L18: Clinical reasoning in management of the elbow 2 Flashcards
What are 3 evidences for MWM in lateral elbow tendinopathy (LET)?
- MWM is better than placebo in immediate improvement of pain-free grip (~50% during and post) and pressure pain thresholds (10-15% post)
- Excitatory effect on SNS function with MWM (e.g. HR, BP, skin temperature)
- MWM is effective for tennis elbow, and it might be more than local effect at elbow.
- Reduce abnormal afferent input - reduce pain - allow more gripping
- Endogenous pain relief
What is the evidence for therapeutic exercises in lateral elbow tendinopathy (LET)?
- Therapeutic exercise improves pain, strength and disability over time
- Resistance exercise is effective for LET. But optimal mode and dosage are unclear.
What are the 5 staged exercise approaches for therapeutic exercises for lateral elbow tendinopathy (LET)?
- Pain-free during & after exercise
- Slow concentric & eccentric contractions (8 seconds in total)
- First 2-3 weeks endurance focus: Light load, >15 reps
- Next 4-6 weeks, endurance-strength focus: 10-15 reps > 8-10 reps, 3 sets, short rest
- May progress to high strength: 4-6 reps, 3 sets, long rest
What are 2 evidence for isometric exercises for therapeutic exercises for lateral elbow tendinopathy (LET)?
- Conflicting evidence for Achilles tendinopathy, plantar heel pain)
- Limited, inconsistent evidence for LET pain relief.
What are 4 considerations for isometric exercises for therapeutic exercises for lateral elbow tendinopathy (LET)?
- Can use isometric exercise if patient cannot tolerate load (e.g. Reactive tendinopathy or irritable symptoms)
- Position: Elbow F supported on table
- 4 reps of 30-45s holds
- Progress intensity low > high
What is a short term result as evidence for multimodal program for lateral elbow tendinopathy (LET)?
Corticosteroid or physiotherapy were better than wait-and-see
What are 3 long term results as evidence for multimodal program for lateral elbow tendinopathy (LET)?
- Wait & see and physiotherapy were better than corticosteroid.
- 90% improved by 1 year regardless of physiotherapy or wait-and-see
- Poor outcome with corticosteroid injection (from 3 months onwards compared to physiotherapy or wait-and-see
- 72% recurrence with corticosteroid injection
- Because injection masks pain - overload?
- Because injection impedes healing?
What are 2 evidence for deload tape for lateral elbow tendinopathy (LET)?
- Deload tape improved pain-free grip strength (24%) compared to placebo and control
- Effect lasts 30 minutes
What are 4 major management for lateral elbow tendinopathy (LET)?
- Advice & education
- Manual therapy
- Exercise prescription
- External physical devices
What are 2 advice and education as management for lateral elbow tendinopathy (LET)?
- Pain management (RICE)
- Activity and biomechanical modifications (e.g. ADL, work, sport)
What are 2 manual therapy as management for lateral elbow tendinopathy (LET)?
- MWM lateral or radial glide with gripping
- MWM lateral or radial glide with elbow F/E
What are 3 exercise prescriptions as management for lateral elbow tendinopathy (LET)?
- Motor control exercises
- Progressive wrist strengthening
- Global UL strengthening
What are 2 external physical devices as management for lateral elbow tendinopathy (LET)?
- Deload taping
- Lateral glide or P-A radius tape if TDT +ve
What are 2 evidence for non-surgical and surgical management for medial collateral ligament sprain?
- No studies have compared surgical and non-surgical management
- No RCT
What are 3 low quality studies for medial collateral ligament sprain?
- Return to sport in 90% of quarterbacks with impact-related MCL injury
- RTS ~27.4 days (1-17 weeks)
- RTS in 42% of throwing athletes
- RTS ~24.5 weeks (range: 13-54 weeks)
- RTS in 66% baseball pitchers
- 88% with high grade and distal tear failed non-op management
What are 2 evidence for surgical management for medial collateral ligament sprain?
-
Partial MCL tears may be managed conservatively
- Time to return=4-6 months
-
Complete MCL tears with significant valgus instability may require surgery in overhead athletes
- Surgery is effective for MCL injury, but also longer rehab and complication rates
What/how long is management for partial medial collateral ligament sprain?
- May be managed conservatively
- Time to return=4-6 months
What/how long is management for complete medial collateral ligament sprain?
- Significant valgus instability may require surgery in overhead athletes
- Surgery is effective for MCL injury, but also longer rehab and complication rates
What are 4 features of management for 83% of throwers who are able to return to pre-level of competition for collateral ligament sprain?
- Time to return 10-26 months
- Post-op rehab: Progressive strengthening and throwing over 4 months to 1 year
- Complication rate 10% (6% ulnar neuropathy)
- They had 1 year conservative management before surgery
What are 5 major management for medial collateral ligament (MCL) sprain?
- Advice & Education
- Manual Therapy
- Therapeutic Exercise
- Electrophysical Agents
- External Physical Devices
What are 4 advice and education as management for medial collateral ligament (MCL) sprain?
- Pain management (RICE)
- Anti-inflammatories
- Rest from throwing
- Ice
What are 2 manual therapy as management for medial collateral ligament (MCL) sprain?
- No evidence of manual therapy for MCL injury
- Elbow flexor contracture/tightness - manual techniques to improve ROM
What is an electrophysical agent as management for medial collateral ligament (MCL) sprain?
Can use as adjunct. No evidence.
What is 2 external physical devices as management for medial collateral ligament (MCL) sprain?
- MCL taping to increase stability
- Splinting if elbow F contracture unresponsive to manual therapy to improve elbow E
What are 8 therapeutic exercises as management for medial collateral ligament (MCL) sprain?
- Consider treatment aims, stages of healing
- Pain-free ROM exercise
- Strengthening wrist flexors and forearm pronators to stabilize the medial elbow
- Function-specific strengthening of shoulder and elbow muscles
- Power training
- Correction of throwing biomechanics - liaise with coach
- Gradual return to full activity
- Interval sport program, particularly for athletes
What are 4 features of “function-specific strengthening of shoulder and elbow muscles” for therapeutic exercises as management for medial collateral ligament (MCL) sprain?
- Muscles required for functional tasks
- Progress from general strength postures to functional positions
- Eccentric control
- Thrower’s Ten Exercise Program
What are 4 features of “power training” for therapeutic exercises as management for medial collateral ligament (MCL) sprain?
- Wrist flexors and forearm pronators
- Shoulder and elbow muscles
- 8-12 reps, 3-4 sets, high velocity
- Consider function needs and positions
What are 3 features of “correction of throwing biomechanics - liaise with coach” for therapeutic exercises as management for medial collateral ligament (MCL) sprain?
- e.g. Rotating the body out of the late cocking phase too early
- Elbow lagging behind - increased valgus stress on elbow
- Scapula dyskinesis - decreased shoulder abd - throwing side on - increased valgus stress on elbow
What are 7 features of “interval sport program, particularly for athletes” for therapeutic exercises as management for medial collateral ligament (MCL) sprain?
- Progressively apply forces to healing structures
- Gradually return athlete to full athletic
- Competition as quickly and safely as possible
- Start once full ROM, minimal pain/tenderness
- Sufficient strength & dynamic stability
- No set timetable
- Stop if sharp pain
What is the Thrower’s Ten Exercise Program for therapeutic exercises as management for medial collateral ligament (MCL) sprain?
Designed to exercise major muscles necessary for throwing
