Tennis Elbow, a Condition Caused more often by Activity Off.... Than On the Tennis Court

As summer sports heat up and we scramble to fill the long days of daylight with activities we’ve waited all winter to do, injuries and other overuse conditions affecting the hand, wrist and elbow are bound to occur.

A common overuse condition we see in the office throughout the year and particularly during the summer months is Tennis Elbow, also known as lateral epicondylitis.  “Epicondylitis” refers to inflammation at the epicondyle (where tendon and muscle attaches to the humeral condyle of the elbow).  “Lateral” refers to the outside portion of the elbow.

Considered an overuse or repetitive stress, tendinopathic condition affecting the lower arm muscles and tendons along the outside of the elbow, the condition is named after the sport first identified as a primary cause - affecting five out of 10 recreational and professional tennis players.  Though the condition is caused by many different types of activities causing repeated twisting and strain on the lower arm and elbow - including playing certain musical instruments, sports, manual labor and other everyday activities.

Tennis elbow is frequently seen in those between the ages of 40 and 60.

Symptoms

Symptoms of tennis elbow may initially cause only moderate pain in the outer portion of the elbow, but over time may spread down the forearm and back of the middle and ring fingers.  If left untreated, the pain can cause severe pain and weakness limiting arm function.  

Diagnosis and Treatment

Tennis elbow is generally diagnosed by discussing the discomfort and observing the pain a patient experiences when performing certain arm movements.  In many cases tennis elbow is addressed non surgically with conservative treatment that may include refraining from the activity, anti inflammatory medication or physical therapy with instruction on behavior modification.

If conservative treatment does not resolve the condition, a surgical procedure known as lateral epicondyle release is performed to relieve the tension.

Read more about repetitive stress conditions affecting the hand, wrist and elbow.

Wrist Fractures

The vital role that our hands play in daily life is often times only fully understood when we lose use of one or both as a result of an injury.  The wrist joint is particularly vulnerable because of its range of motion and location - involved in lifting, twisting, hammering, blocking a blow and softening the impact of a fall.  As a result, wrist fractures are among the most common fractures of the hand and upper extremity.

Some of the most common types of wrist fractures include:

Distal Radius Fractures

Scaphoid Fractures

Each of these fractures has their own unique challenge, which is why it is important that wrist fractures are treated by a hand and wrist specialist who understands the delicate bones of the hand and wrist, the blood supply to these bones and the intricate network of ligaments, tendons and nerves.  The wrong treatment, or lack of treatment, could result in long term damage to the joint and decreased hand function.

Distal Radius Fractures

A distal radius fracture is one of the most common types of wrist fractures.  It is named for the location of the break and bone it affects - the distal end of the larger forearm bone known as the radius.  This type of fracture should be carefully examined to determine if the fracture extends into the wrist joint (intra articular fracture) or does not impact the wrist joint (extra articular fracture).  The type of fracture will determine the type of treatment.

Scaphoid Fractures

A scaphoid fracture is a fracture of the scaphoid bone in the wrist, located at the thumb side.  These types of fractures require special attention, as the blood supply for the scaphoid bone enters from the top and most fractures occur in the middle or bottom portion.  This compromises the blood supply and can impede healing. Ensuring its stability is essential in preserving the integrity of the wrist joint  and avoiding avascular necrosis.

The treatment for these types of wrist fractures will depend on the severity of the fracture and other soft tissue damage.  Treatment will also be based on other aspects of a patients overall health and level of activity.  Ensuring the proper alignment and healing of the fracture is important in avoiding future problems in the hand and wrist.  

All treatment is followed by hand therapy and rehabilitation exercises to ensure that there is no loss in arm strength and function.  The goal of Dr. Collins and his hand and upper extremity support staff is to return patients to their daily lives quickly and as strong as they were before the injury.

Broken Bones and Fracture Fixation

Repairing Broken Bones

A broken bone reminds us that our body has its limits.  It also prompts a renewed appreciation for our limbs and the significant role they play in not only the sports and hobbies we love but also essential everyday tasks.  

Proper treatment and rehabilitation is key in restoring a limb to pre injury condition and avoiding future problems that can range from joint instability to arthritis.

Hand, wrist and other upper extremity fractures are among some of the most common types of fractures – as not only are our hands and upper extremity essential in performing everyday tasks but also serve as the first line of defense in breaking a fall or softening impact in an accident.

There are a number of different ways to treat a fracture depending on the severity of the break, other tissue damage and the characteristics of the break.  Once thoroughly assessed, treatment will either be surgical or non surgical.

If surgery is required, it may entail internal fixation.  This is hardware that helps hold the broken pieces together so that the bone can regenerate in ideal alignment.

What many of us may not realize is the array of different plates and screws designed uniquely for different finger fractures, wrist fractures, forearm fractures, elbow fractures and upper arm fractures.  Each designed precisely for the varying size of these different bones and their natural contour.

What may also come as a surprise is the delicate size of the plates …and the screws that hold them in place – as an X-ray depicts a larger than life image.  The actual plates and screws are far less invasive than many patient realize.

Watch Dr. Collins talk about the strength, yet discreet size of the different plates and screws used to repair many of the hand and upper extremity fractures he sees.  

Professional Musicians and Common Overuse Conditions

Professional Musicians and Common Overuse Conditions - New Hand Treatments Music to Their EarsAmid the melodic sounds of the Houston Symphony and Orchestra it is hard to imagine that there are many types of injuries and performance-related conditions that come with a musician’s occupation.

Compared to athletes in a recent presentation for the Center for Performing Arts Medicine,Performing Artists As Athletes: A New Perspective, Dr. Evan Collins talked about the hundreds of thousands of musicians each year incurring an injury as a result of rigorous practice and performance. In fact nearly 76% of musicians experience some kind of injury or condition as a result of their profession over the course of their career.

Athletes have had for years a dedicated Sports Medicine team knowledgeable about the physiological demands that certain sports have on their body – establishing treatment plans accordingly. Not much unlike athletes, musicians have the same demands repeatedly placed on specific joints and muscle groups, which causes excessive strain and damage.

Thinking about the intricate movement of fingers and the fact that nearly a quarter of the motor cortex in the brain is devoted to hand muscles – connected to over 50 nerves, 120 known ligaments, 30 major joints and approximately 30 bones - it’s not hard to understand how injuries can occur with such demands as a musician places on their hands and wrist.

Among the most commonly diagnosed injuries and conditions affecting musicians include overuse and overstress syndrome, mayofascial pain, and tendonitis. These conditions cause persistent pain and loss of endurance, facility and strength.

Fortunately today a number of minimally invasive procedures are allowing musicians to address their injury without lengthy recovery times and obtrusive scarring.

Endoscopic and arthroscopic procedures using fine instruments respectful of the small joint spaces and bones of the hand and wrist are reducing the size of the required incision and causing minimal disruption to surrounding soft tissue.

And the latest advances in non surgical therapies, including injection therapy and rehabilitative therapies designed specifically for musicians are making it easier for these artists to seek help and return quickly to their work… to the delight of us all.

Read more about musicians as athletes.

XIAFLEX - FREQUENTLY ASKED QUESTIONS

Frequently Asked Questions on New FDA-Approved XIAFLEX® Treatment for Dupuytren’s Contracture

Last month we wrote about a new FDA-approved non surgical injection therapy, XIAFLEX®, available for Dupuytren’s patients suffering from Dupuytren’s Contracture. Physicians using the new therapy have undergone special training and can help patients assess the benefits of this treatment over others available.

While nothing should replace a patient-physician consultation, we have compiled some of the most commonly asked questions regarding this new injection therapy to help better inform and prepare patients exploring treatment options.

Q. What exactly is the XIAFLEX injection therapy and how does it work?

A. XIAFLEX is actually “collagenase clostridium histolyticum.” When it is injected directly into the Dupuytren’s cord (disposition of collagen causing the contracture), it disrupts/weakens the collagen and helps your physician to break down the cord.

Q. How long will it take to see results after the injection?

A. While the rate of the improvement will vary from patient to patient, generally some improvement is evident within the first week, with progressive improvement as your physician breaks down the cord. Multiple injections may be necessary depending on the severity of the contracture and number of fingers involved.

Q. Are there any risks with this type of injection therapy?

A. As with any medication, there is risk of an adverse reaction. The FDA requires special training on the medication before a physician can administer it. Risks are minimized when a specially trained, board certified orthopedic hand surgeon administers this medication.

According to the manufacturer of this medication, Auxilliam, some of the safety concerns include:
•  Tendon or ligament damage
•  Nerve injury or other serious injury of the hand
•  Allergic reactions
     •  Swollen face
     •  Hives
     •  Breathing trouble
     •  Chest pain

Q. Are there any other nonsurgical treatment options for Dupuytren’s Disease?

A. Another popular minimally invasive treatment option for Dupuytren’s is the needle aponeurotomy(also known as NA or percutaneous needle fasciotomy, PNF). This procedure does not involve a surgical incision but rather small stitches made by inserting a thin needle into the contracted cord, eventually weakening it and allowing it to be broken down.

New Injection Therapy for Severe Dupuytren’s Contracture

New Injection Therapy, XIAFLEX®, Offers Nonsurgical Relief for Severe Dupuytren’s Contracture

Patients suffering from debilitating contractures able to resume activity with little down time

Those suffering from Dupuytren’s Disease often find the severe contractures associated with it to be debilitating obstacles to many of the activities they enjoy - and often in their professions as well.

Dupuytren’s Disease is a thickening of the tissue (fascia) in the hand slightly beneath the skin. This thickening can cause lumps and pits in the palm of the hand and on the finger knuckles and in severe cases cords (primarily comprised of collagen),which pull the fingers inward towards the palm. This is known as Dupuytren’s Contracture.

While the exact cause of Dupuytren’s Disease is unknown, it is commonly seen in men over the age of 40 and may grow progressively worse if not addressed. While generally painless, symptoms may begin with lumps in the palm of the hand and progress to thick cords spreading from the palm outward to the fingers – most commonly the ring and little fingers. These thickening cords gradually pull the fingers inward towards the palm, hindering hand function.

Traditionally, surgery to release the thick, tight cord was required in order to address severe contractures and restore hand function. More recently a minimally invasive procedure known as a Percutaneous Needle Fasciotomy (PNF), also known as Needle Aponeurotomy (NA), reduced recovery time and proved an effective alternative.

Now, a new nonsurgical treatment known as XIAFLEX injection therapy is an alternative for some patients. This new therapy is the first nonsurgical treatment FDA-approved for use in the United States and offered by only a few hand specialists in Houston. The treatment is proving effective in restoring hand function and relieving symptoms of Dupuytren’s Contracture for qualifying patients.

A prescription medicine, which contains a mixture of proteins, XIAFLEX, is injected into the cord by a physician who specializes in Dupuytren’s Disease. It helps to break down the thick cord by breaking down the collagen in the cord.

In Part 2 of our discussion, we’ll discuss who is a good candidate for XIAFLEX and commonly asked questions regarding the procedure and recovery.

New Dupuytren Procedure Comes to the United States, Proves Promising to Dupuytren Patients - European procedure providing hope to Dupuytren Contracture patients reluctant to undergo surgery

In our last blog of the Dupuytren Series we discussed the effects of Dupuytren’s Disease and who is most often impacted. This blog is dedicated to the discussion of the promising new treatment for those who suffer from severe Dupuytren contractures that either continue to reoccur following conservative treatment or exceed acceptable degrees of contraction and severely limit hand function.

Traditionally, open surgery to remove Dupuytren nodules and release the contracted palmar fascia, generally at the base of the small and ring fingers, was the last resort measure taken by patients afflicted by severe Dupuytren Contractures. This type of surgery came with the same risks and lengthy recovery time associated with open surgery.

Today, an innovative new procedure first established in Europe is addressing these severe contractures less invasively. Known as the Percutaneous Needle Fasciotomy (PNF), or Needle Aponeurotomy (NA), this new procedure can address the contracture without cutting into the skin and disturbing surrounding soft tissue and nerves. This new minimally invasive surgical approach is an outpatient procedure and entails a local anesthetic and tiny needles.

Needles are applied to the affected areas, which are first identified with small marks. The needles are maneuvered in such a way that “punctures” the contracting tissue. The puncturing process weakens this contracting cord and initiates a breakdown. Fingers are freed from the contraction, allowing the hand to function normally.

Patients are then instructed on rehabilitative exercises in order to ensure full resumption of hand function.

The minimally invasive nature of the needle aponeurotomy procedure allows a faster recovery and more rapid return to activity. The risks associated with traditional open surgery are eliminated and patients report minimal pain following the procedure.

While this procedure is not available in every US city, Dr. Evan Collins is one of the few hand specialist who performs PNF.