Ortho 2 Exam 3 (Elbow) --> Lateral Epicondylopathy (2/9)

what are the 4 lateral epicondylalgia tests?

- Cozens

- Mill's test

- Maudsley's test

- grip strength

Cozen's test

- resisted test

- stabilize pt forearm. Pt makes a fist, pronate, radially deviate and extend the wrist

- examiner palpates lateral epicondyle and applies force into flexion against the pt resistance

- (+) = reproduction of lateral elbow pain

Mill's test

- passive test

- examiner palpates lateral epicondyle while pronating the forearm, flex the wrist, extend the elbow

- (+) = reproduction of lateral elbow pain

Maudsley's test

- contractile

- 3rd/middle finger

grip strength test

- patient elbow extended and forearm is neutral

- squeeze until discomfort is felt

what are nirschl stages?

- stages of repetitive microtrauma

- 4 stages

what are the different nirschl stages?

- stage I = inflammatory

- stage II = pathologic tissue changes, fibroblastic and vascular response

- stage III = pathologic change with structural failure

- stage IV = stage II or III plus fibrosis and calcification

what demographics are impacted by lateral epicondylopathy

- 1-3% of the population

- 35-50 year olds

- usually dominant arm

what are the occupational considerations for lateral epicondylopathy?

- occupations that involve elbow flex/ext and wrist flex/ext for 2+ hours

what are the sport considerations for lateral epicondylopathy?

- racquet sports (tennis, handball)

- gymnastics

what are the 3 MOI for lateral epicondylopathy? how do each present?

- acute indirect

> clear onset, bruising, loss of function

- acute direct

> traumatic

- chronic (MOST COMMON)

> gradual onset

exam findings for lateral epicondylopathy?

- tenderness for palpation

- possible swelling

- PROM pain with: wrist flexion, pronation, elbow extension

- pain with contractile extension and radial deviation

what are the 5 types of lateral epicondylopathy

1. lesion ECRL (extensor carpi radialis longus)

2. insertional tendinopathy at ECRB (extensor carpi radialis brevis)

3. ECRB at RCL/radial head

4. ECRB strain

5. EDC (extensor digitorum common) inflammation

what are 2 other tests that can be done to assess lateral epicondylopathy?

- cervical spine exam

> C6

- ULNT

> radial

treatments for lateral epicondylopathy

- eccentric exercises

- mid/lower trap strengthening

- cervical manipulation

- thoracic manipulation/acupuncture

- wrist manipulation

- modalities

- STM

- education

how did eccentric training impact lateral epicondylopathy?

- overall pain reduction of 10% compared to concentric training group

- increase muscle strength compared to concentric training

(Peterson, Butler 2014)

should you strengthen mid and lower trap with patients who present with lateral epicondylopathy?

- yes

- strength improved from 3+-4/5 to 5/5

- improved grip strength

- improved DASH scores completely (to 0)

(Bhatt, Glaser 2013)

how does cervical dysfunction affect lateral epicondylopathy?

- pts with LEp may present with cervical dysfunction even if there is not obvious neck pain

- may reflect central sensitization mechanisms

how did cervical manipulation impact lateral epicondylopathy?

- short-term analgesic effects

- can allow for more vigorous stretching and strengthening exercises

what is central sensitization

- hyperalgesia allodynia = pain response to nonpainful stimulus

how does elbow manipulation impact lateral epicondylopathy?

- support the use of Mulligans for immediate, short, and long term benefits

> mobilizing the joint DURING activities

how can acupuncture impact lateral epicondylopathy?

- if there is elbow pain/swelling with a fall or traumatic MOI (subacute or chronic)

- can resolve subjective complaints and objective findings quickly

how does wrist manipulation impact lateral epicondylopathy?

- scaphoid manipulation

- 3 week success rate

> scaphoid manip group had 62% improvement compared to group 2 (modalities, stretching, strengthening)

what is the ideology behind scaphoid manipulation impacting LEp

- decreased wrist extension ROM can be due to hypomobility

- the extensors have to work harder because of the decreased ROM, which can cause pain

- mobilizing the scaphoid can increase ROM and decrease pain (extensors wont have to work as hard)

does low level laser therapy impact lateral epicondylopathy?

- short term pain relief

- less disability

- should be performed with an exercise routine

does ionto impact lateral epicondylopathy?

- significantly improved grip strength

does US impact lateral epicondylopathy?

- conflicting evidence

what is Mill's manipulation?

- used for fibrous epicondylopathy

- 10 minutes of deep transverse friction massage immediately followed by 1 application of Mill's manipulation

- pt seated... bring wrist into full flexion, forearm into pronation, shoulder in full IR

- bring patient through flexion and extension a few times, then provide a high velocity low amplitude thrust at the olecranon at end range extension

what is important to note about treatment for LEp?

eccentrics should increase pain to a 4/10 max

what are the phases of pain?

- 1: soreness after activity, usually gone within 24H

- 2: mild stiffness and soreness before activity but disappears with warm up. no pain with activity. soreness after that goes away within 24H

- 3: mild/moderate stiffness and soreness with pain during activity that does not alter activity

- 4: pain during activity which alters activity

- 5: constant pain even at rest

what should you do if an exercise causes phase 3 pain (3)

- decrease amount of weight you're lifting

- decrease the number of repetitions

- moving through pain free ROM

how do PRP injections impact lateral epicondylopathy?

- no significant difference at 12 weeks

- significant difference at 24 weeks

- conflicting evidence --> some strong evidence against

how does a corticosteroid injection impact lateral epicondylopathy?

- short term relief

- corticosteroids are anti-inflammatory, which would have no impact on chronic LEp

> the steroid itself wouldn't do much, but the injection can be enough to induce a healing response in that area

surgical treatment for lateral epicondylopathy

- ECRB tendon release

- done arthroscopically

- open release