Epicondylitis Flashcards
Lateral Epicondylitis
Tennis Elbow: Characteristics
chronic collagen degeneration in the extensor tendons and enthesopathy (irritation of the attachment site) at the lateral epicondyle of the humerus
repeated tensile stress on tendons leads to collagen degeneration and enthesopathy
ECRB is most affected; all other wrist extensor muscles may be involved
pain aggravated by actions that engage extensor muscles in a contraction (concentric, isometric or eccentric)
wrist flexion produces pain due to extensor tendons being stretched
in acute cases, pain results from fibre tearing in tendon or periosteal tears at ECRB tendon attachment
sports, occupations or hobbies that require repetitive grasping; also repetitive supination or pronation (wheel chair athletes, tennis)
uni or bilateral
other conditions can co-exist: MFTPs can cause extensor muscles to be hypertonic, create an excess tensile load on tendons
History
Observation
Lateral Epicondylitis
History: pain in lateral elbow region, radiates into forearm
aching or sharp pain
ask about gradual or sudden onset
ask about activities requiring repetitive gripping or static contractions of forearms or wrist
may have difficulty grasping or lifting a smaller item
Observation:
not inflammatory; unless periosteal tear or enthesitis (but not visible)
Palpation
Lateral Epicondylitis
tenderness and pain at extensor tendon attachment at lateral epicondyle
wrist extensors feel hypertonic
pain increased if wrist put in flexion and muscles/tendons palpated
fibrotic or ropey feel
may be referrals from TPs near elbow or forearm when forearm muscles palpated
entrapped posterior interosseous nerve could produce pain down forearm
Range of Motion and Resistance Testing
Lateral Epicondylitis
AROM: pain may or may not be present with wrist extension; pain at end range of flexion as extensors stretched
PROM: pain at end range of flexion as tendons stretched
MRT: pain with wrist extension; weakness due to reflex muscular inhibition; weakness can also be from compression of posterior interosseous nerve compression
Special Tests
Lateral Epicondylitis
Tennis Elbow Test
standing or seated
therapist wraps one hand around patient’s elbow so thumb is pressing on extensor tendons distal to lateral epicondyle of humerus
therapist’s other hand grasps patient’s hand and uses it to resist patient’s wrist extension
offer resistance only, do not push
contracting wrist extensors causes pain as affected tendons pulled near attachment site
pressing on tendons while in contraction, stress to damaged tissues is exaggerated
Differential Evaluation
Lateral Epicondylitis
radial tunnel syndrome
myofascial trigger point activity
ligament damage near elbow
radial neuropathy
cervical radiculopathy
joint pathology of elbow
medial epicondylitis
Medial Epicondylitis
Golfer’s Elbow: Characteristics
affect wrist flexors where they attach to the medial epicondyle of the humerus; not inflammatory; excessive tensile stress on the flexor tendons causes chronic collagen degeneration & enthesopathy at attachment site
repetitive or prolonged contractions of the wrist flexors & pronators (golf, overhead tennis serve)
often due to manipulation of tools and equipment with hands or throwing actions
may derive from repetitive supination & pronation of forearm (stresses Pronator teres); proximity of its attachment at medial epicondyle cause it to be involved
concentric, isometric or eccentric contractions aggravate pain
pain may occur in motions requiring wrist extensions where flexor tendons are stretched
pain during activity, subsides after activity ceased
poor conditioning is another cause
may result from injury leading to chronic tendon irritation; may be some initial inflammation with minor tendon fibre tearing
other conditions seen along with ME are carpal tunnel syndrome, ulnar nerve pathology (passes through hiatus in the Flexor carpi ulnaris)
History
pain on medial side of elbow, radiates into forearm, general aching or sharp pain
gradual onset
ask about activities of repetitive gripping or static contractions of forearm and wrist
identify ergonomic factors that overuse flexors
ask about sudden changes in activity level (poor conditioning)
may be pain with shaking hands
ask about symptoms related to nerve pathologies (cubital or carpal tunnel syndromes or pronator teres syndrome)
Observation
not inflammatory; unless periosteal tear or enthesitis (but not visible)
may see cubital valgus but structural, not necessarily a symptom
Palpation
tenderness and pain at flexor tendon attachment at medial epicondyle
wrist flexors feel hypertonic
pain increased if wrist put in extension and muscles/tendons palpated
fibrotic or ropey feel
may be referrals from TPs near elbow or forearm when forearm muscles palpated
Range of Motion and Resistance Testing
AROM: pain possible with wrist flexion if severe; as condition worsens, less force required to cause pain; pain at end ROM with extension as tendons stretched; pain may also occur at end range of supination as pronator teres stretched
PROM: pain at end range with wrist hyperextension as tendons stretched and end range of supination if pronator teres involved
MRT: pain with wrist flexion; pain with pronation if pronator teres involved; weakness possible due to reflex muscular inhibition; weak grip possible
Special Tests
Golfer’s Elbow Test
standing/seated
therapist grasps patient’s elbow so thumb presses on flexor tendons distal to attachments at medial epicondyle
therapist’s other hand offer resistance to patient’s wrist flexion
offer resistance only, do not push
engaging wrist flexors causes pain at medial epicondyle as tensile force added
pressing on tendons while in contraction, stress to damaged tissues is exaggerated
Differential Evaluation
arthritis
pronator teres strain
cubital tunnel syndrome
cervical radiculopathy
pronator teres syndrome
median nerve compression near elbow
thoracic outlet syndrome
ulnar collateral ligament injury
osteochondritis dissecans
epicondylar apophysitis
stress fractures
ulnar nerve pathology
flexor muscle strain
Symptom Picture:
Acute
gradual onset, tenderness, local to the tendon, 1 or 2 days after activity
initially, pain diminishes with renewed activity
progresses to pain during activity as the severity increases
micro-tearing occurs with adhesion formation as the tendon attempts to heal
repetitive use tears these new adhesions causing more inflammation, and a cycle of re-injury
inflammation, heat and swelling develop along the tendon or tendon sheath
crepitus may develop with tenosynovitis and para tendinitis
there is decreased ROM of the affected muscle(s)
Symptom Picture:
Chronic
pain occurs during and after activity
chronic inflammation, fibrosis and adhesions are present
chronic swelling or thickening may be observed if the tendon is superficial enough
crepitus may be present
decreased ROM and decreased strength
flareup to the acute stage may occur with repeated overuse
tendon may degenerate to such a degree that tendon rupture occurs
Treatment Goals
Acute
Reduce inflammation
Reduce pain
Decrease SNS firing
Treat any compensating structures
Reduce edema
Reduce hypertonicity and TPs
Maintain ROM
Mobilize hypomobile joints
Treatment Plan
Acute
Positioning: limb is elevated and pillowed securely
Hydrotherapy: cold
Diaphragmatic breathing
Trunk and unaffected limbs treated using effleurage and petrissage
Lymphatic drainage
Unidirectional effleurage, stationary circles, local techniques proximal to tendon
Address TPs proximal to tendon; effleurage, muscle stripping
Decrease hypertonicity in antagonists of affected muscles; segmental petrissage
Decrease hypertonicity in affected muscles; Golgi tendon organ release on unaffected tendon of affected muscles; vibrations on site
Pain-free PROM to proximal and affected joint to maintain ROM
Gentle joint play to hypomobile joints in affected limb
Treatment Goals
Chronic
Decrease, sympathetic, nervous system firing
Treat compensatory structures
Reduce facial restrictions
Reduce any chronic oedema
Reduce hypertonicity and trigger points
Improve tissue health
Reduce adhesions
Mobilize hypomobile joints
Restore ROM
Stretch shortened muscles
Treatment Plan
Chronic
Positioning: patient comfort
Hydrotherapy: deep moist heat to soften adhesions and increase local circulation
Diaphragmatic breathing
Fascial glide to assess & fascial techniques to treat adhesions
Reduce hypertonicity and TPs proximally; rhythmic techniques, effleurage, repetitive petrissage, ischemic compressions
Treat antagonists; skin rolling, long effleurage, petrissage
Treat affected muscles with similar techniques; work towards lesion
Reduce adhesions in affected tendon; skin rolling, fascial spreading, muscle stripping, frictions, myofascial release with passive lengthening
Frictions followed by passive stretch to re-align fibres, ice
Distal limb treated with effleurage, petrissage to increase venous return
Joint play on hypomobile joint in affected limb
PROM to affected joints
Passive stretch to affected muscles and antagonists
Self-care Goals
Acute
Educate the patient regarding activities
Stretch shorten muscles
Strengthen weak muscles
Self-care Plan
Acute
Relative rest from activity that causes pathology
Hydrotherapy: ice
Slow, pain-free stretch of affected muscles and antagonists to regain flexibility
Regain full strength in affected muscles to prevent re-injury
Progressive strengthening when no pain on activity and when full, pain-free stretch is obtained (isometric)
Self-care Goals:
Chronic
Educate the patient regarding activities
Stretch shortened muscles
Strengthen weak muscles
Educate the patient regarding activities
Refer the patient
Self-care Plan:
Chronic
Hydrotherapy: contrast, ice after activity
Self-massage
Stretching to maintain flexibility
Strengthening using isometric, then isotonic exercises (once full PROM is pain-free)
Eccentric, isotonic exercise is slow, gradual increase in speed
Modify sport or occupational activities
Contraindications
Frictions are avoided if the patient is on anti-inflammatory medication
