10/7 - Elbow Complex Part 2 Flashcards
what attachment is likely implicated in lateral tendinosis
origin of extensor carpi radialis brevis
what is tendinopathy in general terms
degenerative condition, NOT INFLAMMATORY
what are the 3 possible etiologies of tendinopathies
- vascular
- degeneration d/t vascular compromise
- ability to absorb and generate force declines - mechanical loading
- microscopic degeneration leading to scar tissue - neural modulation
- neurally mediated mast cell degranulation and release of substance P
what is a way that we might be able to detect a mechanical loading etiology to a tendinopathy
might be able to palpate changes
could have some tenderness
what are 4 risk factors for a tendinopathy
inc age
tendons crossing 2 joints
excessive loading (volume, magnitude, speed)
altered biomechanics
how do altered biomechanics contribute to a risk factor for tendinopathies
weakness
limited flexibility
poor form w movement
how is inc age a risk factor for tendinopathy
age has a cumulative effect of load over time
what impact does prox weakness have on distal mobility
inc demand on distal mobility
- will rely on distal ms to work harder to create stability
what is the most typical MOI behind a tendinopathy
overuse
what is the main way to rehab a tendinopathy
loading the tissue
- inc collagen formation in the area
why are isometrics chosen initially for management of a tendinopathy
d/t high reactivity
what type of resistance do we want to be adding when rehab-ing a tendinopathy
heavy and slow
- for concentric exercise
what are other names for tendinosis
epicondylitis
epiconylalgia
what does lateral tendinosis lack
an inflammatory response
what is the best way to try to recreate sx at any ms
ask ms or work or put ms on stretch
what actions do pts w lateral tendinosis have difficulty with
gripping
passive wrist flex
active wrist/finger ext
what is the demographics for lateral tendinosis
females 35-50
physical/office work (ie typing)
what are tests to r/i lateral tendinosis
cozen test - resist wrist ext in pronation and RD (getting ECRB to work)
maudsley - 3rd finger resistance (EDC)
mill - elbow flex to 90, pronation
- support elbow & flex wrist and extend elbow
what modification can be added to the mill test to further provoke sx if mill test not sufficient
add ulnar deviation
what are differential dx for lateral tendinosis (6)
- tendinitis vs tendinosis
- C6-7 nerve root
- radial tunnel syndrome
- posterolateral rotary insufficiency
- posterior interosseous n. compression
- intra-articular pathology
what is a main way that can tease out lateral tendinosis from other differential dx
assessing the end feel
- degenerative n. vs muscular restriction
- capsular or bony?
what intervention was helpful in lateral tendinosis? what wasn’t?
MWM - improved pain and grip
Mill’s manip - improve pain but not grip
what is another term for lateral tendinosis
tennis elbow
is a tendinosis acute or chronic? what are the implications of this?
chronic
lacks inflammatory response
what is one reason other than chronicity that you don’t see inflammatory process in individuals w tendon irritation
taking anti-inflammatory meds
what are the main structures implicated w a medial tendinosis
FCR
pronator teres
what is another term for medial tendinosis
golfer’s elbow
what are MOI for medial tendinosis (3)
flexor-pronator fatigue
UCL fails to stabilize valgus forces
rapid change in level of stress
what are components to a physical exam to r/i medial tendinosis (4)
- palpation of medial epicondyle
- pain w/i 5 cm - grip strength
- (+) pain, deficit - strength - wrist flex, pron
- stretch - wrist ext, sup
what is a precaution when utilizing a HHD to assess grip strength in someone you suspect medial tendinosis in
caution in the presence of ulnar neuritis
what are 4 differential dx for medial tendinosis
C7, C8, T1 n. compression
thoracic outlet syndrome
ulnar n. injury
medial elbow instability (UCL)
C7,8/T1 and thoracic outlet vs medial tendinosis
thoracic outlet and cervical pain are more diffuse and broader area
- not pinpoint area like MT
sx of ulnar n. damage/irritation
weakness w opposition
weakness, paresthesias, numbness
what intervention will benefit majority of people with tendinosis
conservative management or PT
what is the criteria to require surgical intervention for tendinosis (3)
failure of conservative management >1yr
constant pain
intra-articular pathology
which tendinosis is more commonly requiring an intervention
lateral tendinosis
what are 3 typical surgical procedures for lateral tendinosis
- release of common extensor origin
- debridement &/or repair of extensors
- decortication or drilling of lateral epicondyle
what is the typical post-op rehab after a surgical intervention for tendinosis
gradual restore of motion
once mobility is back, then restoring strength
location of sx and c/o in bicipital tendinopathy
c/o pain at radial tuberosity
sx w resisted elbow flex and supination
rehab program for bicipital tendinopathy (4)
relative rest
restore ms length & GHJ capsular mobility
eccentric loading of elbow flexors & supinators
progressive return to throw program
MOI for distal biceps tendon rupture
rapid eccentric contraction while in supination
what motions will cause pain and weakness in a distal biceps tendon rupture
elbow flex and supination
what are visible signs of a distal biceps tenodn rupture
popeye deformity
(+) ecchymosis in antecubital fossa
what is super important in the management of a distal biceps tendon rupture and why
TIMELINE - direct referral to surgeon
- if surgical, needs to be as soon as possible, the longer it takes to get to a surgeon - the less option surgery is
as biceps retracts up, harder to restore anatomic footprint
- quality of tissue deteriorates and length of tissue dec
general progression of post op management of distal biceps tendon rupture repair
focus on restoring full ROM by 6 weeks
- gradual ext
triceps strengthening first
then biceps isometrics
- do co-contraction exercises first to avoid isolated biceps contractions
unrestricted activity by 16 weeks
what are risk factors for a nerve injury (3)
superficial location of nerve
pathway thru narrow bony canal or in b/w ms
nerve location high risk area for trauma
what are typical nerve injury mechanisms
direct or indirect trauma
traction
friction
compression
what is the most common MOI for ulnar nerve (2)
traction
valgus force at elbow
what are the components of the pathway that the ulnar n. passes through
walls - medial epicondyle and olecranon
roof - aponeurosis
floor - UCL, joint capsule, olecranon
what is the MOI for cubital tunnel syndrome (2)
traction (valgus force in throwers)
postures of valgus
what are differential dx for cubital tunnel syndrome
cervical radiculopathy
thoracic outlet syndrome
what is a consideration w the common c/o with cubital tunnel syndrome
c/o painless “snapping” or “popping” during A/P flex/ext
- if accompanies by numbness and tingling that is the rubbing the nerve which will cause irritation
what are 4 tests to r/i cubital tunnel syndrome
tinel @ ulnar n.
froment sign
elbow flex test
pressure provocation test
what are the keys to success in non-operative management of cubital tunnel syndrome (2)
prevent excessive flex postures
prevent ext pressure on nerve
what are patient education points for cubital tunnel syndrome
avoid elbow flex >90
avoid valgus stress
avoid excessive wrist/finger flex
what are indications for surgical intervention for cubital tunnel syndrome (3)
failure of conservative management
evidence of ms atrophy
(+) nerve conduction findings
what type of outcome measures are often used and what are 2 examples
patient reported outcome measures
- DASH and qDASH
