ELBOW

Question 1

MEDIAL EPICONDYLALGIA

Answer 1

• Microtearing of the common flexor tendon at the medial epicondyle of the humerus esp. FCR and PT
- PL less commonly affected and not FCU

• Insertional tendinopathy of common flexor tendon origin.
o 3 stages of tendinopathy: reactive, disrepair and degenerative
• Affects wrist flexors and forearm pronators
• Main pathology in forearm flexors, especially pronator teres

AGGRAVATING FACTORs
• tasks of repeated loaded gripping and wrist flexion as well as resisted forearm pronation
• supination and valgus forces at the medial elbow during activities such as throwing, golf and tennis
Prevalence
• age 40-60
• Sports : golfers, tennis players who put a lot of top spin on their forehand, baseball, javelin, weightlifting, archery, racquetball
• Occupation/ADLs: repeated forceful wrist movement, vibrating too use

Question 2

ME Patient history

Answer 2

MOI
o Insidious/gradual > often associated with increase in activity or new activity
o Or acute onset of pain associated with a single instance of wrist flexor/forearm pronator exertion
o Increased repetitive loading from activities involving repeated wrist flexion
o Traumatic: medial blow to the elbow

• Complains of:
o Localised pain around the medial epicondyle after unaccustomed/increase in activity (repetitive wrist flexion activities etc)
o Sharp, stabbing, burning pain around the medial epicondyle
o Exacerbated by wrist flexion and forearm pronation in work, sports or ADLs
o Pain eased by ice

Question 3

Ax ME

Answer 3

palp: pain at medial epicondyle and 5-10mm ant and distal
- pain on MMT/resisted of wrist flex. FINGER FLEXION and pronation in elbow extension
- pa. stretching in WRIST Ext (generally no flexion ROM issues) - PAIN W/ COMBINED FINGER AND WRIST EXT.
- pain + weakness w/ gripping

Question 4

differential diagnosis of ME

Answer 4

Differential diagnosis
•	Referred pain C5-7 (negative Spurling’s test)
•	Humeroulnar joint problems
•	MCL strain
•	Ulnar neuropathy/impingement
•	Medial OA of the elbow

Surgical treatment
• Recommended at 3-6 months if no response to conservative treatment

Question 5

ME Mx

Answer 5

same for lateral epi.

Golfer’s swing
•	Correct posture  all about the kinetic chain
o	Protracted shoulders- pec minor
o	Reduced trunk mobility
o	Reduced hip mobility
o	Foot positioning
•	correct the above  with manual therapy

Locally
• Think of stretch-shortening cycle- this causes nociceptive problems at medial elbow tendons - START W/ CONCENTRIC wrist flexor exercises first.
• Need to address power of wrist flexors, because golf incorporates explosive MVMTS
• Massage with movement can also help
o Medial glide MWM
• Deloading tape

Address degeneration
• Need to load progressive to encourage the laying down of new tissue and improve the healing capacity of the tendon through exercise

Question 6

PIN

Answer 6

Entrapment of radial or posterior interosseus branch of radial nerve between the radiohumeral joint and the supinator muscle.
•RN DEVIDES at capitellar joint
•PIN passes distal to the origin of the ECRB, enters the arcade of Frohse to emerge from the supinator muscle distally

• Compression of the nerve can occur at 4 sites:
o Fibrous bands in front of the radial head
o Recurrent radial vessels
o Arcade of Frohse (supinator muscle) *
o Tendinous margins of ECRB *

• Can be from hypertrophy of supinator muscles > overuse from repetitive pronation and supination (handling loads >1kg) or from traumatic injuries e.g. elbow joint fracture

• Complains of:
o Paraesthesia in the hand and lateral forearm (sensation changes)
o Pain over the forearm extensor mass
o Wrist aching
o Pain in the middle or upper third of the humerus

Question 7

PIN AX

Answer 7

• Observation: Muscle change hypertrophy of supinator muscle
• Palpation: Pain with sustained palpation or through static contraction of the supinator muscle
o Maximal tenderness over the supinator muscles (4 finger below the lateral epicondyle). Can also be tender at the radiohumeral joint.

• Movement exam
o Compression leads to weakness of thumb abductors and extensors and wrist muscles.
o Painful to radially deviate
o Pain/weakness on resisted sup w/ elbow flx at 90˚ and the forearm fully pronated.
o weakness at EPL and EPB - pain and focal weakness with resisted 3rd MCP (middle finger) extension with elbow extension (careful as this can also mean LE)

Question 8

PIN other

Answer 8

Differential diagnosis
• lateral epicondylalgia
• muscle strains

Other assessment
• Generally need to refer on for nerve conduction studies show nerve compression
• US for nerve entrapment diagnosis
• Surgery is needed to release compression of nerve

Question 9

PIN Mx

Answer 9

A& E:

• relative rest
• avoiding aggravating positions, possibly using NSAIDs for pain relief
• caution with hot/sharp items due to altered sensation

Address what is causing the nerve compression
• Muscle overactivity/tightness?
• Muscle weakness/imbalance
• RH joint mobility

Manual therapy
• Soft tissue therapy over the supinator muscle/ at site of entrapment
• Neural mobilisations
Exercises
• Target strength and endurance deficits in forearm muscles
• Stretching
Taping
• Possibly look at deloading the muscle to reduce compression of the nerve
Surgery
• Decompression surgery if conservative management fails