifters, but it most often occurs in golfers. Intense valgus forces during the late swing and acceleration phases of the golf swing or the late phases of the golf swing just before and during contact with the ball or ground contribute to the prevalence of medial epicondylitis among athletes.
Although the disease is often associated with athletes, it is also common in the general population, commonly seen in carpenters, utility workers, butchers and food service workers. Medial epicondylitis is often caused by poor body mechanics, improper technique, and/or inadequate equipment or tools.
Risk factors for developing medial epicondylitis include smoking, diabetes, obesity, and tasks that require repetitive flexion of the wrist or pronation of the forearm for at least two hours a day.
Patients with medial epicondylitis typically complain of pain in the medial elbow that is aggravated by activities, particularly grasping, throwing, and flexing/pronating the forearm. After resting the limb, symptoms usually go away. The pain most often develops gradually, but may be acute at the beginning due to injury. Sometimes patients experience radiating pain in the forearm or wrist. Patients may complain of increased pain upon awakening in the morning and often report associated numbness in the area of the ulnar nerve due to its anatomical location posterior to the medial epicondyle within the cubital tunnel.
Depending on the severity of the pain, there may be signs of swelling or erythema on examination of the elbow, although in most chronic cases of medial epicondylitis, visible signs on examination are limited. Tenderness to palpation is usually most noticeable 5–10 mm from the medial epicondyle at the flexor pronator insertion. Pain typically worsens with resisted wrist flexion and pronation, with resisted wrist pronation being the most common finding on examination.
Given the fairly characteristic symptoms, the diagnosis can be made clinically based on history and physical examination, so further diagnostic testing is not always necessary. However, in settings where the clinical picture is unclear, imaging can help confirm the suspected diagnosis of medial epicondylitis as well as rule out alternative etiologies.
Plain radiographs may show calcification of the flexor-pronator tendons or traction osteophytes. Magnetic resonance imaging (MRI) is generally considered the gold standard for diagnosing medial epicondylitis. MRI findings consistent with medial epicondylitis include a thickened common flexor tendon sheath with increased signal intensity. MRI can also help rule out other intra-articular or soft tissue pathologies.
Ultrasound (US) has a sensitivity and specificity of 95.2 and 92%, respectively, for the diagnosis of medial epicondylitis. The most common ultrasound findings are focal hypoechoic changes in the common flexor tendon, tendon thickening, partial or complete tears, Doppler neovascularization, and cortical abnormalities in the medial epicondyle. Ultrasound also allows for dynamic imaging studies that may add additional value in the assessment of ulnar nerve subluxation and ulnar collateral ligament instability under valgus stress. In patients whose evaluation suggests ulnar neuritis or neuropathy, electromyography and nerve conduction studies may be useful adjunctive diagnostic tools.
Non-surgical treatment is the mainstay of treatment for medial epicondylitis.
Initial pain relief is achieved by limiting exercise and taking nonsteroidal anti-inflammatory drugs (NSAIDs). When using NSAIDs, topical medications are preferred, but if oral NSAIDs are used, a course of 10 to 14 days should be used to limit possible side effects/complications.
Some patients benefit from bracing using a resistance brace. A night wrist band can also prevent stress caused by your sleeping position. An alternative to traditional fixation is the application of kinesiology tape. Although outcome studies for medial epicondylitis are limited, benefits have been seen using kinesiology tape for lateral epicondylitis.
Patients with medial epicondylitis should actively engage in exercise therapy. The first goal is to establish a full, pain-free range of motion. This is followed by stretching and progressive isometric exercises. As the patient's condition continues to improve, resistance exercises are added to the program. The overall goal is to increase muscle strength beyond pre-injury strength. Once the patient can perform repetitive exercises without discomfort, they return to sports.
Corticosteroid injections have been shown to help relieve symptoms in the short term (up to six weeks after injection), but there was no difference compared to controls in the long term (3 and 12 months after injection). Prolotherapy, platelet-rich plasma (PRP), autologous blood and botulinum toxin injections may also be useful in treating epicondylitis. However, most studies have focused on the treatment of lateral epicondylitis, and further research is needed to determine overall effectiveness.
NB! Caution should be exercised with any injection for medial epicondylitis, given the proximity of the target site to the ulnar and medial antebrachial cutaneous nerves. It is recommended to use ultrasound navigation during the procedure whenever possible.
Surgery is usually not required. However, if there is no benefit from the above conservative treatment within 6 to 12 months, surgical treatment may be considered. Given the proximity to the ulnar nerve, an open surgical technique is preferred. Surgical treatment involves debridement of the degenerated tendon, release of the flexor tendon at the medial epicondyle, and cortical drilling of the epicondyle to increase blood supply. If there is concomitant ulnar neuropathy, transposition is also performed intraoperatively. After surgery, rest and splinting are recommended for the first week to reduce pain and swelling. Therapy begins 7–10 days after surgery to increase passive range of motion. Light isometric exercises are introduced 3–4 weeks after surgery. A progressive strengthening program usually begins between 6 and 12 weeks. After approximately 3–6 months, patients gradually return to sports.
Prevention
- It is possible to avoid the development of epicondylitis of the shoulder if you load your arms moderately and protect the joints from injury or hypothermia.
- Before physical activity, you need to do a warm-up.
- You should consume foods containing calcium and vitamins more often.
- It is important to get rid of bad habits, since drinking alcohol and smoking contribute to poor absorption and excretion of calcium from the body.
At the first signs of epicondylitis, you should immediately consult a doctor.
How does development occur?
The elbow joint is formed by the interaction of nerve endings with the lower part of the forearm. The humerus consists of a lateral and medial epicondyle (peculiar protrusions). The external epicondyle is firmly connected to the tendons, which is consequently responsible for the proper functioning of the hand as a whole.
With great physical activity, such protrusions wear out and minor damage to the bone tissue appears. All these effects provoke an inflammatory process, which will subsequently lead to the formation of external epicondylitis.
Symptoms of a fracture of the lower end of the humerus.
Fractures of the lower third of the shoulder are characterized by severe pain. Preventing movement in the elbow joint, swelling, bruising, pain when touched, a feeling of instability, bone crunching, or crepitus of bone fragments, and in rare cases, protrusion of bone fragments through the skin - an open fracture.
With fractures of the humeral condyles, there is a high risk of damage to blood vessels and nerves. For this reason, during a clinical examination, it is extremely important to assess the sensitivity and pulsation of the arteries at the level of the forearm and hand. If damage to blood vessels or nerves is suspected, non-invasive diagnostic methods should be used. Such as ultrasound. It is also necessary to evaluate the presence of signs of the onset and progression of compartment syndrome at the level of the forearm, and, if necessary, perform a fasciotomy.
Externally, pronounced swelling is detected at the level of the elbow joint and the lower third of the forearm; in the first day the hematoma may not be visible, but it appears and grows later, and can spread to the fingers.
Upon admission of such a patient, after applying temporary immobilization, it is necessary to send the patient for X-ray examinations. In most cases, standard radiographs may be sufficient; sometimes a CT scan is performed when the X-ray picture is not clear enough.
If a clinical examination also reveals pain at the level of the forearm, it is also necessary to take radiographs along its length to exclude fractures at this level.
The radiographs of the elbow joint shown below reveal a comminuted fracture of the condyles of the left shoulder with 4 large fragments.