Week 7: Management of Elbow Conditions

Question 1

Extensor Tendinopathy - General info
* Lateral elbow tendinopathy affects …..% of the general pop
* …… prevalence between sexes
* …… arm more involved (…..:1)

Answer 1

3%
Similar
Dominant arm (2:1)

Question 2

First line care for extensor tendinopathy

Answer 2

81.45% Physio
9.90% Steroid injection

All other options less than 2%

1.82% Wait and see, advice/self management, orthotics
1.09% surgery
0.73% Shockwave therapy
0.73% Manual therapy
0.36% PRP injection
0.36% Autologous blood injection
0.36% Refer to elbow surgery

Question 3

Second line care for extensor tendinopathy

Answer 3

27.27% Steroid injection
10.55% Shockwave
9.82% Wait and see, PRP injection, surgery, acupuncture, orthotics, physiotherapy (exercise based)
1.14% Education

Question 4

What impairments exist in extensor tendinopathy?

Answer 4

• Widespread muscle weakness (upper limb)
• Reduced grip strength
• ↓ wrist extensor strength
• Finger extensor strength preserved

Question 5

Mobilisation with movement and exercise, corticosteroid injection, or wait & see for tennis elbow: randomised control

• Group 1: 6 weeks of elbow manipulation + exercise
• Group 2: corticosteroid
• Group 3: wait and see

Broad results?

Answer 5

• Corticosteroid is superior at 6 weeks, but 47/65 had recurrence and subsequently regressed
• At 6 weeks, Exercise + Manipulation is better than no treatment and better than corticosteroid at 1 year

Question 6

Mobilisation with movement and exercise, corticosteroid injection, or wait & see for tennis elbow: randomised control

• Group 1: 6 weeks of elbow manipulation + exercise
• Group 2: corticosteroid
• Group 3: wait and see

Treatment trends?

Answer 6

• “Wait & See”: steady improvement in elbow function over time
• “Corticosteroid Injection”: Initially experiences rapid improvement in elbow function, then symptoms recur and then start to improve (and remain worse than wait and see or CSI at 1 year)
• “Physiotherapy”: improves initially faster than wait and see, but not as quickly as CSI. Then shows continuous gradual improvement to 1 year

Question 7

Mobilisation with movement and exercise, corticosteroid injection, or wait & see for tennis elbow: randomised control

• Group 1: 6 weeks of elbow manipulation + exercise
• Group 2: corticosteroid
• Group 3: wait and see

Prognosis?

Answer 7

• ~90% significantly improve with a wait-and-see approach (not complete recovery though)
• 33% of patients might experience prolonged pain/recurrence of symptoms at 1 year
• Only a few (~5%) don’t respond to non-operative measures and have surgery

Question 8

What score on the patient-rated tennis elbow evaluation questionnaire is indicative of a good prognosis

Answer 8

<54/100 (Poor = >54/100)

**other indicators of good prognosis = pain duration <3 mths, no adverse prognostic indicators.

Low risk subgroup <33/100
Moderate risk subgroup >33/100
High-risk subgroup >54/100

Question 9

Adjuncts for extensor tendinopathy?

Answer 9

• Counterforce braces
• Taping
• Manual therapy

Question 10

Where should a brace be positioned for extensor tendinopathy, what is the mechanism behind its use?

Answer 10

Position: over the common extensor origin
Mechanism: dissipation of forces away from the injured tissue

Question 11

What taping is used for extensor tendinopathy?

Answer 11

Taping
* Diamond taping
- ↑ pain-free grip strength
- Test to P1 before and after application of taping

Question 12

True or false: Massage over tendon insertion for extensor tendinopathy.

What other manual therapy technique can be used?

Answer 12

False (Avoid massage over tendon insertion).

Lateral glide

Question 13

Having concomitant neck or shoulder pain is a poor prognostic indicator for extensor tendinopathy?

Answer 13

Correct

Question 14

What finger will often have pain in a resisted IMT of extension in extensor tendinopathy?

Answer 14

Middle finger extension

Question 15

What movements are pain-free in extensor tendinopathy?

Answer 15

Pain free with passive movements e.g. over pressure elbow ext/flexion

Question 16

What are the four stages of exercise for extensor tendinopathy?

Answer 16

Isometric loading
Isotonic
Progressive intensity
Impairment-specific exercises

Question 17

Provide examples of exercises for extensor tendinopathy

Answer 17

Isometric elbow flexion (with band/weight)
Isotonic elbow flexion (with band/weight) *
General upper limb exercises (avoid elbow ext with wrist in pronation)

*Progressed into more elbow extension

Question 18

Key points for extensor tendinopathy rehab
- …..-free movements
- Start with ……. holds
- Progress to ……. (and eccentric?)
- Needs ….. loading
- Must limit ……. activities
- Pain management is …….
- Include …… movements
- Need to incl elbow ….. / ,,,,,

Answer 18

• Pain-free movements
• Start with isometric holds
• Progress to concentric (and eccentric?)
• Needs progressive loading
• Must limit aggravating activities
• Pain management is important
• Include functional movements
• Need to incl elbow extension / flexion

Question 19

Stretching for extensor tendinopathy?

Answer 19

• Probably not an important treatment aspect:
• Highly irritable presentations
• Stretching reproduces pain
• A healthy tendon should be able to handle stretching loads, but that doesn’t mean it needs to be a focus of treatment

Question 20

When should exercise be commenced in the treatment of extensor tendinopathy?