Week 6 Lateral Elbow Tendinopathy Flashcards
Tendinosis
Morphologic Changes
Neovascularization
(Tendon pathology/Pain system changes)
Peripheral sensitization
Central Sensitization
(Tendon pathology/Pain system changes)
Strength deficits & Imbalances
Motor control issues
Upper limb use changes
(Pain system changes/Motor system impairments)
tendon pathology; pain system changes; motor system impairments
Motor system impairments in upper limb for patients presenting with LET:
(Increased/Decreased) grip strength due to pain.
Decreased wrist (flexion/extension) strength due to pain.
(Increased/Decreased) scapula stabilizer strength and endurance.
Can develop lateral elbow tendinopathy (LET) if you have (increased/decreased) scapula stabilizer strength and endurance.
Decreased; extension; Decreased; decreased
Treatment Based on Pain and Prognostic Factors
Broke it down to low risk, mod, and high risk.
PRTEE – Patient rated tennis elbow evaluation
Low – wait and see approach is a good thing
Teach them to limit use of extensor mass, how to stretch and monitor symptoms, then see if they are any better.
Low – shouldn’t see them up to 3 times a week
High risk –
Have you tried everything? Have to come up with something new every 2 weeks if not seeing changes.
Got it
PRTEE- Pain scale
Regular outcome measure for tennis elbow evaluation. For (medial/lateral) elbow tendinopathy.
lateral
Lateral Elbow Tendinopathy Clinical Presentation:
(ECRB/ECRL) is the most common musculotendinous unit involved. Age of onset is -. Pain on or near the (medial/lateral) epicondyle. Aggravated by repetitive forceful gripping activities. They will point to the (medial/lateral) epicondyle. Tell them to point with one finger. If they kind of point and slide, it is more than just (medial/lateral) epicondyle problems.
ECRB; 35-50; lateral; lateral; lateral
LET
(ECRB/ECRL) is the Most Commonly Implicated Tendon
Common Extensor Tendon (CET) slides against capitellum during elbow motion
ECRB vulnerable
Limited vascular supply to under surface of ECRB
Pic - lateral is to the left, medial to the right
CET – Common extensor tendon
EDC – Extensor digitorum communis
Seeing the underside of the extensor mass
All these tendons blend in to one fascial sheath and puts ECRB at the most vulnerable position.
ECRB;
Extensor carpi radialis brevis origin, nerve supply and its role in lateral epicondylitis
Can’t truly separate the (ulnar/radial) nerve from the tendon in terms of pain because they are both right there.
radial
Anatomical study: superficial head of (supinator/ECRL) contributes significant tensile forces to the CET origin
Put weights on different tendons to determine what muscles were involved in creating tensile forces in the common extensor tendon origin. The supinator is part of the LET. The supinator plays a role.
supinator
Examination
Painful Conditions of the Elbow
LET Radial Tunnel LCL Injury (PLRI) PL Plica Syndrome (Medial/Lateral)
Medial Epicondylitis (MET) Cubital Tunnel MCL or UCL Injury “Unhappy Triad” (Medial/Lateral)
“Little Leaguers Elbow”
Osteochondritis Dissecans
Arthritis (OA or RA)
(Generalized/Medial)
LCL injury (posterior lateral rotator instability)
Poterolateral plica syndrome
Little leaguers elbow – pitch counts in little league to prevent elbow problems.
Arthritis – older age
Lateral; Medial;Generalized
In people with Lateral Elbow Tendinopathy, (pain/loss of ROM) is the primary complaint. This will result in degrees of pain and tenderness in the LE, (pain/loss of ROM) limiting their grip, and (pain/loss of ROM) limiting the ability to accept load with elbow (flexed/extended).
Pic - chair lift test . If they have pain in the tendon, won’t be capable of lifting chair.
pain; pain; pain; extended
Most structures in the elbow have nerve root innervation from C_-C_.
Perform an (upper/lower) quarter screening examination for potential nerve root pathology. Rule out shoulder and wrist pathology.
Probably do UQ screen on most elbow cases because it could be neurogenic.
C5-C8; upper;
Primary Differential Diagnosis of LET
Coo
LCL Injury (Posterolateral Rotary Instability):
(MCL/LUCL) attaches to lateral epicondyle
25% of failed tennis elbow surgical cases develop PLRI
PLRI with Tennis Elbow - (insidious/traumatic) onset: suggest that corticosteroids may contribute to degeneration of lateral stabilizing tissues. Corticosteroids can soften connective tissue which makes tendons and ligaments weaker.
LUCL – Lateral ulnar collateral ligament
It needs to be considered in lateral elbow tendon pain
Can only have 3 corticosteroid injections per year
If starting to notice patient has been shopping around for different surgeons, start thinking of potentially too many corticosteroid injections.
Corticosteroids can soften connective tissue which makes tendons and ligaments weaker.
Getting more than 3 can lead to spontaneous ruptures.
insidious; LUCL
Characteristic findings of posterolateral plica syndrome:
Painful click or snap with terminal (flexion/extension) and (pronation/supination) in the absence of gross instability.
Maximal tenderness posterior to (medial/lateral) epicondyle and centered at posterior ______joint.
Symptoms mimic lateral epicondylitis
Repetitive microtrauma related to the thickening/fibrosis of plica.
Instability of the elbow may exacerbate the inflammation, leading to snapping.
(Arthroscopic/Corticosteroid) management may provide a successful treatment option
They don’t have instability but painful click and snap.
Plica is a developmental fold in our joint capsule that instead of straightening out as we develop, it stays folded and becomes irritated which leads to inflammation and fibrotic. It can start to hurt due to this. If you rub fingers over it you can feel it click.
extension; supination; lateral; radiocapitellar; arthroscopic;
Tennis Elbow Examination
Patient History:
Patient Age
Duration of Symptoms- Itis or osis?
Number of Recurrences
Mechanism of Injury - are they doing repetitive work, playing a racket sport?
Nature and Location of Pain - chronic or acute?
Got it
LE – Lateral epicondyle
RT – radial tunnel
Deep branch of the radial nerve is the arrow
(Anterior/Posterior) interosseous nerve is going into the supinator through the _____ tunnel. Prior to that it is to the deep branch of the (radial/ulnar) nerve. It is at high risk and this is where radial tunnel comes in. The pain for the radial tunnel is going to be on the common _____ mass.
Posterior; radial; radial; extensor
Yellow-orange - _____
Dark orange - _____
Green - ______
Radial tunnel; lateral epicondylalgia pain; Posterior radiocapitellar
Tennis Elbow Tests
Resisted (Index/Middle) Finger Extension
C_____ Test (Tennis Elbow Test)
M____ Tennis Elbow Test
Nirschl’s Hand Shake Test
Middle; Cozens; Mills
(Mills/Cozen’s) Test
Elbow is stabilized by examiner’s thumb on the lateral epicondyle.
Patient actively makes a fist, pronates and extends the wrist with radial deviation while the examiner resists the motion
Positive: Sudden severe (paresthesia/pain) in the area of the lateral epicondyle
Contractile test looking at pain with resistance.
Cozens; pain
(Cozens/Mills) Tennis Elbow Test
Patient’s elbow is fully extended with forearm pronated and wrist fully flexed.
Can be performed actively by the patient or passively by the examiner.
May be used as a manipulation technique to rupture adhesions or as a non-traumatic test to provoke pain around the lateral epicondyle.
Tensile test (putting max tension on the common extensor tendon.
Mills
Relative REST
Not always easy to do! Rest from (aggravating activities/movement) not from (aggravating activities/movement)
Activity Modification :
Self selected
Patient Education
Secondary to orthotic intervention or limb positioning
Modify or avoid aggravating activities
Use orthoses, limb positioning, and pain free therapeutic exercise - Evidence of orthotic efficacy – low quality studies
Pic - RT syndrome, a counterforce brace is (indicated/contraindicated)
aggravating activities; movement; contraindicated
The consensus is that management of tendinopathy should optimally involve addressing loading of the tendon.
There is strong evidence for all types of resistance training for forearm extensors for lateral epicondylosis.
The idea here is we need to load it concentric-eccentric, or eccentric only, have to load it.
Strong Evidence
All types of resistance training for forearm extensors
No optimal type of resistance
No parameters for optimal dosage
Eccentric is very easy with the wrist. Grab with other hand and then lower it down.
Got it
Lateral Glide MWM for Lateral Elbow Tendinopathy
Compelling evidence that joint mobilizations have a (positive/negative) effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET
Use local elbow joint mobilization techniques to reduce pain and increase pain free grip strength in patients with LET.
Seems to have a positive effect as a stand-alone or adjunctive treatment in improving outcomes in the short term.
positive
Weak Evidence
Taping Electroanalgesia Iontophoresis Dry Needling Total Arm & Scapula Stabilizers Strengthening
Conflicting Evidence
Acupuncture
Low-level laser
Phonophoresis
Orthoses
Manual Therapy -
Soft tissue
Wrist, Cervical, Thoracic
Got it
Sleeping Positions
Avoid tension on EDC and ECRB if resting pain present
Splint is to reduce the stressor to the forearm so we may put them in splints that prevents them from (flexing/extending) their wrists. You would want them to stop from (flexing/extending) their wrist when they sleep. Pillows prop them up in a good position.
extending; extending
Ergonomics
Clinicians may consider the use of ergonomic instructions, frequent work breaks, and work station modifications to reduce stresses on the lateral elbow.
Great picture that shows how you are supposed to be setup. Little evidence on LET. The arm position – if their elbow isn’t at _ degrees and supported and the wrists aren’t in (flexion/neutral) we should be concerned and tell them to adjust that. If wrists are put into extension to tap the keyboard, constantly using extensors. Put them in neutral to resist extensor torque generated.
90; neutral;
