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So in the last, uh, five to six minutes,

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I'm gonna talk about the medial and lateral tendons

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and the phenomenon known as epicondylitis.

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So here I wanted to show you just pictures

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of the footprints here.

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This is the, this common flexor tendon.

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The pronator terries attaches higher

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or above, not with the common flexor tendon.

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If we look on the lateral side, here is the footprint

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of the common extensor tendon.

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The extensor carpi radiologist long attaches superior to

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that of the common extensor tendon.

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And if we turn this over,

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of course we see the ancon footprint.

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So there are a lot of tend here, not all of which are part

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of the common flexor

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and the common extensor tendon attachments with regard

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to the most common sites of involvement in

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what we call epicondylitis.

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On the medial side, it is the pronator terries

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and the flexor carpi radiologist.

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Statistically, they are the most common

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sites of involvement.

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On the lateral side,

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it's the extensor carpi radiologist brevis, remembering

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that the extensor carpi radiologist long

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attaches separate from the attachment site

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of the common extensor tendon.

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Now we call this epicondylitis. It's a poor name.

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The normal tendon.

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You can see the beautiful arrangement

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of these collagen fibers.

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They're longitudinal

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and orientation, they have cellular tissue between them.

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And this is the pathology of what we call epicondylitis.

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It's angio fibroblastic hyperplasia, not much inflammation

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yet we use that suffix itis, which is really not correct.

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We see disorganized collagen, we see loose matrix,

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other findings, epicondylitis I know is the term

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that is being used and certainly I use that in my practice,

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but it is not pathologically correct it.

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Lateral epicondylitis far more common than medial

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seven to one ratio.

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In some reports, tensile loads will eventually lead to tears

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that are initially microscopic and they don't heal well.

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And the nearby ligaments may also be involved.

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Now with any tendon attachment, if there's abnormal tendon

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tension, you may get outgrowths.

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We call these anthea fights.

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They're particularly common involving the epic condyles,

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especially the medial epicondyle.

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Here's what they look like In one of the specimens, uh,

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that we had with regard to lateral epicondylitis,

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some people regard again, hyper

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hypovascular as a problem.

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In terms of the common extensor tendon, there are two

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Zones of what, where the vascularity is not so extensive.

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One is a proximal zone shown here adjacent to the humerus.

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The second one distal shown here in the area of the circle

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is just lateral to the radial head.

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So a lot of the pathology is reported

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to be in these particular areas.

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I'm not gonna show you a lot of examples of this.

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What I look for are thickened tendons

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and if there are tendon tears, I look

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for abnormal high signal.

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Here we can see that both in the coronal

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and sagittal planes.

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And I find particularly useful is the sagittal plane

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when it is fluid sensitive sequence,

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because that will show you often I think the best view

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of the tearing

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and of the bright signal associated

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with lateral epicondylitis.

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In some of these cases, such as this one,

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a secondary finding beyond the primary finding shown here is

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edema within the ancon muscle.

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Now there are a few reports of this,

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the initial one from Mark Cole who used to be at UCSD,

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but we don't know exactly why.

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You can see ancon muscle edema.

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Three theories have been suggested

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that this is an associated muscle strain,

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that it may be a compartment syndrome

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because the ancon muscle can in fact be involved

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with compartment syndromes

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or it may relate to denervation of branches

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of the radial nerve.

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But here's one example, here's another one.

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You can see the involvement

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of the common extensor tendon here.

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But note also the edema that is seen within

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the ancon muscle with regard

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to medial epicondylitis, this is, uh, less common,

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far less common in my practice, said to occur In golfers,

5:00

pitchers, bowlers

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and other athletes, they come in with pain and tenderness.

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Anter medially, the two most common sites of involvement,

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the pronator terries, and the flexor carpi radiologist

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and ligaments and nerves may also be involved.

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So I'll show you one example.

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Again, I'm looking for abnormal morphology and high signal.

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The yellow arrow points it out involving here,

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the common flexor tendon about the elbow.

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And then finally, I would just tell you that this, uh,

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particular condition of epicondylitis is generally related

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to repetitive stress

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and gets worse over a period of time without treatment.

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But there are acute injuries that can also lead to tendon

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and ligament abnormalities.

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We've already kind of talked about them.

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I thought I would just show you at one

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or two cases here. This

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Was a young patient who fell off a sled

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with hyperextension

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and a valgus injury, injuring not only the triceps,

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but also injuring tendons, uh, mainly on the medial side

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as well as the ligaments on that side

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with lesser involvement on the lateral on lateral side.

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And then one further example here, likely related

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to an elbow dislocation, extensive tendon

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and ligament abnormalities located both

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medially and laterally.

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So acute injuries can also cause problems to tendons

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as well as ligaments about the elbow.

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So what I've done in my allotted period of time is

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to cover the four major tendon groups,

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talking a bit about anatomy, emphasizing what I consider

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to be the most complex anatomy that of the triceps.

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But there's complex anatomy with all of these.

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Thank you very much. And again, Steve will take over

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and show you some cases related to this subject.