Lateral Epicondylitis Lecture PDF

Lateral epicondylitis Dr. Sahar Mowad Lecture of orthopedic physical therapy Beni suef University Injuries to the elbow, specifically humeral epicondylitis, occur frequently as a result of the repetitive loads encountered in athletes from both repetitive and forceful mu...

Lateral epicondylitis Dr. Sahar Mowad Lecture of orthopedic physical therapy Beni suef University Injuries to the elbow, specifically humeral epicondylitis, occur frequently as a result of the repetitive loads encountered in athletes from both repetitive and forceful muscular activations inherent in throwing, hitting, serving, and spiking. Management involves early diagnosis and treatment coupled with a total arm strengthening or kinetic chain rehabilitation emphasis EPIDEMIOLOGY AND ETIOLOGY  One of the most common repetitive overuse injuries of the elbow is humeral epicondylitis. Epidemiologic incidences of humeral epicondylitis range from 35% to 50% in adult tennis players  reported hypervascularization of the extensor aponeurosis and an increased quantity of free nerve endings in the subtendinous space.  Humeral epicondylitis as a degenerative condition consisting of a timedependent process including vascular, chemical, and cellular events that lead to a failure of the cell-matrix healing response in human tendon humeral epicondylitis as an extra-articular tendinous injury characterized by excessive vascular granulation and an impaired tendon healing response termed “angiofibroblastic hyperplasia.” the primary structure involved in lateral humeral epicondylitis as the tendon of the extensor carpi radialis brevis. One third of cases involve the extensor communis tendon. Additionally, the extensor carpi radialis longus and extensor carpi ulnaris can be involved  Clinical picture Pain and tenderness over the lateral epicondyle of the elbow (or, more accurately, the bony insertion of the unaccustomed activity involving forceful gripping and wrist extension It is usually localized to the lateral epicondyle, but in severe cases it may radiate widely. It is aggravated by movements such as pouring out tea, turning a stiff doorhandle, Diagnosis X-ray is usually normal, but occasionally shows calcification at the tendon origin In patients with longstanding symptoms which do not respond to treatment, the possibility of a painful radial nerve entrapment (‘radial tunnel syndrome’) should be considered Doppler sonography Clinical picture The elbow looks normal, and flexion and extension are full and painless Characteristically there is localized tenderness at or just below the lateral epicondyle; pain can be reproduced by passively stretching the wrist extensors (by the examiner acutely flexing the patient’s wrist with the forearm pronated) or actively by having the patient extend the wrist with the elbow straight Treatment 90 per cent of ‘tennis elbows’ will resolve spontaneously within 6–12 months The first step is to identify, and then restrict, those activities which cause pain. Modification of sporting style may solve the problem. A tennis elbow clasp is helpful. Injection of the tender area with corticosteroid and local anaesthetic relieves pain but is not curative Common Impairments  Gradually increasing pain in the elbow region after excessive activity of the wrist and hand.  Pain when the involved muscle is stretched or when it contracts against resistance.  Decreased muscle strength and endurance for the demand.  Decreased grip strength, limited by pain.  Tenderness with palpation at the site of inflammation,  such as over the lateral or medial epicondyle, head of the  radius, or in the muscle belly. Common Functional Limitations/Disabilities Inability to participate in provoking activities, such as racket sports, throwing, or golf Difficulty with repetitive forearm/wrist tasks, such as sorting or assembling small parts, typing on a keyboard or using a mouse, gripping activities, using a hammer, turning a screwdriver, shuffling papers, or playing a percussion instrument Nonoperative Management of Overuse Syndromes: Protection Phase Immobilization. Rest the muscles by immobilizing the wrist in a splint such as a cock-up splint, where the elbow and fingers are free to move. Avoid provoking activities. Instruct the patient to avoid all aggravating activities, such as strong or repetitive gripping actions. Cryotherapy. Use ice to help control edema and swelling Develop Soft Tissue and Joint Mobility Multiple-angle muscle setting (low-intensity isometrics). Have the patient remove the splint several times a day and perform gentle multiple- angle setting techniques to the involved muscle followed by pain-free ROM. Technique for wrist extensor muscles Patient position and procedure: Sitting with the elbow flexed, forearm pronated and resting on a table, and the wrist in extension. Begin with gentle isometric contractions with the wrist extensors in the shortened position. Resist wrist extension, hold the contraction to the count of 6, relax, and repeat several times; then move the wrist toward flexion and repeat the isometric resistance. Do not move into the painful range or provide resistance that causes a painful contraction. When full wrist flexion is obtained without pain in the lateral epicondyle region, progress by placing the elbow in greater degrees of extension and repeat the isometric resistance sequence to the wrist extensors. Progress until gentle resistance can be applied to the wrist extensors in the position of elbow extension and wrist flexion. It may take several weeks to reach this position. Cross-fiber massage. Apply gentle cross-fiber massage within tolerance at the site of the lesion. Teach the patient to self-administer the submaximal isometric and cross-fiber massage techniques in a home exercise program. Maintain Upper Extremity Function Active ROM. Have the patient perform ROM to joints not immobilized to maintain the integrity of the rest of the upper extremity. Resistive exercises. Have the patient perform shoulder and scapular ROM exercises with the resistance applied proximal to the elbow.  Controlled Motion and Return to Function Phases Increase Muscle Flexibility and Scar Mobility  Manual stretching techniques  Self-stretching techniques  Cross-fiber (friction) massage Restore Joint Tracking of the RU Joint Mobilization with movement (MWM). Self-mobilization MWM for lateral epicondylitis. Lateral glide is applied to the proximal forearm (A) with resistance added to wrist extension, (B) with patient squeezing a ball to bring in the wrist extensors, and (C) self-treatment. Improve Muscle Performance and Function Isometrics. Dynamic exercise Functional patterns General strengthening and conditioning Plyometric exercises Patient Education  Education includes advice and techniques on prevention, recognition of provoking factors, and identification of warning symptoms.  Teach the patient how to reduce the overload forces that caused the problem and retrain the patient in proper techniques.  In addition to exercises, include home instructions on the application of friction massage and stretching the involved muscle prior to using it. OPERATIVE TREATMENT  Some cases are sufficiently persistent or recurrent for operation to be indicated.  The origin of the common extensor muscle is detached from the lateral epicondyle.  Additional procedures such as division of the orbicular ligament or removal of a ‘synovial fringe’ are sometimes advocated; they probably make very little difference to the outcome.  Surgery is successful in about 85 per cent of cases.