Jose Ma D Bautista, MD
Associate Professor in Orthopedics
College of Manila
University of the Philippines - Manila
STENOSING TENOSYNOVITIS
Stenosing tenosynovitis occurs when there is a size mismatch between the tendon and the pulley or sheath through which it passes. The sheath or pulley can narrow or the tendon increase in size. This mismatch prevents the smooth gliding of the tendon. In an Orthopedic Surgeon’s clinic the most commonly seen of these conditions would be the trigger finger and the De Quervain’s Tenosynovitis..
The common causes would be overuse, inflammatory or systemic conditions which lead to tendon thickening or adhesions . There is an absence of inflammatory cells in this condition. It’s proposed that microruptures develop in the tendon due to repetitive stress, and in light of the tendon’s poor intrinsioc blood supply, there is altered tendon healing, leading to tendinosis.
TRIGGER FINGER
Stenosing Tenosynovitis at the A1 pulley is the most common tendon pathology seen (Fig. 1).
Fig. 1. Trigger Finger. (glenelgorthopaedics.com.au)
This usually presents as pain, clicking or locking at the level of the A1 pulley. During the physical examination, a tender nodule can be palpated at A1. PIP joint contracture can also be seen. Evidence of carpal tunnel syndrome, whether clinically or in an electrodiagnostic study, will be seen in 60% of those with trigger fingers.
Although physical therapy and the use of an orthosis has been tried for this condition, a corticosteroid injection would be the first-line of treatment (Fig. 2). Long-term relief is seen in 47-92% of trigger finger patients after steroid injections.
Fig. 2. Corticosteroid Injection (orthoinfo.aaos.org)
For patients in whom other methods have not provided relief, or where symptoms recurred after initial relief, surgery may be recommended. This consists of longitudinally incising the A1 pulley, done either through a skin incision over the pulley or percutaneously , using a large gauge hypodermic needle (Fig. 3).
Fig. 3. Trigger Finger Release (oamichigan.com)
DE QUERVAIN’S TENOSYNOVITIS
De Quervain’s Tenosynovitis is the other common stenosing tenosynovitis, and this involves the tendons in the first dorsal compartment, the Extensor Pollicis Brevis and the Abductor Pollicis Longus (Fig. 4). As compared with the trigger finger, the additional pathology in this condition is the presence of a septum between the two tendons in approximately 40% of the population. This septum affects both the success rate of conservative treatment and the steps which need to be done during surgery.
Fig. 4. First dorsal compartment (esportshealthcare.com)
Patients complain of pain at the dorsoradial wrist. It may be associated with pregnancy, lactation and activities which involve repeated radio-ulnar deviation of the wrist. There is usually tenderness over the first dorsal compartment, with fullness or swelling over the area frequently present. The Finkelstein (Fig. 5) or the Eichoff’s (Fig. 6) tests are provocative tests used to clinch the diagnosis.
Fig. 5. Finkelstein test. (www1.racgp.org.au)
Fig. 6. Eichoff’s test (quizlet.com)
Although splints and physical therapy have been used for this condition, a steroid injection has a much greater chance of success for this condition, at 62-100%. Failure of treatment should make us consider the need for surgery. This consists of releasing the first dorsal compartment by completely incising the extensor retinaculum over it and releasing the septum (if any) between the EPB and the APL tendons (Fig. 7).
Fig. 7. Release of first dorsal compartment (sonjkacerovac.com)
LATERAL EPICONDYLITIS (TENNIS ELBOW)
Patients with Tennis Elbow very rarely do actually play tennis.
It also isn’t actually an epicondylitis as microscopic evaluation of the affected tissues don’t show signs of inflammation. The part of the tendon just before its insertion , which is the part usually involved, is hypovascular. Repetitive motion, particularly repetitive eccentric motion, may lead to hypoxic tendon degeneration, especially of the extensor carpi radialis brevis just distal to its attachment to the lateral epicondyle (Fig. 8).
Fig. 8. Lateral Epicondylitis (Yoon & Ahmad. orthobullets.com)
Patients present with lateral elbow pain of an insidious onset. It’s aggravated by activity and relieved with rest.
On PE, there should be no deformity nor noticeable swelling. Range of motion is full. There will be tenderness just distal to the Extensor Carpi Radialis Brevis insertion at the lateral epicondylePain may be elicited using 2 maneuvers. The first is the Maudsley’s test, and the other is Cozen’s sign.
While performing the Maudsley’s test, with the elbow, wrist and fingers extended, and the forearm in pronation, the middle finger is pushed downward. The test is positive when there’s pain at the lateral epicondyle. In a common differential, the radial tunnel syndrome, the pain during this maneuver would be felt 2-3 inches more distal in the forearm (Fig. 9).
Fig. 9. Maudsley’s test (vimeo.com)
When doing the Cozen’s test, the elbow is flexed at 90 degrees and the forearm is pronated. The patient is then asked to extend the wrist against resistance. Pain will be elicited in patient s with tennis elbow. (Fig. 10)
Fig. 10. Cozen’s test (quizlet.com)
Conservative treatment of this condition commonly consist of the use of an orthosis as well as injectables.
Counterforce braces (Fig. 11) and wrist splints do provide relief to tennis elbow patients. It’s still unclear which of these is a better option.
Fig. 11. Counterforce brace for tennis elbow (ritewaymed.com)
As in all other conditions where it is used, steroid injections provide short-term relief. Watchful waiting, or doing nothing, actually has been shown to provide greater improvement at 52 weeks than a steroid injection.
Autologous blood (AB), or extracted blood, and platelet-rich plasma (PRP), or centrifuged blood, have also been used. At this point, the jury is still out as to their efficacy. Some studies do show better long-term pain relief with either AB or PRP, while some don’t. This may be explained by there being no standardized way in preparing the PRP. Other modalities being studied are dry needling and extracorporeal shockwave therapy. There aren’t enough studies to recommend for or against these options.
Whatever has been done, if the patient’s elbow is still problematic at 6 months, then surgery may be recommended, the lateral epicondyle release. This procedure consists of releasing the ECRB origin together with excising a portion of its damaged tendon, as well as any bone spurs (Fig. 12).
Fig. 12.Lateral Epicondyle Release (midwesdtbonejoint.com)