RU2532302C1 - Method of treating patients with epicondylitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for treating patients with epicondylitis. That is ensured by applying a complex of measures, in particular a restraint of motions in the involved segment, physiotherapy and drug treatment. A pain syndrome is pre-evaluated by a visual analogue scale (VAS). A proximal forearm is immobilised with an epicondylic bandage in the daytime for 7-10 days in sportsmen, and for 2-3 weeks in common patients. Therapeutic exercises (TE) are prescribed from the first day of treatment. The first part of TE consisting of isometric and static exercises aiming at strengthening arm muscles is done before noon. The second part of TE comprising relaxing exercises is performed in the late afternoon or after any physical loads. The patient continues with the therapeutic exercises after the bandage is removed and to be used for professional or sports loads only. Electric stimulation is conducted daily for 7-10 days with using TENS apparatus or its analogues generating electrical signals covering the enthesis and the involved forearm muscles. Arthrofoon is administered with underlying electric stimulation. If the pain syndrome value according to the VAS is less than 4 points, the preparation is administered as a monotherapy in a dose of 4 weeks a day for three months. If the pain syndrome according to the VAS is more than 4 points, Arthrofoon is administered in a dose of 8 tablets a day in a combination with a selective non-steroid anti-inflammatory preparation in a therapeutic dose for no more than 10 days. The therapeutic regimen also contains Sirdalud 2-4 mg one hour before bedtime for 2 weeks. There are also administered vasodilators improving microcirculation of the involved segment, intramuscularly for 10 days. The therapeutic complex is also added with Milgamma B 2 ml, 5 injections, and another 5 injections triduan. Wobenzyme is administered for 3-4 weeks. Calcemine or Calcemine-advance, the preparations of calcium are administered for six months. The therapeutic course according to the presented regimen is repeated half a year later. The physical exercising for the arm muscles strengthening are to be further done two or three times a week on the average for min. 30 minutes for the life term if suffering high loads or doing any top-class sports for the purpose of maintaining the forearm tonus. The segment of interest is fixed with an orthesis when suffering a load. The therapy with the TENS or similar apparatus of the forearm muscles of interest and the enthesis follow a pronounced load 2-3 hours before bedtime and shall be accompanied with a session of relaxing exercises.

EFFECT: method provides the evident and stable clinical effect characterised by the complete recurrence-free recovery by the physical restoration of the tissue structure within the inflammation with the high quality of life and a surgical intervention avoided.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, outpatient surgery, and can be used to treat patients with epicondylitis.

Epicondylitis is a common disease in outpatient practice. Epicondylitis (tennis elbow, porter’s elbow) is a clinical syndrome: aseptic inflammation of the periosteum and tendon-ligamentous apparatus in the region of the internal (medial) or external (lateral) epicondyle of the shoulder, manifested by pain in the elbow joint, first with movements, and then constant with radiation along the muscles of the forearm soreness on palpation of the epicondyle in the area of muscle attachment. It develops with muscle strain due to uniform repetitive movements in the elbow joint in connection with sports (tennis, baseball, golf) or professional activities (e.g. with musicians); regarded as a variety of tendinopathies. The disease occurs against the background of repeated uniform loads. The following professions are at risk: computer users, milkmaids, installers, painters, seamstresses, etc.

Treatment of the disease includes limitation of movements in the elbow joint (in the acute period - tire immobilization), local injections of glucocorticoids.

Imperfect conservative treatment of shoulder epicondylitis has been noted since the description of this disease, it requires not only a long time, but it does not always lead to a stable recovery of the patient. Depending on what the etiopathogenesis of the disease seemed to be, surgeons proposed various operations, considering them as a “last resort”, acceptable only after unsuccessful long-term conservative treatment.

Known methods of treating patients with epicondylitis often do not provide constant remission, especially with a constant uniform sports or professional load, when the patient cannot refuse these loads, not wishing for many reasons to change his profession or leave sports.

A known method of treating patients with epicondylitis (A.G. Belenky Local injection therapy for degenerative diseases of the musculoskeletal system, M., 2003, pp. 28-29), including the introduction of corticosteroid drugs with anesthetic - hydrocortisone, Kenalog, diprospana in the zone of greatest pain, while the needle is held as deep as possible into the bone, and the drug is administered under high pressure. The course is prescribed 2-3 injections with a weekly interval.

However, this method has a number of significant drawbacks, which include a technically difficult injection, as the authors of the method themselves note, there is a danger of nerve damage. With the introduction of corticosteroids, gross skin atrophy, depigmentation, aggravation of degeneration, often followed by spontaneous tendon ruptures, often occur. In addition, with the introduction of hydrocortisone, a violent microcrystalline reaction occurs. Secondary administration of corticosteroids does not allow achieving primary remission: relapses become more frequent, and ultimately the pain syndrome begins to be chronic and persistent, while CS preparations do not bring a therapeutic effect.

A known method of conservative treatment of patients with epicondylitis (R.F. Akhmetyanov, E.N. Lukyanov et al., “Extracorporeal UVT of degenerative-inflammatory diseases of the musculoskeletal system.” Traumatology and orthopedics: present and future. Materials of the International Congress, Moscow, 7 April 9–9, 2003. PFUR Publishing House, pp. 19–20) by shock wave therapy of a physiotherapeutic treatment method based on the action of acoustic shock waves. Designed in clinics in Germany and Switzerland. The basis of this method is the impact on the affected structure of ultrasound of high energy power. The duration of the session leaves 15 minutes for each anatomical zone. Therapeutic shock waves, not stopping, propagate in soft tissues and, without damaging them, have a direct effect on bone and cartilage, bone spikes, growths and other formations with increased acoustic resistance. The procedure restores the natural metabolism, starts the processes of restoration and cell renewal, improves metabolic processes in the tissues.

The disadvantage of this method is the presence of pain that occurs during the session, which can have a very high severity, which does not allow the method to be used in individuals with a low pain threshold. As in the previous method, relapses often occur, and the method with repeated use also becomes ineffective.

A known method of treating patients with epicondylitis (Orthopedic aspects of epicondylitis, current views on the pathogenesis and treatment of shoulder epicondylitis (Shishov SV: In the book. Selected issues of myofibrillosis. - M. - 1993. - T.1. - P.25-29 ), including surgical intervention.The indication for it is the lack of effect from conservative treatment for 1 year.The most commonly used operation according to the method of VB Ulzibat: partial enthesis - dissection of the extensor tendons at the attachment site.

However, such an surgical intervention is certainly crippling and if performed with athletes or people with certain professional characteristics of the motor regime, it can lead to the loss of professional capabilities or the loss of sports achievements. In any case, a decrease in the functionality of the limb is too high a price for reducing pain.

A method for treating patients with epicondylitis has been adopted as the closest analogue. ” (J. Merth. Handbook of a general practitioner. Transl. From English. PRACTICE. M. pp. 570-572), including limiting the motor regime for the affected limb: - "do not make movements that cause pain." Perform bandaging of the elbow, bring the limb into an elevated position. From the first days, active therapeutic physical education (exercise therapy) is prescribed with overcoming any pain syndrome. The effectiveness of physiotherapy exercises is evaluated after 6 weeks. A solution of corticosteroids is injected into the pain zone twice with an interval of 2-4 weeks. If treatment is ineffective, an operation is performed - excision in the pain zone of scar tissue with the mobilization of the proximal ends of the forearm muscles. According to the author, the effectiveness of surgical treatment is 70%. Athletes are recommended before training to “tightly bandage the forearm slightly below the elbow joint with an elastic bandage

However, the method is not without drawbacks. As a rule, people seek medical help for whom the pain syndrome has a long history and who, despite the sparing regimen, are tired of waiting for an independent recovery. In addition, it is known that the treatment of athletes has its own characteristics. One of them is the inability to take breaks in training. The above complex treatment also does not guarantee against relapse. Tight bandaging causes disturbances in microcirculation of already altered muscles and it is difficult to imagine an athlete training with a tightly bandaged forearm. The introduction of glucocorticoids is fraught with many complications: septic infectious, local (aggravation of the local destructive process), as well as general (elevation of blood glucose, weakened immunity, changes in blood rheology, exacerbation of pancreatitis). The application of the method does not exclude relapse in the future.

The objective of the invention is to provide a highly effective method of treating patients with epicondylitis, which allows to obtain a pronounced and persistent clinical effect, to prevent relapse of the disease and possible complications.

The essence of the invention lies in the fact that in a method of treating patients with epicondylitis, which includes a set of measures: limiting the motor regime of the affected segment, physiotherapy and pharmacotherapy, the level of pain syndrome is preliminarily assessed according to the Visual Analogue Scale, the proximal forearm is immobilized with epicondillary bandage in the daytime during 7-10 days to patients-athletes or 2-3 weeks to ordinary patients, from the first day of treatment, physiotherapy exercises are prescribed, the first part of which, consisting of isome tric and static exercises aimed at strengthening the muscles of the arm, carried out in the first half of the day, and the second part, consisting of relaxing exercises, in the afternoon or after any exertion, while physiotherapy exercises are continued after removing the bandage, using it only during professional or sports loads, in parallel, daily electrical stimulation is carried out for 7-10 days using the CHENS device or its analogues by applying electrical signals to the area of interest and These muscles of the forearm, against the background of electrical stimulation, carry out complex drug therapy, which includes anti-inflammatory and reparative therapy with Arthrofoone, and with a pain level not exceeding 4 points, it is prescribed in monotherapy at a dose of 4 tablets per day for three months, and when its level is above 4 points - at a dose of 8 tablets per day in combination with a selective non-steroidal anti-inflammatory drug in a therapeutic dose of not more than 10 days, the muscle relaxant C is included in the treatment regimen dalud 2-4 mg one hour before bedtime for 2 weeks, vasodilators that improve microcirculation of the affected segment: in injections, which are administered intramuscularly daily for 10 days, Milgamma containing 2 ml B complex vitamins in a quantity of 5 injections, and then another 5 injections in two days on the third, enzyme preparation Wobenzym for 3-4 weeks, as well as calcium preparation Calcemin or Calcemin advance, which is prescribed for a period of six months, the course of treatment according to the scheme is repeated six months later, further patient recommended At high loads or against the background of professional sports, they are sent for life to maintain the strength of the muscle tone of the forearm; performing physical exercises aimed at strengthening the arm muscles two or three times a week for at least 30 minutes on average, fixing an interested segment with an orthosis for the duration of the load, processing with the CHENS device or its analogue of the interested muscles of the forearm and the area of enthesis after expressed loads 2-3 hours before bedtime and a session of relaxing exercises.

Using the invention allows to obtain the following technical result.

The proposed method is highly effective. It allows you to get a pronounced and persistent clinical effect, characterized by a complete relapse-free recovery, including patients with high professional or sports loads.

If all methods practice light work in the future, especially with surgical treatment, the proposed method provides a high quality of life: a return to the old way of life and work or sports loads.

The method provides a high treatment outcome without complications. The high efficiency of the selected pharmacotherapy regimen is accompanied by a high degree of treatment safety. Addiction does not occur.

The method provides physiological restoration of the tissue structure in the area of inflammation and obtaining stable good long-term results, thus excluding unjustified surgical interventions.

The use of the method has practically no contraindications other than the generally known when using the drugs specified in the scheme.

The technical result is achieved due to the new technology for the treatment of epicondylitis developed by the authors, which provides for therapeutic and rehabilitation measures, carried out in a certain sequence and aimed at treating pathology with the achievement of a relapse-free result.

The new technology is based on the facts established by the authors.

The clinic of epicondylitis is determined by the formation of a “vicious circle” with a constant prolonged tension of insufficiently strong muscles to perform individual loads. There is irritation of the attachment point of the forearm muscles to the epicondyles of the humerus: periostitis, enthesis, a “vicious circle” is formed, accompanied by a chronic local inflammatory process, microcirculation disturbance, neuropathic syndrome, the occurrence of a trigger zone with morphological changes in tendons and muscles.

First aid is the removal of the affected area from the load process. This is achieved by applying a special bandage, which includes a viscoelastic insert that carries out a directed action on the attachment points of the forearm muscles, which contributes to the redistribution of the load and, in the first place, with the transposition of the attachment points of the muscles. At the same time, the periosteum periosteum of the shoulder stops irritating - the pain syndrome stops, the "vicious circle" breaks.

During the first two weeks, normal loads are reduced (for professional athletes) or completely removed (for non-athletes), which allows reinforcing the result of breaking the “vicious circle”. In parallel, physical exercises of physiotherapy exercises (LFK) started according to the scheme developed by the author against this background allow you to strengthen the muscles and prepare them for stress.

As a local therapy, they affect the enthesis zone and the interested muscles of the forearm with the CHENS apparatus (or its analogues: SCENAR, DENAS and DIADENS). The action of these devices is completely harmless to the body due to the fact that the signal of the device is as close as possible to the signals of the patient’s nervous system and during treatment, the effect is carried out mainly on the surface skin receptors. Thermal or any other type of radiation from the devices does not come, so the devices can even be used to treat cancer patients without fear of worsening their condition.

Electrostimulation device therapy using devices of the CHENS type is a non-drug, non-invasive method, i.e. non-damaging therapeutic effect on the human body and is aimed at enhancing the internal forces of the body, regulating metabolism, blood circulation, normalizing the functioning of the nervous system. Effects of electrostimulating therapy: general regulatory, normalizing metabolism, nerve fiber conduction, neuro-vegetative functions, vascular tone, stimulating repair processes, including tissue regeneration. Local electrical exposure provides analgesic and anti-inflammatory effects.

In the technology used, the affecting pulse dynamically changes when exposed by dynamically adjusting the skin impedance: the shape and duration of the affecting pulse are close in characteristics to the pulse, which, after distortion by the skin, adipose tissue, muscle tissue, etc. will be close to a nerve impulse. In treatment, the dynamics of changes in its signal is adjusted to the dynamics of changes in the state of the “pain” zone. In response to this, the body's response to recovery is also enhanced, since it perceives the artificially increased pathological signal as real. This forces the body to produce a more powerful response to combat “pain”. The technology of the devices DENAS and SCENAR allows you to restore the functions of the body to the level at which it functioned before the onset of the disease. SCENAR restores homeostasis to a premorbid level. If the patient has a pacemaker, electrostimulation by the CHENS device or other electrical devices is not used.

The key point in the algorithm for the comprehensive treatment of epicondylitis, in addition to local electrical stimulation of the muscles of the forearm and the area of enthesis, is the inclusion in its scheme of drug therapy aimed at eliminating chronic inflammation, optimizing the functional state of the segment concerned, repairing the tissue of enthesis, and preventing relapse.

Drug therapy of epicondylitis is carried out using a complex of drugs selected by the author according to the scheme developed by him.

As an anti-inflammatory drug, the drug Arthrofone is used, the treatment regimen of which is compared with the severity of pain, for which the well-known Visual-analogue scale (VAS) is used.

Arthrofoon modulates the production and functional activity of endogenous tumor necrosis factor alpha (TNFα) in rheumatoid arthritis, osteoarthrosis, osteochondrosis. It has anti-inflammatory and analgesic effects. By reducing the production of a number of pro-inflammatory cytokines, inflammatory mediators inhibits the progression of inflammatory damage to tissues and target organs in inflammatory and degenerative diseases. Virtually no contraindications and side effects.

The drug is extremely relevant in the treatment of chronic degenerative diseases of the musculoskeletal system, since in this case, the basis of the disease is sluggish, mild inflammation. However, it can manifest itself on the part of any elements of the musculoskeletal system: muscles, tendons, ligaments, cartilage, etc. The rough effect of corticosteroid drugs or the long-term massive intake of non-steroidal anti-inflammatory drugs (NSAIDs) exacerbates dystrophic processes and, against the background of the analgesic effect, pathological changes in the joint continue to increase.

Ultra-low doses of antibodies to tumor necrosis factor-alpha (TNF-α), the drug Arthrofoone provides targeted pathogenetic therapy of the degenerative process in enthesis. A special technology for the preparation of solutions of ultra-low doses of antibodies gives them biological activity comparable to non-steroidal anti-inflammatory drugs. However, for the manifestation of high activity of the drug, their long-term use is required.

Arthrofone is taken sublingually outside of a meal.

When taking Artrofoon, the need for symptomatic anti-inflammatory drugs decreases, therefore, with a pain syndrome level not exceeding 4 points (according to YOURS), the drug is prescribed as monotherapy.

The drug is safe for prolonged course use.

When prescribing Arthrofoone in combination with a short course of non-steroidal anti-inflammatory drugs (NSAIDs) and chondroprotectors, the effect of the latter is enhanced, and from the side of NSAIDs, the level of side effects decreases. Since the inflammatory process with epicondylitis, as a rule, is chronic, the appointment of the drug based on the smallest doses of arthropoon provides a soft, correct effect on inflammation, especially with pain syndrome not exceeding 4 points according to YOUR. With epicondylitis, we are talking about suppressing inflammation in a very small structure, and therefore the prolonged use of NSAIDs, in which the drug is distributed throughout the body, is inappropriate. In comparative studies, the effectiveness of oral NSAIDs in patients with epicondylitis practically did not differ from the placebo effect.

In the case of persistent pain, when the pain syndrome, reflecting the level of the inflammatory process in the focus, exceeds 4 points, an additional short course of NSAIDs is performed.

Nicotinic acid / or trental, compliance, etc. are used as a vasodilator. Vasodilators relieve spasm of the microvasculature, which leads to circulatory hypoxia of the tissues of the zone of interest (in this case, enthesis) and is one of the leading factors in the pathogenesis of pathological disorders in degenerative-dystrophic pathology of the musculoskeletal system.

As a preparation containing a complex of B vitamins: Milgamma is prescribed. It consists of group B drugs and lidocaine. Group B drugs are of great importance for the normal functioning of nerve tissues. Milgamma vitamins contribute to the regeneration of nervous and muscle tissue, improve blood circulation, anesthetize and positively affect the conductivity of neuromuscular impulses. The solution for injection contains vitamin B1 - thiamine, vitamin B6 - pyridoxine, vitamin B12 - cyanocobalamin. Thiamine affects synaptic transmission, thereby improving nerve conduction. Its deficiency provokes the accumulation of carbohydrate decomposition products in the nervous tissue. Pyridoxine is necessary for the formation of various active mediators - dopamine, adrenaline, histamine, tyramine, serotonin. Also, this vitamin is involved in the processing of amino acids by the body. After phosphorylation, pyridoxine enters the blood plasma, after which it may enter the cell. It has a powerful effect on the functioning of the muscular system. Cyanocobalamin is involved in the synthesis of creatinine, nucleic acids, choline, methionine, prevents anemia and takes part in the metabolism. In addition, it is an analgesic.

The indication for epicondylitis is the presence of pain and dystrophic neuropathy, muscle-tonic syndromes.

As enzyme preparations use: Wobenzym or its analog, which is a combination of highly active enzymes of plant and animal origin. It has immunomodulatory, anti-inflammatory, fibrinolytic, decongestant, antiaggregant and secondary analgesic effects. Wobenzym has a positive effect on the course of the inflammatory process, limits the pathological manifestations of autoimmune and immunocomplex processes, and positively affects the immunological reactivity of the body. It stimulates and regulates the functional activity of macrophage monocytes, natural killer cells, stimulates antitumor immunity, cytotoxic T-lymphocytes, and phagocytic cell activity.

Under the influence of Wobenzym, the number of circulating immune complexes decreases and membrane deposits of immune complexes are eliminated from the tissues. Wobenzym reduces interstitial plasma cell infiltration. It increases the elimination of protein detritus and fibrin deposits in the area of inflammation, accelerates the lysis of toxic metabolic products and dying tissues; improves resorption of hematomas and edema; normalizes the permeability of the walls of blood vessels. reduces thromboxane concentration and platelet aggregation. Regulates the adhesion of blood cells, increases the ability of red blood cells to change their shape, regulating their plasticity; normalizes the number of normal discocytes (platelets) and reduces the total number of activated platelet forms, normalizes blood viscosity, reduces the total number of microaggregants, thereby improving microcirculation and rheological properties of blood, as well as supplying tissues with oxygen and nutrients. It normalizes lipid metabolism, reduces the synthesis of endogenous cholesterol, increases HDL, reduces the level of atherogenic lipids, and improves the absorption of polyunsaturated fatty acids. It increases the effectiveness of antibiotic therapy, increasing the concentration of antibiotics in the blood plasma and the focus of inflammation, and also reduces such a side effect as dysbiosis. Reduces the severity of side effects associated with the use of hormonal drugs, including hypercoagulation. Regulates the mechanisms of nonspecific protection, stimulates the production of interferons, thereby exhibiting antiviral and antimicrobial effects. The secondary analgesic effect of Wobenzym is manifested through exposure to the causative factors of the acute inflammatory process.

Sirdalud, a central muscle relaxant, is included in complex drug therapy.

The main point of application of its action is in the spinal cord. By stimulating presynaptic α ₂ receptors, tizanidine inhibits the release of excitatory amino acids that stimulate receptors sensitive to N-methyl-D-aspartate (NMDA receptors). As a result, the polysynaptic transmission of excitation is suppressed at the level of intermediate neurons of the spinal cord. Since it is this mechanism that is responsible for excess muscle tone, when it is suppressed, muscle tone decreases. In addition to the muscle relaxant properties, tizanidine also has a central, moderate, analgesic effect. Cirdalud is effective both in acute painful muscle spasm and in chronic spasticity of spinal and cerebral origin. Reduces spasticity and clonic convulsions, as a result of which resistance to passive movements decreases and the volume of active movements increases, which allows optimizing therapeutic exercises and accelerating the therapeutic effect of complex therapy.

To improve the quality of bone tissue, which always suffers in the area of attachment of the tendon to the periosteum and is manifested by the area of resorption on the x-ray, improve muscle-neural conduction and improve the quality of connective tissue, calcium-D3-containing third-generation drug, Calcemin, is prescribed. The choice of drugs is due to the fact that Calcemin has a positive effect on the bone structure to a greater extent than other calcium preparations due to the content of osteotropic trace elements in it and prepares the skeleton for increased loads in the postoperative period. In addition, the drug improves neuromuscular conduction, providing a moderately pronounced relaxing effect.

Calcium, which is part of the preparation, is a building component for bone tissue, regulates vascular wall permeability, participates in the regulation of conduction in synapses and neuromuscular joints, participates in contractile activity of skeletal and smooth muscles, and is an essential component for blood coagulation. Calcium is represented in the preparation by carbonate and citrate salts. Calcium carbonate contains the maximum amount of elemental calcium. Calcium citrate reduces the dependence of calcium bioavailability on the state of the gastrointestinal mucosa, prevents calculus formation in the urinary system even in the case of prolonged use, and reduces the excess production of parathyroid hormone.

Vitamin D (cholecalciferol) in the composition of calcemin promotes adequate absorption of calcium, is involved in the regeneration and construction of bone tissue.

Zinc is an integral component of various body enzymes (over 200 species) that synthesize proteins and nucleic acids. It also provides gene expression, regeneration and cell growth. Positively affects the activity of the enzyme alkaline phosphatase.

Manganese promotes the synthesis of substances that are components of bone and cartilage (glycosaminoglycans). Potentiates the calcium-saving ability of vitamin D.

Copper is involved in the formation of elastin, collagen. Helps stop the phenomenon of demineralization of bone structures.

Boron normalizes the activity of the parathyroid hormone - parathyroid hormone. The latter is involved in the metabolism of calcium, cholecalciferol, phosphorus, magnesium. The effect on the mineral metabolism of parathyroid hormone is independent of the intake of vitamin D3.

Thus, the complex treatment algorithm in a concise form can be defined as follows: stopping the pain syndrome - interrupting the pathological imupulsation in the trigger zone - strengthening the muscles of the hand (and, primarily, the forearm) - ensuring the regeneration of tissue of enthesis.

The authors first proposed a method for the treatment of epicondylitis, which includes a set of therapeutic measures aimed at improving the trophism of degeneratively affected tissues, interrupting the "vicious circle". The authors first proposed a method of treating epicondylitis, which includes a set of therapeutic measures aimed at improving the trophism of degeneratively affected tissues, interrupting the “vicious circle”, rapidly relieving pain, preventing relapses of the disease, and invalidizing a patient with epicondylitis.

A method of treating epicondylitis is aimed at all pathogenetic links of the degenerative process: it simultaneously provides an adequate analgesic, anti-inflammatory, angioprotective, regenerative effect, breaks the vicious cycle of the pathogenesis of the disease.

Timely comprehensive treatment of epicondylitis with an emphasis on the most complete and quick relief of pain and the creation of a muscle case of the upper limb, sufficient to provide the required loads (the requirements for the work of the limb), improving metabolic processes in the tissues of the affected segment can prevent chronic process under conditions of increased load and recurrent course of the disease, fully restore the function of the affected limb.

The application of the proposed method allows in 100% of cases to avoid the use of corticosteroids and surgery on a pathologically altered segment, to increase the rehabilitation potential of the patient and the quality of life of the patient.

Despite the clear successes of sports medicine, corticosteroids and crippling surgical treatment of entheses, for example, with epicondylitis, continue.

The author first established the following. Adverse treatment outcomes are primarily determined by the fact that during surgical treatment, the incision of an altered tendon or ligament will forever leave an inferior scar tissue, which makes it difficult for the patient to return to his former life and previous loads. Relapses are possible, since the effect is not directed to the cause, but to the effect. Conservative treatment, including injections of corticosteroids, leads to aggravation of degenerative changes and a high risk of spontaneous rupture of the tendon or ligament. In addition, the improper use of immobilizing elbow joint funds supports irritation of the area of attachment of enthesis and forms a relapse of the disease.

The chronic course of the inflammatory process forms a stagnation of lymphatic drainage, violates the elimination of pro-inflammatory factors, which, in turn, enhances degenerative, dystrophic changes in the tissues of the segment concerned.

The complex process of structural changes in paraarticular tissues, in turn, leads to a decrease in muscle balance and the risk of formation of tendomyogenic contracture. As the degenerative-dystrophic process progresses, the entire upper limb is involved in the pathological process, leading to severe disability of the patient.

Thus, in the postoperative period or after conservative treatment with corticosteroids against the background of a temporary elimination of the pain syndrome, some patients, after completing the full course of standard rehabilitation, cannot withstand the previous increased loads. In the future, with an increase in loads exceeding the usual, a relapse of the disease occurs.

The application of the proposed treatment algorithm allows to achieve a high positive treatment effect without the risk of the above complications.

The method is as follows.

A patient is examined to confirm the diagnosis of epicondylitis. Assess the level of pain on the Visual Analogue Scale (YOUR).

From the first day of treatment, comprehensive therapeutic measures are carried out.

The affected segment — the proximal forearm — is immobilized with Bauerfeind epicondylar bandage (Fig. 1) in the daytime for 7-10 days to athletes-patients or 2-3 weeks to ordinary patients. The bandage has a viscoelastic insert that allows you to directionally unload the attachment points of the forearm muscles and minimize external loads on the segment. After that, the bandage is worn only under loads. In this case, as if there is a transfer of the point of attachment of the muscle in the area of pressing it with a special rubber cushion of the bandage. This ensures complete unloading of the zone of attachment of the muscle tendon to the periosteum of the humerus.

From the first day from the start of treatment prescribed physical therapy (exercise therapy). Moreover, its first part, consisting of isometric and static exercises aimed at strengthening the muscles of the hand, is carried out in the first half of the day, and the second part, consisting of relaxing exercises, is carried out in the afternoon or after any exertion. Moreover, during the first two to three weeks, exercise therapy is carried out in the position of a fixed limb, and then they switch to exercise therapy without a bandage, using it only during professional or sports loads. The criterion of possible loads in exercise therapy is the complete absence of pain during exercise.

In parallel, electrical stimulation is carried out daily for 7-10 days by applying electrical signals to the enthesis zone and the interested muscles of the forearm, for which they use the CHENS device or its analogues - DENAS, SCENAR, etc.

Against the background of electrical stimulation, pathogenetic anti-inflammatory and reparative pharmacotherapy is carried out according to the developed scheme, aimed at the regeneration of tissues of the enthesis zone.

When the level of pain does not exceed 4 points according to YOUR, the anti-inflammatory drug Arthrofoin is prescribed in monotherapy at a dose of 4 tablets per day for three months. At a pain syndrome level of 4 points or more, Artrofon is prescribed at a dose of 8 tablets per day in combination with selective non-steroidal anti-inflammatory drugs: NICE, or Nimesulide, or Nimulide at a dose of 100-200 mg for 7-10 days.

To relax the tense muscles of the forearm, a drug is prescribed - muscle relaxant Sirdalud 2-4 mg an hour before bedtime for 2 weeks.

The patient’s body is also injected with drugs that improve microcirculation of the affected segment — vasodilators, which use nicotinic acid or trental or compliment, etc. in injections that are administered intramuscularly in 1-2 ml daily for 10 days.

The treatment regimen includes the introduction into the patient’s body of the drug Milgamma containing group B vitamins of 2 ml in the amount of 5 injections daily, and then another 5 injections in two days on the third.

Enzyme preparations are prescribed: Wobenzym or Phloenzym in a dose of 3 tablets three times a day for 3-4 weeks.

To restore the entire complex of tissues, including bone, tendon, muscles, calcium preparation Calcemin or Calcemin advance is additionally introduced into the drug treatment regimen, which is prescribed for a period of six months.

Treatment according to the proposed scheme is repeated six months later as a prophylaxis and consolidation of the primary treatment and elimination of relapse.

In the future, the patient is recommended at high loads or against a background of professional sports for life to maintain strength of the muscle tone of the forearm performing physical exercises aimed at strengthening the muscles of the arm two to three times a week for an average of at least 30 minutes, fixing the segment with an orthosis for the duration of the load, processing with the CHENS device or its analogue of the interested muscles of the forearm and enthesis zone after expressed loads 2-3 hours before bedtime and a relaxation exercise session.

The method has passed clinical trials in the base clinic of the Department of Traumatology RMAPO GKB No. 15 named after O.M. Filatov and in the city polyclinic №22 South-Western Administrative District of Moscow. It was used in 19 patients (volunteers) with epicondylitis aged 16 to 56 years, including 7 women and 12 men.

As a result of treatment, a pronounced and persistent clinical effect was achieved in all patients without complications and side effects. When examining patients after three years, there was no evidence of epicondylitis or recurrence of the pathological process, even in people with severe occupational stresses.

Example 1. Patient Ch., 16 years old, a professional athlete-tennis player turned about a pronounced pain syndrome, the inability to perform the simplest sports loads. This condition lasted for 4 months. The patient was examined. The diagnosis was confirmed: right-sided lateral-medial epicondylitis. Pain syndrome at rest corresponds to 4 points on YOUR. The patient repeatedly went to various clinics of the city. The introduction of corticosteroids into the area of enthesis and surgical treatment have been proposed. The patient refused the proposed treatment (risk of losing a sports career) and turned to the department of traumatology and orthopedics of the RMAPO. The treatment according to the proposed method.

The proximal forearm is immobilized with Bauerfeind epicondylar bandage for a period of 10 days during the day. From the first day from the start of treatment, exercise therapy was started. Its first part, consisting of isometric and static exercises aimed at strengthening the muscles of the arm, was carried out in the first half of the day, and the second part, consisting of relaxing exercises, in the afternoon. During the first three weeks of exercise therapy, the patient exercised in the position of a fixed bandage of the limb, then exercise therapy was performed without a bandage on the arm, and the bandage was used only during training and sports performances for two months.

Also, from the first days during the week, local electrical stimulation was performed by applying electrical signals to the enthesis zone and interested forearm muscles with the CHENS device.

Against the background of electrical stimulation, anti-inflammatory and reparative pharmacotherapy was carried out: the anti-inflammatory drug Arthrofoon was prescribed in monotherapy at a dose of 2 tablets twice a day for three months.

To relax the tense muscles of the forearm, a drug was prescribed - muscle relaxant Sirdalud 2 mg one hour before bedtime for 2 weeks.

A course of injection therapy was carried out: nicotinic acid 2 ml daily for 10 days and Milgamma, 2 ml in the amount of 5 injections daily, and then another 5 injections in two days on the third.

The enzyme preparation Wobenzym was prescribed in a dose of 3 tablets three times a day for 4 weeks.

Prescribed calcium preparation Calcemin for a period of six months.

The treatment was successful. A complete recovery of the patient has been achieved. There is no pain syndrome. No complaints were filed. No complications or side effects were detected.

Treatment according to the proposed scheme is repeated six months later.

The patient is observed for 7 years: fulfills the recommendations of the doctor, continues to engage in professional sports. No recurrence of epicondylitis was observed. A follow-up examination once a year did not reveal complaints from the upper limbs.

Example 2. Patient M. B. 57 years old turned about pain in the right elbow joint. Occupation: geologist, built a house on a summer cottage. On examination, an enthesis zone was revealed, palpation of the medial epicondyle of the right shoulder was sharply painful. Diagnosis: right-sided medial epicondylitis.

Pain syndrome corresponds to 6 points on YOUR.

The proximal forearm was immobilized with an Bauerfeind epicondylar bandage for a period of 3 weeks. From the first day from the start of treatment, exercise therapy is recommended in the state of forearm fixation for two weeks, then without it. The bandage was used only for the period of physical activity.

At the same time, local electrical stimulation was performed daily for 10 days by applying electric signals to the enthesis zone and the interested muscles of the forearm with the SCENAR device.

Against the background of electrical stimulation, anti-inflammatory and reparative pharmacotherapy was carried out with Arthrofoon at a dose of 8 tablets per day in combination with selective non-steroidal anti-inflammatory drug NYSE at a dose of 100-200 mg for 7 days, a muscle relaxant sirdalud 4 mg was prescribed one hour before bedtime for 14 days , Calcemin - advance 1 tablet 2 times a day, Wobenzym - 3 tablets 3 times a day for 2 weeks and 5 tablets 3 times a day for another 2 weeks.

A course of injection therapy was carried out: trental 2 ml daily for 10 days and Milgamma, 2 ml in the amount of 5 injections daily, and then another 5 injections two days later on the third. The course of treatment was repeated after six months.

Long-term results of 4 years - during examination, no complaints were revealed, there were no relapses, the patient completely returned to his previous lifestyle and work. Fulfills the recommendations of a doctor.

Claims (1)

A method of treating patients with epicondylitis, which includes a set of measures: limiting the motor regime of the affected segment, physiotherapy and pharmacotherapy, characterized in that the level of pain is assessed on a Visual-Analogous scale, the proximal forearm is immobilized with epicondillary bandage in the daytime for 7-10 days patients-athletes or 2-3 weeks - ordinary patients, from the first day of treatment prescribed physical therapy, the first part of which, consisting of isometric and static exercises aimed at strengthening the muscles of the hand, carried out in the first half of the day, and the second part, consisting of relaxing exercises, in the afternoon or after any exertion, while physical therapy is continued after removing the bandage, using it only during professional or sports loads, in parallel daily, for 7-10 days, electrical stimulation is performed using the CHENS device or its analogues by applying electrical signals to the enthesis zone and interested muscles whose, against the background of electrical stimulation, they carry out complex drug therapy, which includes anti-inflammatory and reparative therapy with Arthrofoone, and with a pain syndrome not exceeding 4 points, it is prescribed in monotherapy at a dose of 4 tablets per day for three months, and at its level above 4 points - in a dose of 8 tablets per day in combination with a selective non-steroidal anti-inflammatory drug in a therapeutic dose of not more than 10 days, Sirdalud muscle relaxant 2-4 mg per hour is included in the treatment regimen from sleep for 2 weeks, vasodilators that improve microcirculation of the affected segment: in injections, which are administered intramuscularly daily for 10 days, Milgamma preparation containing a complex of vitamins of group B of 2 ml in an amount of 5 injections, and then another 5 injections two days later, on the third, enzyme preparation Wobenzym for 3-4 weeks, as well as calcium preparation Calcemin or Calcemin advance, which is prescribed for a period of six months, the treatment according to the scheme is repeated six months later, in the future the patient is recommended at high loads or against the background of professional sports for life to maintain the strength of the muscles of the forearm muscles; performing physical exercises aimed at strengthening the muscles of the arm two or three times a week for at least 30 minutes on average, fixing an interested segment with an orthosis for the duration of the load, processing with the CHENS device or its equivalent the muscles of the forearm and the area of enthesis after expressed loads 2-3 hours before bedtime and a session of relaxing exercises.

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