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Elbow Overuse

Humeral Epicondylitis PPT

QuestionAnswer
Overuse Syndrome Insidious onset of inflammation of a structure as a result of repeated loading beyond the tissues structural capacity
Overuse can occur in many populations Athletes; Pre-adolescent throwing athletes; Assembly line workers; Golfers; Carpenters; & many more
Multifactoral Model of Injury Intrinsic risk factors (age, flexibility, strength, previous injury) create a pre-disposed athlete
Multifactoral Model of Injury Athlete then interacts with extrinsic risk factors (biomechanics of sport, equipment, field conditions, playing schedule) to produce a susceptible athlete
Multifactoral Model of Injury Athlete isn't normal, but fxnal at this point An inciting event then leads to clinical injury, symptom production & performance decrement
Risk Factors in Young Baseball Players (Research) Age >11; Height >150 cm; Pitching; Days of training; Grip strength; Shoulder ER ROM <130; Increased ER & IR strength
Lateral Epicondylitis Tennis elbow; Humeral epicondylitis; Lateral elbow stress syndrome
Facts about Lateral Epicondylitis Usu. dominant elbow; Repetitive microtrauma overload; Typically wrist ext or alternating pron/sup Cumulative effects of process of alteration & adaptation over time
Tennis Elbow Lesion affecting the origin of the tendons of the muscles that extend the wrist Occurs frequently with ADLs due to repetitive loads Athletes- hitting, throwing, serving, spiking
Tennis Elbow Degenerative condition consisting of a time dependent process including vascular, chemical & cellular events that lead to failure of the cell-matrix healing response
What muscle begins the process of tennis elbow? ECRB followed by other extensors
Differential Dx Common extensor origin (tendonitis; microtearing with painful granulation; degen changes in tendon) Lateral lig sprain; Radiohumeral bursitis; Annular lig inflammation; Degen changes of radial head; C-spine radiculopathy; Post. interosseous n. entra
Differential Dx Ulnar n. neuropraxia; Carpal tunnel syndrome; Radial n. entrapment; Osteochondritis dissecans; Joint calcification; OA; Periostitis; Orbital lig abnormalities; Synovial fringe impingement
Primary Pathologic Tissue Origin of ECRB; 1/3 involve EDC; Can also involve ECRL & ECU
Pain Cause of pain probably multifactorial; Presence of substance P receptors found at insertion of proximal ECRB in those with HE; Indicates neurogenic involvement
Etiology/Epidemiology Repetitive forceful arm mvmts; Sports/occupational activities; Meat cutters, plumbers, aircraft Frequently in men & women in 40s-50s equally; Dominant arm involved in >75% all cases
Physical Exam Thorough exam should always include entire UE & trunk Kinetic chain for power generation during sports
Physical Exam TTP over ECRB; Not always bilaterally symmetrical; Unilaterally dominant athletes may be unequal in size due to adaptive changes; Tennis players
Physical Exam Strength in unilaterally dominant athletes may be anywhere from 5-35% stronger; Thus returning to only 100% may represent incomplete rehab
Physical Exam Maximal tenderness located up to 5 mm anterior and distal to the lateral epicondyle; Discomfort with resisted wrist ext or passive wrist flex Symptoms worsen when elbow is in full ext
Physical Exam Stress testing of the extensor brevis & finger extensors will incite lateral elbow s/sx; May have pain to resistance of radial deviation
Conservative Management 80% pts will improve at 1 year after dx; Up to 40% will have prolonged discomfort & require modifications of normal activities
Poor Improvement with conservative management is associated with what? Manual labor; Dominant side involvement; High levels of physical strain; High levels of baseline pain
Conservative Management Goals Reduce pain; Increase ROM; Increase muscular strength & endurance; Ensure RTC & scapulothoracic stabilization full strength
Oral Medication Study 1 Daily meds vs. Placebo x28 days Multi-center, RTC, double-blinded S/sx reduction of pain in tx group No clinically significant difference in fxn or grip strength
Oral Medication Study 2 Daily meds vs. placebo x2 weeks Multi center, RCT showed no difference b/t placebo & naproxen
Corticosteroid Injections RCT's have shown s/sx improvement at early follow-up (3 days to 6 weeks) Compared to NSAIDs, PT, rest, & placebo At 1 year out- no improvement
PT Eccentric Training Stretching vs. stretching + concentric or eccentric training x6 weeks; S/sx in all groups- no difference
PT- Eccentric Training Isokinetic wrist extensor eccentric training to standard PT; Pain scores, subjective outcomes, strength; S/sx improvement in all groups
PT- Eccentric Training One study showed marked improvement with eccentric training
PT Relative rest rather than strict mobilization; Wrist splint commonly used; Modification of activities & work; Gentle static stretching
PT Study- Stretching vs. US Benefits of ex. over US: Pain relief, sick leave, fewer doctor visits & surgeries
PT Study- Mobilization & strengthening (isotonic) vs. injection or wait & see Benefits of exercise over injection: pain relief; improved satisfaction with treatment; Lower recurrence rates
Extracorporeal shock wave therapy (ESWT) Used to tx variety of tendinopathies; Mechanism not well understood; Conflicting results; Systematic review of 9 placebo-controlled trials report little to no benefit
Surgical Intervention (Nirschl Technique) Incision extends from 1" proximal & just anterior to lateral epicondyle to the level of the radial head; Splitting incision b/t ECRL & extensor aponeurosis, which exposes ECRB; Ext longus retracted anteriorly, brings extensor brevis into view
Nirschl Technique Removal of angiofibroblastic degeneration of ECRB; Normally extensor aponeurosis & lateral epicondyle not disturbed
Angiofibroblastic Tendinosis Findings upon surgery: numerous blood vessels; large amt of unorganized fibrotic tissue; chronic low-grade re-injury; Absence of inflammatory cells; Process not acute; Repair process has been turned off
Nirschl Technique Removes all pathologic tissue; Vascular enhancement- 3 holes drilled through cortical bone of anterior lateral condyle to cancellous bone level
Nirschl Technique Extensor longus now firmly repaired to the anterior margin of the extensor aponeurosis
Medial Epicondylitis Golfer's Elbow; Epitrochleitis; Medial tennis elbow; Little leaguer's elbow
Golfer's Elbow Overuse syndrome of the flexor-pronator mass May occur precipitated by minor elbow trauma
Differential Dx Arthritis; Cervical radiculopathy; Chondromalacia; Cubital tunnel syndrome; Fibrosis; Joint laxity; Loose bodies
Differential Dx Olecranon/coronoid impingement; Osteophytes; Referred pain from biceps insertion or brachialis; Tardy ulnar n. palsy; UCL instability; Ulnar trochlear synovitis
Primary Pathologic Tissue Micro or macroscopic disruption w/in FCR or pronator teres near origin on medial epicondyle; May involve FCU & FDS; Associated ulnar n. s/sx in up to 60% of cases
Etiology & Epidemiology More often males; B/t ages 24-65; Average age 44; Reported with: golf, bowling, archery, baseball, weightlifting, football, racquetball, javelin throwing
Etiology & Epidemiology Repetitive microtrauma followed by chronic inflammation
Physical Exam Local tenderness predominantly at the tip of the medial epicondyle & 1" along track of pronator teres & FCR; (+) Tinel's sign in medial epicondylar groove
Physical Exam Pn with wrist flex & pronation; Palpation ant. to medial epicondyle; Pain with resisted wrist flex/pronation Pain with passive wrist ext; May be swelling/warmth; Flexion contracture if chronic; Grip strength may be decreased
In medial epicondylitis, when doing Nirschl technique, where is the resection of angiofibroblastic degeneration usually? Origin of pronator teres & FCR
Medial Epicondylitis- Nirschl Technique Repair of common flexor origin Medial epicondyle attachments of normal tissue not disturbed
Vangsness & Jobe Surgical Technique Reflection of common flexor origin & excision of degenerative tissue Reattachment of forearm flexors
Avulsion of the Medial Epicondyle Before epiphyseal closure, rapid strong contraction of forearm flexors can avulse medial epicondyle; Tenderness in medial elbow of adolescent should arouse suspicion; Radiographic eval important; Prophylactic splinting may be req'd
Goals & Treatment of Phase I: Acute Phase Decrease inflammation/pain; Promote tissue healing; Retard mm atrophy; Cryotherapy; Whirlpool
What types of modalities may be used in phase I? HVGS; Phono/Ionto; Cross-friction massage; Soft tissue massage; Avoidance of painful mvmts
Goals of Phase II: Sub-Acute Phase Improve flexibility; Increase muscular endurance; Increase functional activities; Return to function
Exercises for Phase II: Sub-Acute Phase Emphasize conc/eccentric strengthening; Concentration on involved mm group(s); Wrist ext/flex; Forearm pron/sup; Elbow flex/ext
Exercises/Modalities for Phase II: Sub-Acute Phase Shoulder strengthening; Flexibility ex's; Counterforce brace; Cryotherapy post-exercise; Gradual return to stressful activities; Gradually re-initiate once painful mvmts/activities
Goals for Phase III: Chronic Phase Improve mm strength & endurance; Maintain/enhance flexibility; Gradual return to sport/high level activities
Exercises for Phase III: Chronic Phase Strengthening ex's with emphasis on conc/ecc; Continue to emphasize deficiencies in shoulder/elbow strength; Flexibility ex's; Gradually diminish use of counterforce brace
More exercises for Phase III Cryotherapy PRN; Gradual return to sport activity; Equipment modification (grip size, string tension, playing surface); Emphasize maintenance program
Created by: 1190550002