Lateral Elbow Pain: Posterior Interosseous Nerve Compression

At the Centeno-Schultz Clinic we acknowledge that lateral elbow pain can be debilitating and impact daily function.

Not all lateral elbow pain is lateral epicondylitis as illustrated by a recent patient seen in clinic.

Joey is a 17 y/o hocky player with 1 year history of lateral elbow pain which was constant, progressive in nature and aggravated with rotation of his palm upward (supination).  He has undergone PT, trial of NSAID’s, heat, ice and 2 steroid injections without relief.  High dose steroids have signficant side effect both on tissue and stem cell function.

Joey had compression of posterior interosseus nerve which was confirmed by MSK ultrasound.  Treatment options include US guided Regenexx PL/SCP injections and possible hydrodissection.   A patient’s testimonial illustrates the potential of treating nerve injuries with ulrasound guided platelet therapy.

The posterior interosseous nerve (PIN) is nerve in the forearm. 

Posterior Interosseous Nerve

It is the continuation of the deep branch of the radial nerve.  It passes thru supinator muscle in its course from anterior to the posterior surface of the forearm. The PIN may become entrapped at the tendinous border of the supinator known as Aracade of Froshse. Posterior interosseous neuropathy is purely a motor syndrome resulting in finger drop, and radial wrist deviation on extension.  

Other causes of PIN dysfunction include trauma, synovitis, tumors, and iatrogenic injuries.

Exam:

Pain with resisted supination of the forearm.

Pain with resisted extension of extension of middle finger.

Tenderness over lateral epicondyle and distally over the aracade of Froshe. 

Other causes of lateral elbow pain which warrant consideration include:

C7 radiculopathy

Lateral epicondylitis

Extensor tendon rupture

Intersection Syndrome: A cause of forearm pain

At the Centeno-Schultz Clinic we acknowledge that forearm pain can be disabling.

Intersection syndrome is a painful condition on the radial (thumb) side of the forearm when inflammation occurs at the intersection of the first and second extensor tendons. 

The first compartment is compromised of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) whereas the second compartment includes ECRB and ECRL (extensor carpi radialis brevis and longus).

Presentation:  pain approximately 4 cm above the back of the wrist joint where the first and second compartment tendons cross.

 

Tendons are surrounded by a slippery sac called a tenosynovium which allows the tendons to glide.  Inflammation of the tenosynovium (tenosynovitis) impairs the tendons ability to glide and results in pain.

Etiology can be traumatic or due to repetitive wrist flexion and extension commonly seen in weightlifters ad rowers.

 Other causes of radial forearm pain include de Quervain tenosynovitis, thumb CMC arthritis, radial sensory nerve irritation and extensor pollicis longus (EPL) tendinitis.

In cases unresponsive to conservative therapy a guided injection under ultrasound is indicated.  At the Centeno-Schultz Clinic MSK US is utilized in joint, ligament and tendon injections.  Accuracy and visualization is critical for successful clinical results.  Below is an ultrasound image of the first and second compartment tendons crossing.  The white arrows identify the tendons of compartment 1 superficially crossing those of compartment 2.  This is the site of inflammation in intersection syndrome that results in radial side forearm pain.

Carpal Tunnel Syndrome: Overview

At the Centeno-Schultz Clinic we acknowledge that wrist pain can be painful and limiting.

Carpal Tunnel syndrome (CTS) is an entrapment of the median nerve in the carpal tunnel causing pain and numbness.  The carpal tunnel is an anatomical compartment located at the base of the palm.  Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch as illustrated below.

A successful case report utilizing  hydrodissection, a non surgical treatment has been discussed in a prior blog.

Patients commonly experience numbness, tingling, or burning sensations in the thumb, index, long and radial half of the ring finger.

Common clinical examinations include Phalen’s maneuver and Tinel’s sign.

Most cases of CTS are of unknown causes.

Diagnosis is often made by EMG/NCS study whereby needles are placed into muscles and electrical activity is evaluated.  The needles and the procedure  can be painful.  At the Centeno-Schultz Clinic MSK ultrasound is a non painful alternative.  A median nerve greater than 10mm in area indicates carpal tunnel syndrome.  A transverse ultrasound image of the median nerve is illustrated below.

Tears in The Rotator Cuff: Articular and Bursal Sided Tears

Stem cell therapy is an alternative to shoulder rotator cuff surgery.

Shoulder surgery is associated with risks.  Extensive rehabilitation is often needed after a rotator cuff repair surgery due to the immobilization needed to help the sewn rotator cuff muscle or tendon to heal.  A recent study demonstrated that less mobilization and faster rehabilitation is better.

Woman have more problems with rotator surgery in part due to differences in stem cell numbers.  Regenexx C is an option that can increase the total number of stem cells at a site of injury.

The rotator cuff is compromised for 4 major muscles and tendons: the supraspinatus, infraspinatus, subscapularis and teres minor.

Most rotator cuff tears involve the supraspinatus tendon.  The anterior aspect of the distal supraspinatus is a common site of injury.  Accurate localization of the tendon tear is essential.  At the Centeno-Schultz Clinic MSK ultrasound and MRI are used to identify rotator cuff injuries.  Most tears are on either  the articular or bursal surface.  This is illustrated below in both longitudinal and  transverse views.

When in Doubt, Cut it Out

Patients are seeking alternatives to shoulder replacement surgery with increasing frequency.  Patients are concerned with complications, death and signficant downtime associated with shoulder replacements. 

The shoulder is a complex joint composed of tendons, ligaments, muscles and cartilage on the articulating surfaces.  Pain can arise from any or all of these structures.  At the Centeno-Schultz Clinic we are committed to identifying the principal source of pain in patients so a successful treatment regimen can be implemented.  Regrettably this is a universal practice.  DS is a case in point.

DS is an active 62 y/o rancher who sought a second opinion.  He had a 6 month history of left shoulder pain which was constant in duration, progressive in duration, principally located in the posterior shoulder without any radiations.  Aggravating factors including lifting whereas alleviating factors included rest and sleep.  DS had been evaluated by a surgeon and was identified as a suitable candidate for total shoulder replacement. DS had not undergone any conservative to date: no physical therapy, massage or myofasical deactivation.  X-ray was signficant for narrowing of the joint space.

DS and I were concerned that no conservative therapy had been undertaken.  Additionally the only study to date was an x-ray which examines bone and does not evaluate tendon, ligament or cartilage.  An MRI was ordered which was signficant for severe tendinosis of two of the rotator cuff tendons and arthritis of the shoulder joint.  DS declined the replacement and underwent two MSK US guided injections into the rotator cuff tendons and reports 65% improvement to date.  He is scheduled for additional treatment but remains active on his ranch without signficant limitations. 

Bottom Line:  Pain can arise from many different structures and can often times be treated successfully with non surgical regenerative treatments.

Treatment of Lateral Elbow Pain with PRP

Pain on the outside aspect of the elbow is referred to as lateral epicondylitis or tennis elbow.  It can be quite disabling affecting both the quality of life and range of motion.

Lateral epicondylitis is caused by irritation of the common extensor tendons as they insert onto the bony surface of the elbow.

PRP (platelet rich plasma) has become increasing popular as non surgical treatment in common orthopedic conditions.

Has it been used in the treatment of elbow pain?

Yes!

Peerbooms demonstrated PRP to be more effective than steroids in the treatment of lateral elbow pain.  100 patients were randomly assigned treatment with either PRP or steroids.  At one year 73% of patients treated with PRP reported significant improvement vs 49% in the steroid group.

Steroid use has been associated with significant side effects including ligament and cartilage compromise and cell death (apoptosis).

At the Centeno-Schultz Clinic advanced cell treatments including PRP are used in the treatment of lateral elbow pain and other common orthopedic conditions including meniscus tears, supraspinatus tears,  osteoarthritis of hip, knee and ankles.  MSK ultrasound and or x-ray is used in injections to ensure accurate placement of platelets.

Steroids and Cell Death: Apoptosis

 

Apoptosis is the process of programmed cell death.  The process is controlled by a variety of factors both within and outside of  cells.  High dose steroids have been demonstrated to create cell death in muscles, bones, cartilage and ligaments.  High dose steroids are commonly used to treat a variety of painful conditions which include rotator cuff tears, lateral epicondylitis, patellar and Achilles tendonitis, pes anersine bursitis,  lumbar facet dysfunction and sciatica.

At the Centeno-Schultz Clinic we acknowledge the negative effect of  high dose steroids.  Our aim is to identify the source of a patient’s pain and provide a therapy which will attempt to repair the damaged tissue.  Our treatments are not aimed at advancing the degenerative process or triggering apoptosis.  Accordingly we use only very small doses of steroids when necesary and have a large number of regenerative therapies which promote healing: prolotherapy, platelet rich plasma (PRP), Regenexx SCP, Regenexx AD and Regenexx SD.

Shoulder Pain and Ultrasound Guided Injections

Platelet rich plasma, prolotherapy and autologous stem cells are non-surgical treatments for shoulder pain.  Clinical success is dependent upon selecting the appropriate treatment option and placing the solution into the targeted site.

Ultrasound has become the standard of care at the Centeno-Schultz Clinic.  Ultrasound does not involve exposure to x-rays and provides a rich image of the bone, muscles, tendons and ligaments. It also allows for a dynamic evaluation whereby the patient is able to go through the activities that cause them pain.  This is not the case with MRI’s given that they require a patient to remain completely still.  MRI’s provide a static image of the shoulder which may not be helpful in some cases of impingement.

This last weekend Ron Hanson M.D. was an instructor at a highly respected shoulder ultrasound course.

We are very pleased to have Ron’s gifted clinical and ultrasound skills here in Denver/Boulder area at the Centeno-Schultz Clinic.

Wrist Pain: Alternatives to Steroid Injections

De Quervain snydrome is a common cause of wrist pain.

It is inflammation of the sheath that surrounds two critical tendons which are responsible for thumb moment.  Just a like the outer plastic lining on any electrical cord holds all the small wires together, the tendon sheath holds the extensor pollicis brevis and abductor pollicis longus tendons in a protective sleeve.

Inflammation and or chronic degeneration of the sheath or tendons can result in pain, swelling over the radial side of  the wrist accompanied with difficulty in gripping.  The Finkelstein test is a common diagnostic test.

Treatment options include rest, splinting, injection of steroids and surgery.

At the Centeno-Schultz Clinic we understand the risks involved with steroids and offer alternatives in the form of prolotherapy, PRP and Regenexx PL.  Clinical success comes from accurately delivering the prescribed  solution to the targeted area.  To that extent we use ultrasound to that ensure growth factors or stem cells are placed within the damaged tissue.  Below is  an ultrasound image from clinic of the two tendons and the enveloping sheath.

Rotator Cuff Tears: Non-Surgical Treatment Options

The rotator cuff is compromised of 4 major muscles and tendons that act collectively to stabilize the shoulder joint.

The four muscles include the supraspinatus, infraspinatus, subscapularis and teres minor.  Tendons are the fibrous portion of the muscle that anchors the muscle to bone.  This fibrous anchor can be inflamed resulting in a tendinitis or can be  chronically degenerative resulting in tendinosis.  The one of  4 muscles can have a partial or full thickness tear.

At the Centeno-Schultz Clinic ultrasound is utilized to determine the source of pain.  The pain may arise from a tear in one or more of the four rotator cuff muscles or inflammation or degenerative changes in the fibrous tendon anchor. Other explanations exist which will be discussed in another blog.

Rotator cuff tears can be treated with Regenexx SD whereby a patient uses their own mesencymal stem cells.  Tendinosis  can be treated with Regenexx SCP.

The Regenexx family of procedures represent the highest quality stem cell therapy with the largest number of stem cell treatment options in one clinic and which are ICMS certified.