Tendinopathies of the UE Test 2 Flashcards
cause of tendinopathy
- Trauma induced tendinopathy- fall and damage tendon
- Poor blood flow
- Poor posture and mechanics
- Poor proximal stability and core strength decreases ability to maintain a good safe posture leading to added stress on the tendons.
Types of Tendon pain
Itis- inflammation
osis- scar tissues (degenerative process with fibrosis, decreased circulation)
algia- nerve irritation
Tenosynovitis- the synovial sheath the tendon runs through is also inflamed.
a combination of all the above.
Lateral Epiconylitis
- AKA Tennis Elbow
- starts as inflammation of the tendon fibers that attach the forearm extensor muscles to the lateral epicondyle.
- Routine us of the arm causing shearing of the ECRB over the radial head especially with the elbow extended or an injury to this area may stress or damage the muscle attachment.
- During the healing the tendons often get stuck in fibroplasia. The tissue has a failure to thrive.
- usually caught after the inflammatory stage.
- especially challenging if it is chronic
Number one muscle involved
ECRB- is always involved.
ECRB, EDC, ECRL, ECU
Dr. Robert Nirschl’s stages of LE
Stage 1- Peritendinous inflammation
Stage II- Angioblastic degeneration- angioblastic fibroplasia- pain not due to inflammation/sensory nerve
Stage III- Further degeneration/rupture
Stage IV- Fibrosis and calcification
Evaluation Components
- Chronic if it is lasting longer than 12 weeks and if they have had it before.
- If only a month and a half or 2 months we can still treat it.
- Radial nerve Bifurcates going into the interosseous membrane and becomes a nerve that feeds your wrist extensors (can get trapped in fibrous tissue. Supinator can get big and bulky leading to compression. If irritated it can cause pain that looks like tennis elbow.
Evaluation components
- If apply long finger extension resistance and causes pain at epicondyle it is most likely tennis elbow.
- If pain is at the arcade of frohse then it may be radial tunnel.
Grip strength testing
No iontophoresis if they have had a cortisone injection before treatment.
In straight arm- a significant decrease in grip strength, when flexed grip should be much stronger for a positive sign with tennis elbow
standing grip is stronger than bent elbow.
May be pain just by having the arm straightened out.
treatment interventions
Anything we do in pronation with arms down in front puts a lot of stress on lateral epicondyle. Internal rotation, adduction, and forward shoulder positioning must be fixed.
Arm above head motions can cause a lot of stress with medial epicondyle
May need to do some soft tissue work on pec minor to loose up and help forward shoulder positioning.
determine if condition is acute or chronic
Can fix problem if you don’t fix what is causing it.
Inflammatory: Tendonitis
- rest
- Ice massage or cold packs
- Cortisone injections
- Iontophoresis using dexamethasone
- stretching exercised
- wrist support/tennis elbow strap
- —Reduces force at ECRB origin when applied to 30-50 mm hg at rest (120 mm hg with activity) by 13-15% . What about radial nerve?
- Osterman L. 2004-Counterforce splinting appropriate only in final stages of rehab with return to heavier activity.
- Serves as a tactile cue for behavior modification or has a TENS effect
Chronic Tennis Elbow
- Tissue needs blood flow and remodeling
- Exercise (graded eccentric exercises)
- Progressive stretching
- Joint mobilization
- Modalities (heat focus- hot packs
- Strengthen core and correct posture.
focus on more reps to help remodel scar tissue.
Ultrasound/Phonophoresis
Ultrasound effective with or without medications but only for short term effects. Systemic review (Smidt et al. 2003) 2 of 23 RCTS supported U.S. over placebo.
Iontophoresis
Iontophoresis: Level 2b support when completing 6 visits in 10 days Nirschl RP et al. AM J Sports Med 2003).
Iontophoresis just as effective as phonophoresis when using Naproxen (Baskurt et al. Clin Rehabil 2003).
No Difference found between steroid and placebo (4 treatments in 2 weeks)
Need to watch out for diabetes because it can raise blood sugar- dexamethasone – not as bad as cortisone (no more than 3 a year) because it breaks down everything. Will eventually effect your bone.
Phonophoresis- medication given through ultrasound.
Both are corticosteroids- one can penetrate the skin better (Dex) cortisone is not as easy (the molecule is too big)
Exercise
Level 1b and 2 b evidence (Trudel 2004)
Five supporting studies – Increased grip with decreased pain
Eccentric training regime can considerably reduce symptoms in a majority of patients.. May be superior to conventional stretching. (Svernlov B., Adolfsson, L. 2001)
Joint Mobilization
More effective then ultrasound and standard therapy. (Drechsler WI 1997, Vicenzio 2001, Struijs 2003, Burton 1988).
Mobilization and Mobilization with Movement techniques were both effective in reducing pain.
Kinesiotape
Inhibitory tap is red and lifting is blue
acupuncture- short term pain relief
Extracorporal Shock Wave therapy: Very expensive, Cortisone found to be more effective. Skill level to perform correctly. No evidence to support 20 studies
Low Level Laser Therapy: No evidence except
Protein Rich Plasma
induce healing by providing cellular mediators
Botox Injections
-Decrease muscle activity by blocking acetylcholine gates.
acute vs chronic treatment
Acute-
Ultrasound, ice and iontophoresis
Chronic-
Education (rest), heat, strength
beneficial and harmful exercises
- timing of the exercise withing the healing process needs to be adjusted for each patient.
- pain should be resolved or minimal when beginning resistance training.
- exercises should be performed without pain.
Progressive stretching
Indiana Protocol stretches are an example of using the concept of non-composite and working towards composite movement. The next progression would include overpressure in non-composite and working to composite with overpressure. The patient is advance when the stretch can be performed without pain or discomfort.
Mills progressive stretching
Be careful. Aggressive stretching can cause damage to the tendon. All wounds result in scars and all scars contract. Stretching is important but can be harmful if not controlled.
Flexors should be stretched as well as extensors.
stretching the ECRB
Sarcomere length of ECRB only de-monstrated a significant increase in length with ulnar deviation independent of forearm rotation.
Resistance training
There was no research found to support a specific treatment protocol.
Stretch and controlled eccentric strengthening were found to have significant effects on decreasing pain and improving grip in the long-term. Grip exercises should be performed when pain level has decreased and with the elbow in slight flexion.
Controlled strengthening
Strengthening may begin once pain becomes minimal and as long as it can be performed without increasing pain. A general warm up on the UBE (forward motion) may be performed to increase blood flow. Exercises should be initiated in a non-composite (elbow flexed) position. The motions should be slow and controlled. Some therapist vary speed of motions between sets.
Eccentric exercises more effective.
other beneficials exercises
- Radial nerve glides
- EDC exercises
- transverses abdominal contractions
activity modification
Avoid repetitive wrist movements
Avoid excessive finger extension (keyboarding)
Avoid lifting and pulling resistance-car door, refrigerator door, brief case, coffee pot, skillet, jug of milk, juice etc.
When using the effected extremity try to lift with the flexors with the forearm supinated and close to the body .
Maintain good posture. A forward internally rotated shoulder increases forces on the LE origin.
Medial Epicondylitis
- AKA golfers Elbow
- Results from repetitive wrist and finger flexion or repetitive motion against resistance.
- Involves the common origin of the wrist and finger flexors
- Ulnar nerve can get inflamed resulting in pain tingling and numbness in the ulnar nerve distribution of the hand.
- Avoid lifting with forearm supinated and elbow extended
Talking about the flexors
Medial epicondylitis assessment
- Palpation of the medial epicondyle
- clear ulnar nerve at the cubital tunnel.
treatment
- Kinesio-tape
- progressive stretches
- patient education
- strengthen core and correct posture
- Graded strengthening
Trigger finger
A1 pulley Tenosynovitis
- Common- can happen to multiple fingers at one time
- more fluid and inflammation can increase tension.
-Inflamed tendon forms a knot and gets stuck under the pulley when person flexes and tries to extend.
Trigger finger
Pulley system
- 5 annular pulleys
- 3 cruciate pulleys
-A2 and A4 are necessary for finger mechanics. Prevent bowstringing.
Risk factors
RA diabetes osteoarthritis repetitive gripping sustained pinch
symptoms
- Tenderness at the level of the A1 pulley
- There might be a presence of a nodule or thickening
- Don’t confuse with Dupuytren’s disease
- Finger click when trying to straighten
- finger gets stuck.
Green classification of staging
Grade 1- pain and tenderness at A1 pulley
Grade 2- Catching of a digit
Grade 3- locking of digit which is passively correctable
Grade 4- Fixed locked digit- can lead to the formation of a contracture
Trigger finger treatment
- conservative management through therapy
- splinting
Pt. education
maintain PROM of each joint
perform individual joint blocking exercises
perform finger extension exercises.
trigger finger treatment
Surgical intervention
-the A1 pulley is released leaving the A2 pulley intact.
In patients with RA, the A1 pulley is not released because this would enhance the biomechanical forces that are in part responsible for ulnar drift at the MP joint.
Open procedure. 1 cm horizontal incision
Post-surgical management
2-3 days post op: AROM 6x/day x10 min each-
isolated tendon glides, differential tendon glides, and MP extension/flexion with IP joints flexed – moving into extension as incision heals ( 2-3 weeks)
