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Elbow epicondylitis (elbow joint)

What is epicondylitis

Epicondylitis is a lesion of tissues in the region of the elbow joint, bearing inflammatory-degenerative in nature. The disease begins to develop in the attachment of the tendons of the forearm to namiseom of the humerus, on the outer or inner surface of the joint. Its primary cause is chronic overload of the muscles of the forearm.

When epicondylitis pathological process affects the bone, periosteum, tendon, attached to namesake, and the vagina. In addition to the external and internal condyle is affected styloid process of the radius bone, which leads to the development of steroidica and occurrence of pain at the site of attachment of tendons of muscles, diverting and extending the thumb.

Epicondylitis of the elbow is a very common disease locomotor apparatus, but the exact morbidity statistics is missing, because the disease often progresses in a fairly easy form, and most potential patients do not use medical institutions.

Localisation epicondylitis is divided into the outer (lateral) and internal (medial). Lateral epicondylitis occurs 8-10 times more frequently than medial, and predominantly in men. While right-handers who suffer most right-hand and left-handers left.

The age range that has the disease is 40-60 years. The risk group includes the people, the kind of activity which is associated with the constant repetition of the same monotonous movements (drivers, athletes, pianists, etc.).

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Causes of epicondylitis

In the development of the disease degenerative changes in the joint is preceded by an inflammatory process.

Aggravating factors in this case are:

  • The nature of the main work;
  • Regular microtrauma or direct trauma to the elbow joint;
  • Chronic overloading of the joint;
  • Violation of local circulation;

  • The presence of degenerative disc disease of the cervical or thoracic spine, shoulder periarthritis,osteoporosis.

Epicondylitis is often diagnosed in people whose main activity is associated with repetitive hand movements: Michaud (turning the forearm inward and palm down) and supination (turning outward palm up).

The risk groups include:

  • agricultural workers (tractor drivers, milkmaids);
  • builders (masons, plasterers-painters);
  • athletes (boxers, weightlifters);
  • doctors (surgeons, massage therapists);
  • musicians (pianists, violinists);
  • of service workers (hairdressers, pressers, typists), etc.

By themselves, these professional classes do not cause epicondylitis. The disease occurs when excessive overloading of the muscles of the forearm when her background systematic microtrauma occur periarticular tissues. The result begins to develop inflammation, there are small scars, which further reduces the strength of the tendons to stress and muscular tension, and leads to an increase in the number of minor wounds.

In some cases, the epicondylitis occurs because:

  • Received direct trauma;
  • Congenital weakness of the ligaments in the elbow joint region;
  • A single intense muscle strain.

As mentioned above, the connection of epicondylitis with diseases such as:

  • Osteochondrosis of the cervical or thoracic spine;
  • Scapulohumeral periarthritis;

  • Dysplasia of the connective tissue;

  • Circulatory disorders;
  • Osteoporosis.

On the role of local blood circulation disorders and degenerative phenomena in the occurrence of disease indicate often diagnosed bilateral nature of the lesion and the slow, gradual progression of the disease.


The symptoms of epicondylitis

Common symptoms of epicondylitis include:

  • Spontaneous intense, sometimes burning pain in the elbow joint that over time can acquire a dull, aching character;
  • Strengthening of pain during physical load on the elbow or when the muscle tension of the forearm;
  • The gradual loss of muscle strength in the hand.

When lateral epicondylitis paindistributed over the outer surface of the elbow joint. It increases with extension of the wrist against the resistance of his passive flexion and rotation of the brush outward. In the latter case there was also a weakness of the muscles on the outside of the elbow. Test "coffee cups" gives a positive result (pain increases when you try to lift from the table a Cup filled with liquid). The intensity of pain increases with supination (turning outward) of the forearm of the extreme points of pronation.

In medial epicondylitis the pain is localized on the inner surface of the elbow, worse when flexing the forearm and if resistance to passive extension of the wrist. The pain can give down in the course of the intrinsic muscles of the forearm to the side of the brush. There is a sharp restriction of range of motion in the joint.

There are acute, subacute and chronic stages of the disease. First pain syndrome is accompanied by a sharp or prolonged muscle tension, then the pain becomes constant, appears rapid fatigue of hand muscles. In the subacute stage the intensity of the pain decreases again, at rest they disappear. About chronic say when periodic alternation of remission and relapse lasts from 3 to 6 months.


Types of epicondylitis

Depending on the localization epicondylitis is divided into two main types: external, or outer, which affects the tendons that attach to the outer namesake, and internal, in which inflammation of the tendon running from the internal epicondyle.

The lateral (outer) epicondylitis

In this case inflamed the point of attachment of muscle tendons to the lateral namesake bones. Outside epicondylitis is often called "tennis elbow", because this problem is typical of people who are fond of this sport. In the game of tennis is strain of the muscles-extensors, located on the outer side of the forearm. Such excessive stress on specific muscles and tendons is also observed in a monotonous work, like sawing wood, painting walls, etc.

Lateral epicondylitis is detected when holding the test, which is called "a symptom of a handshake". A firm handshake is pain. Also the pain may appear when you expand the brush palm up, with extension of the forearm.

The medial (inside) epicondylitis

When internal epicondylitis affects the place of attachment of muscle tendons to the medial namesake bones. Other names this type of disease – epitrochlea and "golfer's elbow", which indicates its prevalence among fans of the game of Golf. Also to medial epicondylitislead such sports as throwing, throwing the nucleus.

In contrast to the lateral, epicondylitis is more common during lighter loads, therefore, occurs primarily in women (typists, dressmakers, etc.). Repetitive stereotyped movements, which they perform, are made at the expense of the flexors of the wrist are attached by tendons to the medial namesake of the humerus.

Usually pain occurs when pressure is applied to the inner epicondyle, increases with flexion and pronation of the forearm and radiates along its inner edge. In most cases the patient can accurately determine the localization of the pain. For internal epicondylitis is particularly characterized by a chronic course and the involvement of the ulnar nerve.

Traumatic epicondylitis

To tennis elbow refers to systematic minor trauma in the process of constant repetitive tasks. Usually it is accompanied with deforming arthrosis of the elbow joint, the defeat of the ulnar nerve and cervical osteochondrosis. At the age of 40 years the ability of tissues to regenerate is reduced and the damaged structures are gradually replaced by connective tissue.

Post-traumatic epicondylitis

This type of epicondylitis develops as a consequence of the resulting sprain or dislocation of the joint, with poor adherence to medical advice during rehabilitation, and a too hasty transition to intensive work by the joint.

Chronic epicondylitis

Chronic very common for such diseases as epicondylitis. For a long time when the exacerbation followed by relapses, the pain gradually becomes weak, aching in nature, and the muscles lose strength, to the point that people can't sometimes write or just take something in hand.

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Diagnosis of epicondylitis

The diagnosis is based on patient interviews, medical history data and visual inspection. The difference between epicondylitis from other destructive lesions of the elbow joint is determined by the specifics of the pain syndrome. In this disease the pain in the joint only appear when an independent physical activity. If the doctor himself performs the various movements of the patient's arm without his muscles (see passive flexion and extension), pain arises. This differs from epicondylitis arthritis orosteoarthritis.

Further tests on the symptoms of Thomson and Velta. Test Thomson is as follows: the patient should compress in a fist the brush located in the rear position. She pretty quickly takes place, moving into position, palm up. The detection of the symptom of Velta need to keep the forearm at the level of the chin, and simultaneously straighten and bend the arms. Both the actions performed by the patient hand lags behind the actions of a healthy hand. The conduct of these tests is accompanied by severe pain. Also this disease is characterized by pain in the region of the articular tendons in the abduction hands behind his back.

Epicondylitis it is necessary to differentiate with:

Epicondyle fracture when there is swelling of the soft tissues in the joint, which is not in epicondylitis. Arthritis pain occurs in the joint, and not in namesake, while it is more vague and not clearly localized.

When nerves marked characteristic neurological symptoms, disturbance of sensitivity in zone of innervation.

Syndrome joint hypermobility (if we are talking about young patients) is caused by a congenital weakness of the connective tissue. For its detection examines the frequency of sprains, excessive mobility of the joints, flat feet.

Additional methods of examination in diagnosis of epicondylitis usually doesn't apply. To differentiate from a fracture of the epicondyle is an x-ray, with carpal tunnel syndrome – magnetic resonance imaging, acute inflammatory process, biochemical analysis of blood.

Radiography when epicondylitis informative only in the case of long-term chronic course of the disease. In this case, the detected foci of osteoporosis, osteopenia sprawl, sealing of the ends of the tendons and bone.


How to treat epicondylitis?

Treatment in the outpatient. Therapeutic strategy depends on the duration of the disease, the extentfunctional disorders of the joint and pathological changes of muscles and tendons.

The main objectives are:

  • The cessation of pain in the lesion;
  • Restoration of local blood circulation;
  • Restoring full range of motion in the elbow joint;

  • Prevention of atrophy of muscles of the forearm.

When the weak pains are advised to observe protective mode and try to eliminate movements that cause the pain. If work or sport activities associated with a heavy load on the muscles of the forearm, should be temporarily to provide rest to the elbow joint, as well as to find and remove causes of overload: change the technique to execute specific movements, etc. After the disappearance of pain should start with minimum load and increase it gradually.

In chronic course of the disease and frequent relapses, it is recommended to change occupation or to stop doing the sport.

When expressed pain syndrome in the acute stage is of short-term immobilization of the joint with a cast or a plastic splint for about a week. After removing the splint, you can do hot compresses with camphor alcohol or vodka. In the chronic stage, is recommended day to fix the joint and forearm with an elastic bandage, removing it at night.

The use of NSAIDs

Since the cause pain syndrome with epicondylitis is an inflammatory process that are assigned non-steroidal anti-inflammatory drugs topical application in the form of ointments: Diclofenac, Nurofen, Indomethacin, Nimesil, Ketonal, Nise, etc. Oral NSAIDs in this case, a little justified.

For very severe, unrelenting pain are the blockade with corticosteroids, which are introduced into the area of inflammation: hydrocortisone or methyprednisolone. However, we must note that in the first days it will cause increased pain. The glucocorticosteroid is mixed with anesthetic (Lidocaine, Novocaine). Usually made 2-4 injections with an interval of 3-7 days.

With conservative treatment without the use of corticosteroids pain syndrome is usually removed within 2-3 weeks, when carrying out medicinal blockades within 1-3 days.

Can additionally be assigned Nikoshpan, Aspirin, Phenylbutazone. To change the trophism of the tissues may be held blockade with bidistilled water, they are quite painful but effective. In chronic disease prescribe injections Milgamma.

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Physiotherapy

For the treatment of epicondylitis is used in almost all the possible list of physiotherapy.

In the acute phase may be conducted:

  • High-intensity magnetotherapy course of 5-8 sessions;
  • Diadynamic therapy, the course of 6-7 sessions;
  • Infrared laser radiation, the duration of exposure 5-8 minutes, the course is 10-15 procedures;

After the acute stage is prescribed:

  • Extracorporeal shock wave therapy;
  • Phonophoresis of a mixture of hydrocortisone and anesthetic;
  • Electrophoresis with novocaine, acetylcholine or potassium iodide;
  • Currents Bernard;
  • Paraffin-ozocerite and neftyanoye of an application;
  • Cryotherapy with dry air.

Paraffin baths can be done approximately 3-4 weeks after immobilization of the joint and novocaine blockade. In shock wave therapy acoustic wave should be directed to the joint area and not spread to the ulnar, median, radial nerves and blood vessels.

To prevent muscle atrophy and restore joint functions administered massage, mud therapy, wet and dry air baths and physical therapy. There are good reviews about acupuncture.

In rare cases, chronic bilateral epicondylitis with frequent exacerbations, progressive muscular atrophy or compression of nerve roots does not help even injection of glucocorticosteroid drugs. In this situation, surgical intervention.

Surgery

If conservative treatment the pain does not stop within 3-4 months, this is an indication for surgical excision of the tendons in their places attach to the bone.

The so-called operation of Gohman is carried out in a planned manner with the use of regional anesthesia or under General anesthesia. In the original version of escales tendons in their places connections with the muscles-extensors.

Currently, excision is carried out in the region of attachment of the tendon to the bone. Thus in the outer epicondyle is a small horseshoe-shaped incision of approximately 3 cm, the epicondyle is exposed, and in front of him is 1-2 cm incision of tendon fibers, without affecting the bone. All attachments of the extensors are not violated, but the source of pain on the anterior surface of the epicondyle is released from the muscle pull. The risk of damage to blood vessels and nerve channels is excluded. After the operation surface overlap the seams and plaster, suturesare removed after 10-14 days.

Exercise in epicondylitis

Physiotherapy helps to restore function of the joint. To start it only after the extinction of the acute stage of the disease. Complex physical therapy must be written by the attending physician. Basic exercises aimed at stretching and relaxation of the muscles and tendons.

At the gym you must follow these rules:

  • Increase the load and duration of sessions gradually;
  • Stop exercise immediately if you feel unexpected pain, as they should not cause pain;
  • Doing exercise daily.

Therapeutic exercises improve circulation, stimulate the flow of lymph and the secretion of synovial fluid, increase the elasticity of the ligaments and strengthen muscles, which generally increases the endurance of the elbow joint.

Exercises recommended for the epicondylitis, is divided into active and passive movements performed by another, healthy hands.

Passive movement:

  • To clasp his good hand, the other hand and slowly bend it until feeling tension in your arm, to ensure that the angle between the hand and the forearm was 90 degrees. To stay at the point for 10-15 seconds. Make two sets of 7-10 times. Repeat this same exercise, straightening brush (i.e. taking it up).
  • Standing to put both palms on the Desk. Slightly lean forward so that your palms up with arms straight angle.
  • Put hands on the table, the back surface (palms facing up), fingers sent to him, elbows slightly bent. Also try to create a right angle between hands and forearms, leaning a little away from the table.

After stretching exercises will no longer cause any discomfort, you can move on to exercises to strengthen the muscles and ligaments.

Active movement:

  • Alternately translating the free hand to position pronation and supination, the palm at first looks down, then up;
  • Successively bend and straighten the forearm, the shoulder remains stationary;
  • Bend your arm at the elbow, alternately to compress and unclench the fist;
  • To link hands in the lock, bend and straighten both elbows;
  • rotate the shoulders forward and back, then perform circular movements of the forearms;
  • Raise your straight arms in front of you and alternately make one for the other ("scissors").
  • Take a thick rubber cord and reel it ends on the hands. Put brush healthy hand on the table, brush the patient's hands placed on it palm down. To produce slow extension and flexion of the brush patient hands, stretching the cord to provide resistance. Then deploy the hand palm up and repeat the exercise.
  • Stand straight, feet shoulder width apart, back straight, held at arm's length in front of him hand gymnastics stick vertically. Slowly turn the stick parallel to the floor (palm goes down), and slowly return arm to starting position. Then again rotate the stick to a horizontal position, only the palm is now looking up. Continue to twist the stick, pausing in the extreme positions. Do 2-3 sets of 20.

You can then move on to strength training with minimal load, for example, to work with carpal expander, but avoiding muscle tension.

Some exercises:

  • To pick up a hammer or any other heavy object that is comfortable to hold; the brush facing the back surface up, the angle in the elbow joint is 90-120 degrees. To supinate your (straighten) brush and return to the previous position. Do 2 sets of 10 repetitions, with a break of 2-3 minutes.
  • Take the hammer in the same way, only brush the back surface facing down (palm up). Bend and straighten the wrist. Do 2 sets of 10 repetitions, with a break of 2-3 minutes.

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Prevention of epicondylitis and forecast

Prevention is divided into primary (prevent the disease) secondary (prevent relapse). And in that and in other case it is necessary to observe the established mode of work and rest.

Among specific recommendations are the following:

  • In sports must follow the correct technique of exercises and correctly pick up sports equipment;
  • Try to avoid stereotypical repetitive movements, load on the joint;
  • Before any kind of physical activity to carry outworkout of the joints, warming the muscles and tendons;
  • In the period of exacerbation and in severe physical exertion locking elbow joints using an elastic bandage or elbow pads;
  • Prolonged repetitive movements, take breaks at work.

Drug prevention is a regular intake of vitamin products, as well as timely treatment of any foci of inflammation in the body.

The prognosis for the epicondylitis favorable, subject to preventive measures, you can achieve a stable remission.


uravitsky Igor, the doctor-the rheumatologist