Elbow Sport Injuries PDF

Elbow Injures Dr. Samiah Alqabbani DPT414 1446 Outline Types of elbow injuries Relevant mechanism of injury Management of elbow injuries  Medial Epicondylitis Overuse Injuries Lateral Epicondylitis Ul...

Elbow Injures Dr. Samiah Alqabbani DPT414 1446 Outline Types of elbow injuries Relevant mechanism of injury Management of elbow injuries  Medial Epicondylitis Overuse Injuries Lateral Epicondylitis Ulnar Collateral Ligament (UCL) injury Mechanism of injury The act of throwing produces significant stresses about the elbow joint and surrounding soft tissues, resulting in a sport-specific pattern of injury. Many elbow injuries and conditions that occur in throwing athletes result from accumulated microtrauma secondary to these stresses and the repetitive motion of throwing.  Epicondylitis Lateral epicondylitis involves injury to the extensor carpi radialis brevis tendon, and medial epicondylitis involves injury to the flexor carpi radialis or pronator teres muscles, or both, near their origins. The primary cause is contractile overloads that chronically stress the tendon near the attachment on the humerus It occurs often in repetitive upper extremity activities such as computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration. People with repetitive one-sides movements in their jobs such as electricians, carpenters, gardeners also commonly present with this condition Lateral epicondylitis is more common than medial epicondylitis in the general population and occurs in 1% to 3% of adults, with up to 50% of recreational tennis players developing the condition at some point in their careers.  Sports that involves movement of the arm like tennis, squash, baseball, throwing Lateral Epicond and swimming. Athletes who do repetitive movements have a ylitis higher risk of developing elbow injuries. Also, short- term high intensity sports Mechanism of effort, as in the sudden lifting of a weight (dumbbells) or the forceful throwing of the ball Injury in handball, a movement that also involves the sudden prono-supination of the forearm. Amateur Tennis players are more likely to develop lateral epicondylitis. 50% of nonprofessional tennis players vs. 5% of professional players. Why: Not yet learned the exact technique of playing tennis. Lateral Epicondylitis Risk factors in Sports Prolonged use of wrist Impact forces from Sustained gripping extensors repetitive striking Racquet sports: grip, grip size, string Change in activity or tension, racquet Rotator cuff weakness equipment stiffness, bad strokes, off-center hits  Characteristics/Clinical Presentation The most prominent symptom of lateral epicondylitis is pain. This pain can be produced by palpation on the extensor muscles origin on the lateral epicondyle. The pain can radiate upwards along the upper arm and downwards along the outside of the forearm and in rare cases even to the third and fourth fingers. Decrease flexibility and strength in the wrist extensor and posterior shoulder muscles. Patients report weakness in their grip strength or difficulty carrying objects in their hand, especially with the elbow extended. This weakness is due to finger extensor and supinator weakness. Clinical Course Symptoms last, on average, from 2 weeks to 2 years. 89% of the patients recover within 1 year without any treatment except avoidance of the painful movements  Onset of pain 24-72 hours after provocative activity involving wrist extension Pain may radiate down forearm as far Subjective as the wrist and hand Difficulty with lift and grip (Pain+/- Assessment weakness) Changes in biomechanical factors- new tennis racquet, wet ball, overtraining, poor technique, shoulder injury Warren Classification According to Warren, there are four stages on the development of this injury regarding the intensity of the symptoms. 1. Faint pain a couple of hours after the provoking activity. 2. Pain at the end of or immediately after the provoking activity. 3. Pain during the provoking activity, which intensifies after ceasing that activity. 4. Constant pain, which prohibits any activity.  Pain and point tenderness over lateral epicondyle and/or 1-2cm distal to epicondyle Pain and weakness on resisted wrist extension Pain and/or decreased movement on passive elbow extension, wrist flexion and ulnar deviation and pronation Weak elbow extensors and flexors Objective Weakness on grip strength testing (Dynamometer) Assessment The most common functional limitation in UE is pain on gripping, and this can be measured as pain-free grip strength, which is a reliable and valid measure that is more sensitive to change than maximal grip strength. With the patient lying supine, the elbow in relaxed extension and the forearm pronated, the patient is asked to grip a dynamometer until the first onset of pain, and the mean of three tests at 1-minute intervals is then calculated Grip strength The key difference between pain-free grip strength and maximal grip strength lies in their sensitivity to discomfort and change, as well as what they measure: Pain-Free Grip Strength: This measure assesses the maximum amount of grip strength an individual can apply without experiencing pain. It is considered a reliable and more sensitive measure than maximal grip strength, especially when evaluating patients with conditions like lateral epicondylitis. Pain-free grip strength reflects both muscular function and discomfort, making it an effective tool for monitoring progress in rehabilitation and treatment where pain is a limiting factor. It's particularly useful for tracking subtle changes in conditions where pain is involved because it highlights improvements in both strength and pain tolerance. Maximal Grip Strength: This is the maximum force a person can exert using their grip, regardless of pain. It is a standard measure of muscle strength but is less sensitive to small changes, especially when pain limits the effort. It focuses purely on strength output, often used in athletic and performance settings rather than rehabilitation contexts. Cozen’s Test Cozen’s test is also known as the resisted wrist extension test. The elbow is stabilized in 90° flexion. The therapist palpates the lateral epicondyle, and the other hand positions the patient’s hand into radial deviation and forearm pronation. Then the patient is asked to resist wrist extension. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle Special Tests Maudsley’s Test Cozen’s Test Mills Test Outcome Measures The Upper Limb Functional Index (ULFI) Patient Rated Tennis Elbow Evaluation (PRTEE) QuickDASH (Disabilities of the Arm Shoulder and Hand) Medical Management Non-Operative NSIDS Ice Rest Elbow counterforce brace Steroids Injections Surgical Usually this is after a failed conservative treatment for more than 6 months. It involves removing diseased muscle and reattaching healthy muscle back to bone. Open Surgery Arthroscopic Surgery  Non-Operative Management Elbow Counterforce Brace It plays the role of a secondary muscle attachment site and relieves tension on the insertion at the lateral epicondyle. The brace is applied around the forearm (below the head of the radius) and is tightened enough so that, when the patient contracts the wrist extensors, he or she does not fully contract the muscles Steroids Injections Injection is given subperiosteally to the extensor brevis origin. These injections have an early and beneficial effect. A steroid injection should be followed by 1-2 weeks’ rest and should not be repeated more than 2 times. Steroid injection seems to be effective for about 3 months, indicating that the patient must continue with the exercise program Physical Therapy Treatment The primary aim of Different therapy physical therapy options are provided treatment is to for Lateral reduce pain and Epichondylitis improve function. Physical Therapy Management Manual Therapy (Cyriax-Muligan) Deep Transvers Friction Massage Ultrasound Shock Wave Exercise Therapy Stretching Eccentric Exercise Exercises Evidence-Based Physical Therapy Management of Lateral Epicondylitis Bisset, Leanne M., and Bill Vicenzino. "Physiotherapy management of lateral epicondylalgia." Journal of physiotherapy 61.4 (2015): 174-181. Exercises and Manual Therapy Exercise: There was evidence from several RCTs of sound methodological quality that exercise may be more effective at reducing pain and improving function than other interventions such as US, placebo US, and friction massage, but there may be no difference in effect between different types of exercises. Manual therapy techniques to the elbow, wrist and cervicothoracic spine may reduce pain and increase pain-free grip strength immediately following treatment. There was insufficient evidence of any long- term clinical effects for manual therapy alone. Orthoses: There was conflicting evidence for the effectiveness of orthoses in providing pain relief or improvement in function compared with placebo or no treatment. Elbow orthoses may be as effective as corticosteroid injection in the short term. There was no compelling evidence that any one orthosis is superior to another in the short term, or that adding an orthosis to another treatment provides any additional benefit. Bisset & Vicenzino 2015  PT Modalities Laser: might be beneficial in the short term compared with placebo, but there is likely no difference between laser and other active interventions in the short term or long term. Laser wavelengths other than 904 nm do not appear to have any benefit over that of a placebo. Ultrasound: appears to be no more effective than placebo for pain relief or self-perceived global improvement in the short term Shock wave therapy: SWT is no more effective than placebo or other treatments for relieving pain in LE Bisset & Vicenzino 2015 Other Interventions Acupuncture/dry needling While there appears to be conflicting evidence, acupuncture might be more effective than placebo and more effective than US at relieving pain and improving self-assessed treatment benefit in the short term Multimodal programs In summary, a multimodal program of Mobilization-with- Movement and exercise is likely superior to wait-and-see and placebo injection in the short term, and superior to corticosteroid injection in the long term. Multimodal treatment involving friction massage may be no different or worse than other treatments in providing pain relief Bisset & Vicenzino 2015 MWM = Mobilization-with- Movement, PRTEE = Patient-Rated Tennis Elbow Evaluation, SWT = shock wave therapy, US = ultrasound. Bisset & Vicenzino 2015  Evidence Update Kim, You J., et al. "Efficacy of nonoperative treatments for lateral epicondylitis: a systematic review and meta-analysis." Plastic and Reconstructive Surgery 147.1 (2021): 112-125. Landesa-Piñeiro, Laura, and Raquel Leirós-Rodríguez. "Physiotherapy treatment of lateral epicondylitis: A systematic review." Journal of back and musculoskeletal rehabilitation 35.3 (2022): 463-477 Efficacy of Nonoperative Treatments for Lateral Epicondylitis: A Systematic Review and Meta-Analysis Electro-physiotherapy and Physiotherapy was effective in improving pain , and function (Patient-Rated Tennis Elbow Evaluation score and Disabilities of the Arm, Shoulder and Hand score compared to placebo). Injections did not improve any outcome measures. Patients who received electro physiotherapy and injections reported higher adverse effects than physical therapy patients. (Kim, You J., et al. 2021)​  Physiotherapy treatment of lateral Manual therapy and eccentric epicondylitis: A strength training are the two physiotherapy treatments with systematic review the most beneficial effects on LE, and their cost-benefit ratio is very favorable. Landesa-Piñeiro and Leirós- Rodríguez, 2022​ Extracorporeal shock wave therapy (ESWT) versus local corticosteroid injection in treatment of lateral epicondylitis (tennis elbow) in athletes: clinical and ultrasonographic evaluation Ibrahim, Noha Hosni, et al. 2021 Return to Sport – Elbow Injuries 1. Tolerance of resistive exercise progressions that include the use of both isolated muscle activation of key stabilizing muscles (posterior rotator cuff, flexor pronator group, and scapular stabilizers), as well as tolerance of functional simulation exercise/movement patterns indicating readiness to initiate actual sport-specific movements in the interval sport return program. 2. Objectively documented strength equal to the contralateral extremity with either manual muscle testing or, preferably, isokinetic testing or distal grip strength measured with a dynamometer, and functional ROM are essential requirements that are recommended for inclusion in the evaluation for RTS 3. Additional parameters included in the pre-return to activity evaluation of the throwing athlete include provocation maneuvers that simulate elbow loading encountered during the throwing or serving motion. These include orthopedic manual examination techniques such as the subluxation/relocation test, O’Driscoll’s moving valgus test and standard valgus stress tests in addition to the valgus extension overpressure test  Final Reflection Update Date: submission will be Deadline for Submission: 25- A sample will be uploaded in open 10-11-2024 11-2024 by end of the day BB References: D. M. Walz, J. S. Newman, G. P. Konin, and G. Ross, Epicondylitis: Pathogenesis, Imaging, and Treatment,RadioGraphics, January 1, 2010; 30(1): 167 - 184. Level of Evidence: 2C Warren, RF. Tennis elbow (epicondylitis): epidemiology and conservative treatment, in AAOS Symposium and Upper Extremity Injuries in Athletes, Pettrone, F.A., Ed. St. Louis: C.V. Mosby, 1986; 233-243. Level of Evidence: 1B Bisset, Leanne M., and Bill Vicenzino. "Physiotherapy management of lateral epicondylalgia."Journal of physiotherapy 61.4 (2015): 174-181. Ibrahim, N.H., El Tanawy, R.M., Mostafa, A.F.S. et al. Extracorporeal shock wave therapy (ESWT) versus local corticosteroid injection in treatment of lateral epicondylitis (tennis elbow) in athletes: clinical and ultrasonographic evaluation.Egypt Rheumatol Rehabil 48, 32 (2021). https://doi.org/10.1186/s43166-021- 00081-2 Landesa-Piñeiro, Laura, and Raquel Leirós-Rodríguez. "Physiotherapy treatment of lateral epicondylitis: A systematic review." Journal of back and musculoskeletal rehabilitation 35.3 (2022): 463-477. Kim, You J., et al. "Efficacy of nonoperative treatments for lateral epicondylitis: a systematic review and meta-analysis." Plastic and Reconstructive Surgery 147.1 (2021): 112-125. Helen C. Roberts, Hayley J. Denison, Helen J. Martin, Harnish P. Patel, Holly Syddall, Cyrus Cooper, Avan Aihie Sayer, A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach, Age and Ageing, Volume 40, Issue 4, July 2011, Pages 423– 429, https://doi.org/10.1093/ageing/afr051 Ibrahim, Noha Hosni, et al. "Extracorporeal shock wave therapy (ESWT) versus local corticosteroid injection in treatment of a l teral epicondylitis (tennis elbow) in athletes: clinical and ultrasonographic evaluation." Egyptian Rheumatology and Rehabilitation 48 (2021): 1-14