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Elbow Overuse
Humeral Epicondylitis PPT
| Question | Answer |
|---|---|
| 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 |
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