Humeral Epicondylitis PPT
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| Overuse Syndrome | Insidious onset of inflammation of a structure as a result of repeated loading beyond the tissues structural capacity
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| Overuse can occur in many populations | Athletes;
Pre-adolescent throwing athletes;
Assembly line workers;
Golfers;
Carpenters; & many more
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| Multifactoral Model of Injury | Intrinsic risk factors (age, flexibility, strength, previous injury) create a pre-disposed athlete
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| Multifactoral Model of Injury | Athlete then interacts with extrinsic risk factors (biomechanics of sport, equipment, field conditions, playing schedule) to produce a susceptible athlete
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| 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
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| 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
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| Lateral Epicondylitis | Tennis elbow;
Humeral epicondylitis;
Lateral elbow stress syndrome
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| 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
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| 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
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| 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
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| What muscle begins the process of tennis elbow? | ECRB followed by other extensors
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| 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
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| Differential Dx | Ulnar n. neuropraxia;
Carpal tunnel syndrome;
Radial n. entrapment;
Osteochondritis dissecans;
Joint calcification;
OA;
Periostitis;
Orbital lig abnormalities;
Synovial fringe impingement
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| Primary Pathologic Tissue | Origin of ECRB;
1/3 involve EDC;
Can also involve ECRL & ECU
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| Pain | Cause of pain probably multifactorial;
Presence of substance P receptors found at insertion of proximal ECRB in those with HE;
Indicates neurogenic involvement
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| 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
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| Physical Exam | Thorough exam should always include entire UE & trunk
Kinetic chain for power generation during sports
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| Physical Exam | TTP over ECRB;
Not always bilaterally symmetrical;
Unilaterally dominant athletes may be unequal in size due to adaptive changes;
Tennis players
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| Physical Exam | Strength in unilaterally dominant athletes may be anywhere from 5-35% stronger;
Thus returning to only 100% may represent incomplete rehab
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| 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
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| Physical Exam | Stress testing of the extensor brevis & finger extensors will incite lateral elbow s/sx;
May have pain to resistance of radial deviation
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| Conservative Management | 80% pts will improve at 1 year after dx;
Up to 40% will have prolonged discomfort & require modifications of normal activities
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| Poor Improvement with conservative management is associated with what? | Manual labor;
Dominant side involvement;
High levels of physical strain;
High levels of baseline pain
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| Conservative Management Goals | Reduce pain;
Increase ROM;
Increase muscular strength & endurance;
Ensure RTC & scapulothoracic stabilization full strength
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| 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
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| Oral Medication Study 2 | Daily meds vs. placebo x2 weeks
Multi center, RCT showed no difference b/t placebo & naproxen
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| 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
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| PT Eccentric Training | Stretching vs. stretching + concentric or eccentric training x6 weeks;
S/sx in all groups- no difference
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| PT- Eccentric Training | Isokinetic wrist extensor eccentric training to standard PT;
Pain scores, subjective outcomes, strength;
S/sx improvement in all groups
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| PT- Eccentric Training | One study showed marked improvement with eccentric training
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| PT | Relative rest rather than strict mobilization;
Wrist splint commonly used;
Modification of activities & work;
Gentle static stretching
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| PT Study- Stretching vs. US | Benefits of ex. over US: Pain relief, sick leave, fewer doctor visits & surgeries
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| PT Study- Mobilization & strengthening (isotonic) vs. injection or wait & see | Benefits of exercise over injection: pain relief; improved satisfaction with treatment; Lower recurrence rates
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| 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
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| 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
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| Nirschl Technique | Removal of angiofibroblastic degeneration of ECRB;
Normally extensor aponeurosis & lateral epicondyle not disturbed
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| 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
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| Nirschl Technique | Removes all pathologic tissue;
Vascular enhancement- 3 holes drilled through cortical bone of anterior lateral condyle to cancellous bone level
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| Nirschl Technique | Extensor longus now firmly repaired to the anterior margin of the extensor aponeurosis
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| Medial Epicondylitis | Golfer's Elbow;
Epitrochleitis;
Medial tennis elbow;
Little leaguer's elbow
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| Golfer's Elbow | Overuse syndrome of the flexor-pronator mass
May occur precipitated by minor elbow trauma
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| Differential Dx | Arthritis;
Cervical radiculopathy;
Chondromalacia;
Cubital tunnel syndrome;
Fibrosis;
Joint laxity;
Loose bodies
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| Differential Dx | Olecranon/coronoid impingement;
Osteophytes;
Referred pain from biceps insertion or brachialis;
Tardy ulnar n. palsy;
UCL instability;
Ulnar trochlear synovitis
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| 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
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| Etiology & Epidemiology | More often males;
B/t ages 24-65;
Average age 44;
Reported with: golf, bowling, archery, baseball, weightlifting, football, racquetball, javelin throwing
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| Etiology & Epidemiology | Repetitive microtrauma followed by chronic inflammation
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| 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
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| 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
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| In medial epicondylitis, when doing Nirschl technique, where is the resection of angiofibroblastic degeneration usually? | Origin of pronator teres & FCR
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| Medial Epicondylitis- Nirschl Technique | Repair of common flexor origin
Medial epicondyle attachments of normal tissue not disturbed
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| Vangsness & Jobe Surgical Technique | Reflection of common flexor origin & excision of degenerative tissue
Reattachment of forearm flexors
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| 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
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| Goals & Treatment of Phase I: Acute Phase | Decrease inflammation/pain; Promote tissue healing; Retard mm atrophy;
Cryotherapy;
Whirlpool
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| What types of modalities may be used in phase I? | HVGS;
Phono/Ionto;
Cross-friction massage;
Soft tissue massage;
Avoidance of painful mvmts
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| Goals of Phase II: Sub-Acute Phase | Improve flexibility;
Increase muscular endurance;
Increase functional activities;
Return to function
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| 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
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| 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
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| Goals for Phase III: Chronic Phase | Improve mm strength & endurance;
Maintain/enhance flexibility;
Gradual return to sport/high level activities
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| 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
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| 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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