Epicondilite ed epitrocleite

La presenza di un dolore acuto ed intenso nella regione esterna del gomito prende il nome di epicondilite, in quanto deriva dall’infiammazione di un tendine alla sua inserzione ossea sull’epicondilo omerale.

Su tale sporgenza ossea sono numerosi i tendini dei muscoli (detti per l’appunto epicondiloidei) che prendono inserzione uninedosi in unica entità tendinea chiamata estensore comune, formata da estensore ulnare (posteriore), estensore delle dita, estensore radiale breve (anteriore). Nei casi tipici l’estensore radiale breve del carpo è la prima componente che va incontro a tale forma patologia.

L’epicondilite fu descritta da F. Runge nel 1873 (Zur Genese und Behandlung des Schreibekrampfes), Runge parlò di crampi dello scrittore (Schreibekrampfes), ma fu M. Morris, pochi anni dopo, (Riders sprain; Lancet 1882) il primo che usò la locuzione tennis elbow (gomito del tennista). Infatti, comunemente questa patologia si definisce anche gomito del tennista intendendo sicuramente più la sollecitazione continua che il tennis impone su questo muscolo che la particolare frequenza di questa malattia nei tennisti. Sebbene circa il 50% dei giocatori di tennis sviluppi questa patologia da overuse, il 95% dei casi interessa la popolazione generale.

Vi sono molti modi di classificare l’epicondilite. Una delle più usate è quella relativa agli stadi anatomo-patologici della malattia. In base a questa classificazione si distinguono quattro stadi:
Stadio 1: il danno è di tipo infiammatorio. Non sono presenti alterazioni istologicamente interessanti del tendine. In questo stadio si avverte dolore quando si svolgono attività abbastanza intense; la dolenzia scompare totalmente con il riposo e la terapia antinfiammatoria. Questo stadio è completamente reversibile.
Stadio 2: è presente una degenerazione angiofibroblastica del tendine Il dolore compare anche con attività blandamente intense; non sempre la dolenzia scompare con il riposo; la risposta alla terapia antinfiammatoria non è sempre ottimale.
Stadio 3: si è in presenza di degenerazione patologica e notevole estensione angiofibroblastica. Il dolore è molto intenso, tanto da impedire, molto spesso, lo svolgimento delle normali attività lavorative o sportive.
Stadio 4: sono presenti aree fibrotiche e calcificazioni. La terapia conservativa è spesso priva di qualsiasi efficacia e si richiede un approccio terapeutico importante.

La diagnosi strumentale serve a confermare la diagnosi clinica di epicondilite; l’esame radiografico è comunque il primo esame da effettuare in quanto di basso costo, rapidamente eseguibile ed indicativo non tanto della condizione flogistica in atto, che comunque identifica nel caso sia evoluta in calcificazione (vedi la radiografia sottostante), ma di eventuali forme artrosiche od artritiche dell’articolazione;


Rx del gomito – sul profico osseo dell’epicondilo (lato sinistro della radiografia) si evidenziano due ravvicinate calcificazioni espressione evolutiva cronica dello stato infiammatorio dei tessuti molli perischeletrici.

L’ecografia è la seconda indagine da eseguire perchè in grado di definire con accuratezza lo stato delle componenti tendinee e dei tessuti molli che circondano e si inseriscono sull’epicondilo. Conclude l’iter diagnostico la Risonanza Magnetica che come per gli altri distretti  muscolo-scheletrici è l’esame  più completo, oggi sempre più vicino come costo all’esame ecografico.

l’ecostruttura superficiale del tendine è normale (tipicamente fibrillare) ma risulta ipoecogena (segno di infarcimento flogistico)all’esame colordoppler si evidenzia aumento della vascolarizzazione profonda espresione di forma infiammatorial’ecografia mostra alta sensibilità nell’individuazione delle calcificazioni intra o peritendinee espressione di vecchi episodi flogistici.

 EPICONDILITE – Diagnosi con Risonanza Magnetica

La Risonanza Magnetica è la metodica più indicata nell’identificazione di tutte le lesioni che sono responsabili di questa forma inserzionale. La freccia blu indica l’ispessimento ed iperintensità dei tessuti molli peritendinei in corrispondenza dell’inserzione sull’epicondilo dei tendini estensori: l’iperintensità di segnale di tali tessuti esprime caratterizza la fase infiammatoria come subacuta. I tendini  (freccia blu più sottile) non mostrano alterazione strutturale conservando omegenea ipointensità.

EPITROCLEITE

L’epitrocleite, più comunemente conosciuta come gomito del golfista, è una sindrome dolorosa dovuta generalmente ad un sovraccarico funzionale e/o degenerazione tendinea dei muscoli epitrocleari. Questi sono muscoli interni dell’avambraccio che originano dall’epitroclea e si inseriscono sull’ avambraccio, sul polso e sulla mano. Questi muscoli servono a ruotare all’interno (pronazione) la mano, a flettere il polso e le dita. L’epitrocleite è la causa più frequente di dolore mediale (interno) al gomito. 

Sono tre gli stadi di gravità dell’epitrocleite: nel primo stadio rientrano i casi di infiammazione abbastanza leggera, anche se dolorosa. In questi casi una terapia farmacologica basta per far regredire il dolore e per permettere il ritorno alle normali attività. Il secondo stadio comprende i casi intermedi in cui convivono parti di tessuto sano e parti di tessuto infiammato. L’attenzione che si pone nel trattare tale condizione fa sì che la sua evoluzione porti a una totale regressione o a una cronicizzazione della patologia. Il terzo stadio è il più grave ed è quello in cui è presente buona parte di tessuto lesionato e solitamente necessita di un intervento chirurgico per guarire.

L’ecografia è lo studio più semplice ed indicato ma si presta all’esperienza interpretativa dell’operatore radiologo e non è panoramico come la RM che invece consente di documentare lo stato dei tendini, dei tessuti peritendine, soprattutto dell’eventuale partecipazione patologica dell’osso epitrocleare e di escludere eventuali cause di dolore ad origine intra-articolare.

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