ADVANCED REVIEW AND MANAGEMENT OFElbow Dx and Rx.pdf

ASSESSMENT AND MANAGEMENT OF ELBOW CONDITIONS

1. Elbow&Diagnosis&and&
Treatment&
Lori&Michener,&PT,&Ph.D,&ATC,&SCS&
Chris=ne&Stone,&PT,&DPT,&NCS&

2. Elbow&Complex&&
• Joints&at&Elbow&Complex&
– Humeroulnar&Joint&
– Humeroradial&Joint&
– Proximal&Radioulnar&joint&
• All&joints&are&enclosed&in&the&
same&joint&capsule.&
• Very&Stable&Joint,&Boney&
congruency.&
• Func=onally,&the&elbow&
“adjusts”&for&placement&of&
hand.&

3. Elbow&Diagnosis&
• Lateral&Epicondyli=s&
• Medial&Epicondyli=s&
• Ligamentous&Injuries&
– Lateral&Collateral&Ligament&
– Ulnar&Collateral&Ligament&
• Nerve&Entrapments&
– Radial&Tunnel&Syndrome&
– Cubital&Tunnel&Syndrome&
&

4. Lateral&Epicondyli=s&
(Tennis&Elbow)&
• Dx:&Overuse&tendonopathy&of&wrist&extensor&mm&on&lateral&
epicondyle&
• Sx:&&
– Point&tenderness&over&the&lateral&epicondyle&&
– Pain&with&gripping&and&wrist&extension&&
– Ac=vi=es&that&use&the&muscles&that&extend
&
the&wrist&(e.g.&
pouring&a&pitcher,&liTing&with&the&palm&down)&are&
characteris=cally&painful.&&
– Pain&with&resisted&ext&and&with&passive&wrist&flexion&
• Special&Test:&Lateral&Epicondyli=s&Test&

5. Lateral epicondylitis /Tennis elbow
• AVached&to&Lat&epicondyle:&ECRL,&ECRB,&ECU,&
Supinator,&Ext&digi=&minimi,&extensor&digitorum&
• Primary&involvement:&ECRB&(may&also&ECRL)&
– Pathology&could&be:&Fibro=c&hyperplasia,&swelling,&
tendoni=s,&microWtearing&of&tendon&
• Pain&w/&resisted&wrist&ext;&&&maybe&radial&devia=on&&&
supina=on&
• Pain&with&gripping&
• Pain&with&stretch/PROM:&wrist&flex,&pron,&ulnar&devia=on&

6. Lat epicondylitis / Tennis elbow
• Acute / high irritability:
– Reduce inflammation / tissue
irritation / pain
• Rest, ice, NSAID`s
• Consider cortiocosteroid
injection? (see evidence)
– Stretching of extensors (light)
• Extensors, RD, supinator
– Address the overuse--activity
modification
– Strengthening: avoid unless pain
does not reproduce
• Eccentrics recommended

7. Lat epicondylitis / Tennis elbow
– Counter force strap
• Just with activity &/or for
↓ p! , increases grip strength,
decreases pain
• Will need to wean off as can
cause dependence
– Cock-up splint
• Support wrist ext &
allow rest of extensors

8. Lat epicondylitis / Tennis elbow
• Subacute / Chronic:
– Anti-inflammatory: Rest prn, ice, NSAIDS
– Corticosteroid injection: Recommended ST, ?LT
worse
– Stretching to ↑ soft tissue extensibility
• Extensors, RD, and supinator
– Friction massage to ↑ healing: @ lat. epicondyle
– Strengthening:
• Extensors, RD, supinator, grip, others prn
• Eccentrics is recommended
– Restore mobility if indicated: elbow or other jts

9. Lat epicondylitis / Tennis elbow
– Activity modification
– Functional activity re-training
– US as a unimodal treatment is not recommended
– Counter Force Brace
• Short-term use only
– Cock-up splint
• To support wrist ext & allow rest of ext; short-
term use only
– Surgical options
• Release of common extensor tendon
• Debridement
• Only if fail conservative

10. Lateral Epicondylitis: evidence
• Sys. review: Corticosteroid inj (Smidt N et al; Pain, 2002)
– Short term: injections have better outcome vs
placebo or no treatment
– Long term effect: all groups essentially equally
– lfeel better soonerz with inj, but @ 1 year no
difference
• 2 RCT`s since the Systematic review…
comparing PT and injection

11. Lateral Epicondylitis: evidence
• 2 RCT`s since the Systematic review:
Corticosteroid inj vs PT vs. PT vs Wait & see (Smidt N;
Lancet, , 2002; Bisset BMJ, 2005)
– PT: Ex, US, cross-friction massage: no added benefit
over wait and see (Smidt, 2002)
– PT: Mob w/ movement & Ex: ST (6 wk) ! better
outcomes vs wait and see (Bisset, 2005)
– Wait & See: advice, oral anti-inflamm. / pain, rest
– Long term: PT has better outcomes vs. injection
Conclusion
– Short-term (6 wks): inj better vs PT or W&S
– Long-term (26 – 52 wks): PT better (inj: ↑ recurrence
rate & lower outcomes), AND Wait & see did okay

12. Combined&2&RCTs&(Bisset,&Rheumatology,&2007)&

13. Lateral Epicondylitis: evidence
• Eccentric&training.&(Svernlov&B&et&al;&Scand&J&Med&Sci&Sports,&
11:328W34,&201)&
– 38&pa=ents&with&lateral&epicondyli=s&
– Two&groups:&stretching&vs.&eccentrics&
– 12&wks&of&Rx&
– Decreased&pain,&increased&grip&strength&in&both,&
but&eccentric&was&beVer&
&

14. Eccentrics
• RCT&(n=21)&&Tyler&et&al,&JSES,&2010&
– Group&1&=&Ex&(wrist&ex&stretching,&US,&crossWfric=on&
massage,&and&heat&and&ice)&and&isotonic&wrist&ext&
strengthening&&
– Group&2=&&Ex&=&eccentrics&with&Flexbar&
• Group&2:&
– >&improvement&in&DASH,&pain,&strength,&and&
tenderness&

16. Eccentric&Wrist&Ext&&&
Supina=on&

17. Lateral&Epicondyli=s:&Sys&Rev&(Buchbinder&R,&et&al.&
Am&Family&Physician,&March,&2007&
• Effec=ve&treatments&
– Cor=costeroids&for&shortW
term&p!&relief&
– PT&likely&helpful&ShortW
term;&less&recurrence&w/&
PT&vs&injec=on&
– Consider&Wait&and&See&
(advice,&rest,&oral&an=W
inflammatory&/&pain)&
&&&(see&next&slide)&
• Unknown effectiveness
– Acupuncture (needle, laster,
electro acupuncture); 5
RCT`s
– Exercise and mobilization; 3
RCTs
– Oral and topical NSAIDS
– Bracing (orthoses)
– Surgery

18. 3 RCTs combined (Smidt, BMJ, 2006)

19. Medial epicondylitis: Golfer`s or
Little leaguer`s elbow
• Common&cause:&overuse&&
• Pain&at&medial&condyle&could&be:&cubital&tunnel&nerve&
entrapment&or&aVached&tendons&
– AVached&to&Medial&epicondyle:&pronator&teres,&FCR,&
palmaris&longus,&FCU&
• Pathology&could&be:&Fibro=c&hyperplasia,&swelling,&
tendoni=s,&microWtearing&of&tendon&
• Pain&with&resisted&wrist&flex,&prona=on&
• Pain&with&gripping&
• Pain&with&stretch:&wrist&ext,&sup,&RD&
• Elbow&extension&ROMWWcommon&loss&of&mo=on&

20. Medial epicondylitis: Golfer`s elbow
• DX:&overuse&injury&of&wrist&flexors&
and&pronators&
• Pain&at&medial&condyle&could&be:&
– AVached&to&Medial&epicondyle:&
pronator&teres,&FCR,&palmaris&longus,&
FCU&
• Pathology&could&be:&Fibro=c&
hyperplasia,&swelling,&tendoni=s,&
microWtearing&of&tendon&
• Pain&with&resisted&wrist&flex,&
prona=on&
• Pain&with&gripping&
• Pain&with&stretch:&wrist&ext,&sup,&RD&
&

21. Medial epicondylitis: Golfer`s
elbow
Acute / hi irritability:
– Reduce inflammation / tissue irritation /
pain
• Rest, ice, NSAID`s
• Cortiocosteroid injection (evidence
supports)
– Stretching of flexors, pronators, UD (light)
– Address the overuse--activity
modification
– Strengthening: avoid unless pain does not
reproduce
– Counter force strap:
• Just w/ activity; use ↓ pain (no
evidence)
• Short-term use
– Cock-up splint…
• Maybe… may help to support flexors
to relieve p!
• Short-term use

22. Medial epicondylitis: Golfer`s or Little
leaguer`s elbow
• Subacute / Chronic:
– Anti-inflammatory
• Rest prn, ice, NSAIDS
– Corticosteroid injection (evidence supports)
– Stretching to ↑ ST extensibility
• Flexors, UD, and pronator
– Friction massage to ↑ healing: @ med. epicon
– Strengthening:
• Flexors, UD, pronator, gripping, others prn
• Eccentrics …. Maybe, no evidence
– Restore mobility if indicated: elbow or other jts

23. Medial epicondylitis: Golfer`s or Little
leaguer`s elbow
– Activity modification
– Functional activity re-training
– Counter Force Brace?
• No evidence
• However, if it reduces pain / improves function…
you may want to try it with an individual patient
– Surgical options if conservative PT fails
• Release of flexor tendon
• Debridement

24. Medial Epicondylitis: evidence
• Corticosteroid injection, prospective study. (Stahl S
et al; JBJS, 79:1648-52, 1997)
– Acute medial epicondylitis
– PT & NSAIDS + injection or saline
– Injection group demonstrated improvement in
short term only
• No evidence for exercise, modalities, braces,
friction massage

25. Ligamentous&Injuries&

26. Ulnar&Collateral&Ligament&Tear&
Dx: Tear of UCL on medial side
of elbow. This is typically the
result of repetitive strain of
overhead shoulder activities
such as pitching

Sx: pain and swelling on medial
side of elbow

Special Test: Elbow Valgus Stress
Test

27. Lateral&Collateral&Ligament&Tear&
Dx: Tear of lateral collateral
ligament on lateral side of elbow.
This is a very rare condition.

Sx: pain and swelling on lateral
side of elbow

Special Test: Elbow Varus Stress
Test

28. Elbow&Ligament&Tear&Treatment&
Grade 1 and Grade 2 tears are typically
provided with a brace prn and rest. RICE

Grade III Tears may require surgery in an
overhead athlete but in the general
population, rehab is effective for allowing an
excellent level of functioning.

Rehab without Surgery includes:
• RICE
• modalities prn
• strenghtening mm around the joint
• proprioceptive training

29. Nerve Entrapments

30. Nerve Entrapments
• Treatment
– Splinting
– Rest
– Modalities: pain, swelling
– Avoid provocative positions, activities
– Splints for maintaining lgoodz posture
– Surgical decompression if failing conservative
treatment
• Desensitization, scar management

31. Cubital Tunnel Syndrome
Dx: Compression of Ulnar N.
in cubital tunnel

Symptoms:
• Pain to medial forearm
• Paraethesis to ulnar nerve
• Advanced pathology
includes weakness in 4 & 5
digits with “ulnar Claw”

Special Test: Ulnar Nerve
compression test, Tinel’s Test

32. Ulnar nerve
Neuropathy

33. Radial&Tunnel&Syndrome&
Dx: Compression of radial nerve as it
passed through supinator mm at elbow.

Symptoms:
•  pain distal to elbow, along posterior
arm and forearm
• Pain when using supinator mm.
• Weakness of wrist and finger
extensors esp. laterally- wrist drop
Tests: Long Finger Extension Test

Provacative position include full elbow
extension with repetitive supine/
pronation.