Introduction
- Robert C. Manske, PT, DPT, MEd, ATC, SCS, CSCS
- Mark Stovak, MD, FAAFP, FACSM, CAQSM
Epidemiology
The epidemiology of forearm tendinitis is dependent upon its type.
Intersection Syndrome
Overuse syndrome of the area in which occurs a crossover of the first and second dorsal compartments of the wrist. First compartment consists of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) and second compartment consisting of the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB).
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Prevalence of 11.9% in group of 42 skiers with symptoms developing within first 2 days of activity
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Found equally in men and women
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Most common in rowers, so it is often called “rower’s wrist”; caused by repetitive feathering of the oar out of the water
De Quervain’s Syndrome
A thickening of the sheath encompassing the tendons of the EPB and the APL
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Prevalence equal among races
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More common in women than men
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Often seen in new mothers resulting from their lifting their babies repetitively
Humeral Epicondylitis
This is an overuse inflammatory condition causing pain and dysfunction at the common extensor or flexor origin. Also, there may be a chronic degeneration, regeneration with microtears of the tendinous tissue, resulting in tendinosis.
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Affects tennis players (5% to 10%) of those diagnosed
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1% to 2% of general population affected
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Lateral epicondylitis (tennis elbow) more common than medial epicondylitis (golfer’s elbow)
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Median age of affected persons is 41 years of age
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Incidence in tennis players higher if they play more than 2 hours per day
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Equal male-to-female ratio
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Older patients more likely to have chronic symptoms
Pathophysiology
Intrinsic Factors
Intersection Syndrome
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Repetitive overuse
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Friction between muscle bellies of first extensor compartment tendon (APL and EPB) and adjacent tendons of the second extensor compartment ( Figure 14-1 )
FIGURE 14-1
Intersection syndrome at a point 4 to 6 cm proximal to the wrist joint. APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EPB, extensor pollicis brevis.
(Redrawn from Cox K, Brotzman SB: Hand and wrist injuries: Intersection syndrome of the wrist. In Brotzman SB, Manske RC, eds: Clinical orthopaedic rehabilitation: An evidence-based approach . 3rd ed. Philadelphia: Elsevier; 2011.)
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Entrapment stenosis
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Tightness of sheath of ECRL and ECRB tendons
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Adventitial bursa
De Quervain’s Syndrome
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Repetitive overuse
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Entrapment of EPB and the APL as they pass deep to extensor retinaculum
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First dorsal compartment entrapment of tendons
Humeral Epicondylitis
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Repetitive overuse
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Lateral epicondylitis (tennis elbow): primary muscles involved are the ECRL and ECRB; secondary muscle involved is the extensor digitorum communis ( Figure 14-2 )
FIGURE 14-2
Lateral epicondylitis.
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Medial epicondylitis (golfer’s elbow): primary muscles involved are the forearm flexors, including the flexor carpi radialis longus, flexor carpi ulnaris, and pronator teres ( Figure 14-3 )
FIGURE 14-3
Medial epicondylitis.
Extrinsic Factors
Intersection Syndrome
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Single bout of acute overuse
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Chronic repetitive overuse
De Quervain’s Syndrome
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Single bout of acute overuse
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Chronic repetitive overuse
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Activities that require gripping and ulnar deviation
Humeral Epicondylitis
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Repetitive gripping
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Repetitive supination/pronation at forearm
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Novice tennis players because of poor form
Traumatic Factors
Intersection Syndrome
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Acute single incident
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Repeated wrist extension
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Repetitive wrist motions in any plane
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Pressure over distal wrist
De Quervain’s Syndrome
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Blow to wrist
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Repetitive ulnar deviation
Humeral Epicondylitis
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Concentric/eccentric overload
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Insidious onset
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Repetitive wrist extension
Classic Pathological Findings
Intersection Syndrome
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Pain and swelling in region 4 to 8 cm proximal to Lister’s tubercle, dorsal aspect of forearm
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Pain with thumb extension and abduction
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Pain with wrist extension
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Crepitus with wrist movements
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Location where first and second extensor compartment tendons cross
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Palpation may produce crepitus
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Palpation painful
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Erythema
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Edema
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Squeaking sound with wrist motion
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Known as “squeakers”; common in rowers and those involved in grip activities
De Quervain’s Syndrome
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Tenderness at APL, EPB (first dorsal compartment)
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Pain on radial side of wrist
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Pain may radiate up into forearm
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Pain with resisted thumb movements
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Squeaky feeling (snowball crepitus caused by tenosynovitis) with thumb movements
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Motion may produce crepitus
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Palpation may produce crepitus
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Palpation painful
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Erythema
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Edema or swelling on radial side of wrist
Humeral Epicondylitis
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Tenderness at medial or lateral epicondyle
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Pain with repetitive wrist motions including extension and radial deviation
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Pain with resisted wrist extension or supination
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Pain aggravated with strong gripping
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Pain with passive stretch during wrist motions
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Pain may radiate down into forearm
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Grip strength reduced
Clinical Presentation
History and Physical Examination
Intersection Syndrome
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Acute single episode such as a weekend of skiing, bowling, rowing
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Repetitive unaccustomed overuse such as machinist
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Secretaries
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Carpenters
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Maintenance workers
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Filing workers
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Rice-harvesting workers
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Weightlifters
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Rowing or canoeing
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Raking
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Shoveling
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Pain and swelling in region 4 to 8 cm proximal to Lister’s tubercle
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Pain with thumb extension and abduction
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Pain with wrist extension
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Squeaky sound with wrist movements
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Location where first and second extensor compartment tendons cross
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Motion may produce crepitus
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Palpation may produce crepitus
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Palpation painful
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Erythema
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Edema
De Quervain’s Syndrome
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Acute single episode
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Repetitive unaccustomed overuse
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Repetitive wrist radial deviation
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Repetitive thumb palmar or radial abduction
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Pain with resisted thumb movements
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Squeaky feeling with thumb movements
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Motion may produce crepitus
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Palpation may produce crepitus
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Palpation painful
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Erythema
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Edema or swelling on radial side of wrist
Humeral Epicondylitis
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Athletic individuals
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Baseball players
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Tennis players
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Swimmers
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Laborers who have to frequently grip tools
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Plays sports or recreation greater than 2 hours per day
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Pain with active motions of elbow and forearm
Abnormal Findings
Intersection Syndrome
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Squeak with radial-ulnar deviation of the wrist with crepitus
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Localized swelling at the intersection of the first/second dorsal compartments
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Tenderness at intersection of the first/second dorsal compartments
De Quervain’s Syndrome
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Tenderness at the first dorsal compartment
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Localized swelling to the first dorsal compartment
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Positive Finkelstein’s test
Humeral Epicondylitis
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Tenderness at musculotendinous junction just distal to the medial and lateral epicondyles
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Pain with wrist flexion (medial epicondylitis) and wrist extension or power grip (lateral epicondylitis)
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Cyrix’s muscle tendon unit testing
Pertinent Normal Findings
Intersection Syndrome
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Negative Tinel’s sign at posterior interosseous nerve, median nerve, and ulnar nerve
De Quervain’s Syndrome
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Negative Tinel’s sign at posterior interosseous nerve, median nerve, and ulnar nerve
Humeral Epicondylitis
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Negative Tinel’s sign at posterior interosseous nerve, median nerve, and ulnar nerve
Imaging
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Routine radiographic series
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Ultrasonography
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Magnetic resonance imaging
Differential Diagnosis
Intersection Syndrome
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De Quervain’s tenosynovitis
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Wrist ligament sprain
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Forearm muscle strain
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Arthritis of first carpometacarpal (CMC) joint
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Fracture of radial styloid
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Fracture of scaphoid
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Ganglion cyst
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Infection
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Soft tissue neoplasm
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Entrapment of the superficial radial sensory nerve
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Cellulitis
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Forearm contusion
De Quervain’s Syndrome
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Intersection syndrome
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Scaphoid fracture
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Thumb CMC arthritis
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Thumb metacarpophalangeal arthritis
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Superficial radial sensory nerve irritation
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Posterior interosseous nerve entrapment
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C6 radiculopathy
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Forearm contusion
Humeral Epicondylitis
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Posterior interosseous syndrome
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Radial tunnel syndrome
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Pronator syndrome
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Synovitis
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Chondromalacia of radiocapitellar joint
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Lateral collateral ligament sprain
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Ulnar collateral ligament sprain or tear
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Cervical spine pathology
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C6–C7 nerve root compression causing radiculopathy
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Ulnar nerve entrapment
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Elbow bursitis
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Elbow fracture
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Elbow arthritis
Treatment
Nonoperative Management
Intersection Syndrome
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Activity/recreation modification
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Work modification
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Splinting
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Physical therapy
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Forearm stretching
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Electrical stimulation
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Ultrasound
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Iontophoresis
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Phonophoresis
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Oral NSAID
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Topical ice massage
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Steroid injection
De Quervain’s Syndrome
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Activity/recreation modification
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Work modification
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Splinting
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Physical therapy
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Forearm stretching
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Electrical stimulation
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Ultrasound
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Iontophoresis
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Phonophoresis
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Oral nonsteroidal antiinflammatory drug (NSAID)
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Topical ice massage
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Steroid injection
Humeral Epicondylitis
During the initial 4 weeks, when pathology is a peritendinitis:
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Activity/recreation modification
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Work modification
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Splinting
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Physical therapy
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Forearm stretching
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Electrical stimulation
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Ultrasound
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Iontophoresis
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Phonophoresis
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Oral NSAID
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Topical ice massage
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Steroid injection in tendon sheath
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Eccentric exercises beneficial once inflammation resolves
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Forearm stretching
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Physical therapy
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Cross-friction massage
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Augmented soft tissue mobilization/Graston technique/gua sha
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Extracorporeal shockwave therapy
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Percutaneous tenotomy
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Autologous blood injection
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Prolotherapy injection
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Platelet-rich plasma injection
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Sclerosing injection (polidocanol)
Guidelines for Choosing Among Nonoperative Treatments
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Intersection syndrome and De Quervain’s tenosynovitis are best treated to reduce the inflammation present causing the crepitus.
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The treatment of choice is steroid injection and avoiding the movement pattern that led to the inflammation.
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All of the other treatments listed in the preceding are also reasonable options.
Surgical Indications
There are no absolute surgical indications. It is always the patient’s decision. Relative surgical indications are listed in the following.
Intersection Syndrome
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Failure of conservative measures after 6 months
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Inability to work secondary to the loss of function or pain
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Worsening symptoms despite appropriate conservative care
De Quervain’s Syndrome
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Failure of conservative measures after 6 months
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Inability to work secondary to the loss of function or pain
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Worsening symptoms despite appropriate conservative care
Humeral Epicondylitis
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Failure of conservative measures after 6 months
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Inability to work secondary to the loss of function or pain
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Worsening symptoms despite appropriate conservative care
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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Treatment options are based on the best options for pain management, correction of the underlying etiology of the problem, and rehabilitation to help prevent future reoccurrences from the preceding list.
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Avoid NSAIDs/steroids if there is a history of abdominal pain, ulcers, gastritis, or gastrointestinal bleeding.
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Timing of humeral epicondylitis determines most likely pathology and treatment method.
Aspects of Clinical Decision Making When Surgery Is Indicated
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Failure of conservative measures after 6 months
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Inability to work secondary to the loss of function or pain
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Worsening symptoms despite appropriate conservative care
Evidence
Multiple Choice Questions
- QUESTION 1.
In which compartment(s) does intersection syndrome occur?
- A.
First and second
- B.
Second and third
- C.
Third and fourth
- D.
Only first
- A.
- QUESTION 2.
A 32-year-old factory worker has been diagnosed with intersection syndrome. What is a classic symptom that would indicate or point to intersection syndrome being his pathology?
- A.
Acute injury from golfing
- B.
Numbness and tingling in radial nerve distribution
- C.
History of repetitive radial and ulnar deviation
- D.
Increased symptoms with elbow extension overpressure
- A.
- QUESTION 3.
You suspect your new hand/wrist pain patient has de Quervain’s syndrome. Which of the following symptoms would be seen in a patient with de Quervain’s syndrome?
- A.
Tenderness at APL, EPB
- B.
Pain on radial side of wrist
- C.
Pain may radiate up into forearm
- D.
Pain with resisted thumb movements
- E.
All of the above
- A.
- QUESTION 4.
What is the first and foremost primary immediate goal in treatment of any of the upper extremity tendonitis or bursitis?
- A.
Total arm strengthening
- B.
Regaining lost forearm power
- C.
Elimination of aggravating activities
- D.
Getting sports assessment
- A.
Answer Key
- QUESTION 1.
Correct answer: A (see Pathology)
- QUESTION 2.
Correct answer: C (see Clinical Presentation )
- QUESTION 3.
Correct answer: E (see Classic Pathological Findings )
- QUESTION 4.
Correct answer: C (see Treatment )
Related posts:
Adhesive Capsulitis and Glenohumeral Arthritis
Patellar Instability
Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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