Non-Surgical Treatments for Upper Extremity Overuse Injuries
Yahira Acevedo-Santiago, MD, discusses non-surgical treatments for upper extremity overuse injuries and how surgery is not always the answer. Other options such as physical therapy, injections to reduce pain and inflammation and medications can be tried first.
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Learn more about Yahira Acevedo-Santiago, MD
Yahira Acevedo-Santiago, MD
Yahira Acevedo-Santiago, MD is a physical medicine and rehabilitation physician who specializes in musculoskeletal medicine, geriatrics, sports and recreational injures as well as hand and upper limb rehabilitation, including carpal tunnel, trigger finger, wrist, elbow and shoulder problems.Learn more about Yahira Acevedo-Santiago, MD
Transcription:
Melanie Cole (Host): Today we’re talking about non-surgical treatments for overuse injuries in the upper extremities and my guest is Dr. Yahira Acevedo, she’s a physiatrist at the Good Shepherd Rehabilitation Network. Dr. Acevedo, tell us a little bit about an overuse injury and what is the difference between an overuse, chronic injury and something acute that happens?
Yahira Acevedo-Santiago, MD (Guest): Yes, so overuse injury is a broad term, correct? And what we refer as an overuse injury is what is commonly known as tendonitis. The it is so effects it means inflammation, but it has been demonstrated more recently that the muscles that we are talking about, the main problem is not inflammation, but is the affected tendon healing process which causes chronic and localized pain. There are other overuse related syndromes or disorders which are overuse problems related to arthritis or nerve entrapment which are another complete separate topic to talk about.
Melanie: So, then let’s concentrate on the upper extremities and what are some of the primary factors that contribute to these diagnoses?
Dr. Acevedo: Well there are many factors that contribute to an overuse injury that involves the tendon. Mainly, and more recently, there has been incidents of increased incidents meaning – increased participation in recreational sports activities especially in middle age and older adults. In their efforts to try to stay active; they go and play the same sports they used to play when younger, tennis, golf, softball or running. And they tend to get overuse injuries related to their age. And as I mentioned, age is another factor so people that are over age 35, the tendon starts to age, and the collagen production starts to decrease. So, the muscle and the tendon become stiffer making it more prone to injuries.
Other factors accounting for this are occupational, manual laborers or people that work in factories and assembly lines, people that are hair stylists or that work in computer and desk jobs; if they are not using the proper ergonomics; they can also have a problem with their tendons as an overuse injury. Also, gender-related. There are risks of certain overuse injuries. It is not well understood exactly the reason for this. But it is thought to be related to hormonal influence so differences in male and females and also, difference in how – in their body mechanics or how they carry out activities, as well as the different sports and occupations that the different genders also account, or they practice.
And other factors contributing are prior tendon injuries, for example, an athlete, if we are talking about younger population, throwing sports, and in the case of lower extremity like jumping sports, but especially throwing sports like baseball and basketball. Other factors related are training errors like when someone is practicing a sport and they are trying to increase their frequency of their exercise too fast o the weight that they are using for it is too much; that can also influence and make an overuse injury more apparent. Also, if they are training without the proper equipment and if they have injured in the past and they return too soon; going back to the sport or going back to the activity that had been causing their pain.
Melanie: So, how do you confirm diagnosis? Speak about physical exam and imaging that you might use.
Dr. Acevedo: Yeah, so usually the patients will come to the office. They will tell us about their pain, where is it located. So, we will take a careful history and a physical exam. And that will provide us with the basic expect or have a list of differential diagnoses. We make a diagnosis mostly based on clinical exam and in our role in physical medicine and rehab, is very important. We are musculoskeletal specialists and we are able to identify things that could be missed related to where the pain is and also we can talk about or think about more pain – more proximal or more for example if it happens at the elbow, the pain, we will still need to think about what could be going on in the neck or if there could be anything radiating from the neck. So, it is very important a role for us to try to identify that and other factors that might be contributing to the patient’s symptoms.
So, if we need to do any studies, sometimes we refer to ultrasound which have been more available in the past few years to help in identifying if a tendon is torn or if it is partially ruptured or completely ruptured.
Melanie: What are some non-surgical approaches to treatment and what role does physical therapy and you as a physiatrist play in the rehabilitation of some of these injuries?
Dr. Acevedo: Treatment approaches, well in overuse injuries, we want to be very conservative in the beginning. So, the initial approach that we use is activity modification. It is very important to know the role of what activities to limit to reduce the aggravating activity to or just stopping it for a little bit while the patient recovers. And in that time, refer to our physical therapist and sometimes depending on where in the arm, it could be an occupational therapist specializing in hand therapy. And that will help us in correcting the proper mechanics that may have caused the injury in the first place. And also, will include education for the patient and a gradual increase in activity as they are able. We also talk about different adjustments in the patient’s ergonomics depending on the type of injury that they have and how it happened. So, for example, if it’s a patient that has a wrist overuse injury or tendon problem we might think about or talk about how they are adjusting their keyboard. If they need a different type of keyboard or another setting in their desk job. In other patients that are playing sports for example; we could suggest adjustment to a tennis racket to their tension or to the grip of the handle and as well as for many other situations.
And one of the most important treatment strategies is increasing or improving resistance exercise. We call this eccentric contraction. It is one of the most important things that we use while recovering from these types of injuries. It basically means that the muscle is contracting but its slowly lengthening to go back to where its neutral position is while it’s still contracting. So, if you like curl your biceps for example, and so that’s a concentric contraction because you are shortening that muscle, but then if you are slowly bringing it out but you are still contracting that bicep; it means that it’s an eccentric contraction. That’s what we want to do for these types of injuries basically. The therapist may also use heat or ice or other modalities to help for comfort. We also use – if the injury is more acute – I don’t use it as much for overuse injuries or injuries that are more likely chronic; but people may use Tylenol or most of the anti-inflammatories or topical analgesics for treatment of these.
Melanie: So, Dr. Acevedo when is it appropriate for primary care physicians to refer a patient with upper extremity chronic overuse injuries to a physical medicine and rehabilitation physician such as yourself and what else would you like other providers to know about these types of injuries?
Dr. Acevedo: Yeah, it would be ideal to have an earlier referral of this patient, so we could identify their improper mechanics and route them to the most adequate treatment options. Ideally, the patient goes to the doctor’s office and they have an initial complaint let’s say pain in their elbow. If they follow initial treatments or either topical medicine or analgesics and it doesn’t get any better; usually after a month, if it persists; then it would be ideal for the patient to have a referral with a physical medicine or rehabilitation physician like me. And it is very important as we are specialty trained in musculoskeletal medicine as well as neurologic disorders and orthopedic disorders and we can guide the treatment, the expectations and the further care with the additional knowledge that our training provides us with. And I would like to let my other colleagues know that these overuse injuries are not necessarily caused by inflammation. These are probably or most likely caused by chronic repetitive small injuries to the tendons that do not heal properly. And usually anti-inflammatories and other treatments are not going to be as effective at this point if an injury is more chronic and the other thing that is very important to know for both my colleagues that are treating initially these patients and for the patients that are receiving the treatment is that it is very important to have a realistic view of their rehab process. Overuse injuries are usually chronic. They tend to take a long time to recover. So, usually they might take between three to six months in improvement. So, it would important for them to know not to get desperate in the beginning if they don’t see improvements right away after starting a week of treatment.
Melanie: That’s a really good point to make as we end Dr. Acevedo. Thank you so much for joining us, sharing your expertise as a physiatrist on overuse injuries and chronic injuries of the upper extremities. Thank you again for being with us. This is Be Well a podcast for rehabilitation providers from rehabilitation providers. For more information on resources available at The Good Shepherd Rehabilitation Network, please visit www.goodshepherdrehab.org, that’s www.goodshepherdrehab.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Today we’re talking about non-surgical treatments for overuse injuries in the upper extremities and my guest is Dr. Yahira Acevedo, she’s a physiatrist at the Good Shepherd Rehabilitation Network. Dr. Acevedo, tell us a little bit about an overuse injury and what is the difference between an overuse, chronic injury and something acute that happens?
Yahira Acevedo-Santiago, MD (Guest): Yes, so overuse injury is a broad term, correct? And what we refer as an overuse injury is what is commonly known as tendonitis. The it is so effects it means inflammation, but it has been demonstrated more recently that the muscles that we are talking about, the main problem is not inflammation, but is the affected tendon healing process which causes chronic and localized pain. There are other overuse related syndromes or disorders which are overuse problems related to arthritis or nerve entrapment which are another complete separate topic to talk about.
Melanie: So, then let’s concentrate on the upper extremities and what are some of the primary factors that contribute to these diagnoses?
Dr. Acevedo: Well there are many factors that contribute to an overuse injury that involves the tendon. Mainly, and more recently, there has been incidents of increased incidents meaning – increased participation in recreational sports activities especially in middle age and older adults. In their efforts to try to stay active; they go and play the same sports they used to play when younger, tennis, golf, softball or running. And they tend to get overuse injuries related to their age. And as I mentioned, age is another factor so people that are over age 35, the tendon starts to age, and the collagen production starts to decrease. So, the muscle and the tendon become stiffer making it more prone to injuries.
Other factors accounting for this are occupational, manual laborers or people that work in factories and assembly lines, people that are hair stylists or that work in computer and desk jobs; if they are not using the proper ergonomics; they can also have a problem with their tendons as an overuse injury. Also, gender-related. There are risks of certain overuse injuries. It is not well understood exactly the reason for this. But it is thought to be related to hormonal influence so differences in male and females and also, difference in how – in their body mechanics or how they carry out activities, as well as the different sports and occupations that the different genders also account, or they practice.
And other factors contributing are prior tendon injuries, for example, an athlete, if we are talking about younger population, throwing sports, and in the case of lower extremity like jumping sports, but especially throwing sports like baseball and basketball. Other factors related are training errors like when someone is practicing a sport and they are trying to increase their frequency of their exercise too fast o the weight that they are using for it is too much; that can also influence and make an overuse injury more apparent. Also, if they are training without the proper equipment and if they have injured in the past and they return too soon; going back to the sport or going back to the activity that had been causing their pain.
Melanie: So, how do you confirm diagnosis? Speak about physical exam and imaging that you might use.
Dr. Acevedo: Yeah, so usually the patients will come to the office. They will tell us about their pain, where is it located. So, we will take a careful history and a physical exam. And that will provide us with the basic expect or have a list of differential diagnoses. We make a diagnosis mostly based on clinical exam and in our role in physical medicine and rehab, is very important. We are musculoskeletal specialists and we are able to identify things that could be missed related to where the pain is and also we can talk about or think about more pain – more proximal or more for example if it happens at the elbow, the pain, we will still need to think about what could be going on in the neck or if there could be anything radiating from the neck. So, it is very important a role for us to try to identify that and other factors that might be contributing to the patient’s symptoms.
So, if we need to do any studies, sometimes we refer to ultrasound which have been more available in the past few years to help in identifying if a tendon is torn or if it is partially ruptured or completely ruptured.
Melanie: What are some non-surgical approaches to treatment and what role does physical therapy and you as a physiatrist play in the rehabilitation of some of these injuries?
Dr. Acevedo: Treatment approaches, well in overuse injuries, we want to be very conservative in the beginning. So, the initial approach that we use is activity modification. It is very important to know the role of what activities to limit to reduce the aggravating activity to or just stopping it for a little bit while the patient recovers. And in that time, refer to our physical therapist and sometimes depending on where in the arm, it could be an occupational therapist specializing in hand therapy. And that will help us in correcting the proper mechanics that may have caused the injury in the first place. And also, will include education for the patient and a gradual increase in activity as they are able. We also talk about different adjustments in the patient’s ergonomics depending on the type of injury that they have and how it happened. So, for example, if it’s a patient that has a wrist overuse injury or tendon problem we might think about or talk about how they are adjusting their keyboard. If they need a different type of keyboard or another setting in their desk job. In other patients that are playing sports for example; we could suggest adjustment to a tennis racket to their tension or to the grip of the handle and as well as for many other situations.
And one of the most important treatment strategies is increasing or improving resistance exercise. We call this eccentric contraction. It is one of the most important things that we use while recovering from these types of injuries. It basically means that the muscle is contracting but its slowly lengthening to go back to where its neutral position is while it’s still contracting. So, if you like curl your biceps for example, and so that’s a concentric contraction because you are shortening that muscle, but then if you are slowly bringing it out but you are still contracting that bicep; it means that it’s an eccentric contraction. That’s what we want to do for these types of injuries basically. The therapist may also use heat or ice or other modalities to help for comfort. We also use – if the injury is more acute – I don’t use it as much for overuse injuries or injuries that are more likely chronic; but people may use Tylenol or most of the anti-inflammatories or topical analgesics for treatment of these.
Melanie: So, Dr. Acevedo when is it appropriate for primary care physicians to refer a patient with upper extremity chronic overuse injuries to a physical medicine and rehabilitation physician such as yourself and what else would you like other providers to know about these types of injuries?
Dr. Acevedo: Yeah, it would be ideal to have an earlier referral of this patient, so we could identify their improper mechanics and route them to the most adequate treatment options. Ideally, the patient goes to the doctor’s office and they have an initial complaint let’s say pain in their elbow. If they follow initial treatments or either topical medicine or analgesics and it doesn’t get any better; usually after a month, if it persists; then it would be ideal for the patient to have a referral with a physical medicine or rehabilitation physician like me. And it is very important as we are specialty trained in musculoskeletal medicine as well as neurologic disorders and orthopedic disorders and we can guide the treatment, the expectations and the further care with the additional knowledge that our training provides us with. And I would like to let my other colleagues know that these overuse injuries are not necessarily caused by inflammation. These are probably or most likely caused by chronic repetitive small injuries to the tendons that do not heal properly. And usually anti-inflammatories and other treatments are not going to be as effective at this point if an injury is more chronic and the other thing that is very important to know for both my colleagues that are treating initially these patients and for the patients that are receiving the treatment is that it is very important to have a realistic view of their rehab process. Overuse injuries are usually chronic. They tend to take a long time to recover. So, usually they might take between three to six months in improvement. So, it would important for them to know not to get desperate in the beginning if they don’t see improvements right away after starting a week of treatment.
Melanie: That’s a really good point to make as we end Dr. Acevedo. Thank you so much for joining us, sharing your expertise as a physiatrist on overuse injuries and chronic injuries of the upper extremities. Thank you again for being with us. This is Be Well a podcast for rehabilitation providers from rehabilitation providers. For more information on resources available at The Good Shepherd Rehabilitation Network, please visit www.goodshepherdrehab.org, that’s www.goodshepherdrehab.org. This is Melanie Cole. Thanks so much for listening.