MSK 631 - Elbow Asynchronous Lecture

What condition is the most common cause of elbow pain?

Lateral Epicondylalgia

How frequent is lateral elbow pain compared to medial elbow pain?

7-10 times more likely

What is another name for Lateral Epicondylagia?

Tennis Elbow

What percentage of the population has “tennis elbow” who are not tennis players?

95%

What other condition has association with lateral epicondylalgia?

Tendinitis / Tendonalgia / Tendinopathy

How does Lateral Epicondylalgia develop?

Gradually onsets due to overuse and repetitive activites

What age is most susceptible to lateral epicondylalgia?

35-50

Do men or women are higher incidence of Lateral Epicondylalgia?

Women

Does Lateral Epicondylalgia occur in the dominant hand or non-dominant hand?

Dominant arm

What muscle are associated with Lateral Epicondyalgia?

• ECRB (Extensor Carpi Radialis Brevis)

• ECRL (Extensor Carpi Radialis Longus)

• ED (Extensor Digitorum)

• ECU (Extensor Carpi Ulnaris)

• EDM (Extensor Digiti Minimi)

Which muscle is most commonly affected w. Lateral Epicondylalgia?

Extensor Carpi Radialis Brevis

There is tenderness over the lateral epicondyle for lateral epicondylalgia.

A) Where the maximal tenderness a person experiences?

B) Is there high or lower pain pressure thresholds using algometer?

A) 2-5 mm distal and anterior to the lateral epicondyle

B) Lower pain pressure threshold (less pressure needed to cause pain)

For Lateral Epicondylalgia:

A) Which resisted movements would cause pain?

B) Which passive stretches would cause pain?

A) Wrist and Finger Extension

B) Wrist flexion w/ Arm Extended

How would one describe the pain with Lateral Epicondylalgia?

Deep Aching Pain

What type special tests help diagnose Lateral Epicondyalgia?

Maudsley’s Test and Cozen’s Test

What weakness would a pt experience with Lateral Epicondylalgia?

• Grip strength with extended elbow

• ECRB specific

• Two-pinch grip

If there is referred pain from the cervical spine or shoulder, what imaging could you use to help with differential diagnosis?

MRI and Ultrasound

What are the conditions you should consider for your differential diagnosis when suspecting lateral epicondylalgia?

• Radial Tunnel Syndrome

• Lateral Collateral Ligament Sprain or Instability

• Triceps Tendinopathy

• Intra-articular Pathology

  • Radiocapitellar Plica

  • Chondromalacia

What are the non-surgical treatments for Lateral Epicondylalgia?

• Activity modification, ice, rest, bracing, NSAIDS

• Physical Therapy

• CS or other injections

• Wait and See

What are some Physical Therapy interventions can be used for pts w/ Lateral Epicondylalgia?

Therapeutic Exercise, Manual Therapy, Eccentrics, and Mulligan’s Mobilization With Movement (MWM)

What percentage of patients improve within 12 months without treatment for Lateral Epicondylalgia using the Wait and See treatment?

70-80%

Which of the following is the best surgical procedure for Lateral Epicondylalgia?

Open, Percutaneous, Arthroscopic

Unclear evidence for best results

What are the most effective interventions for Lateral Epicondylalgia?

Manual Therapy

Eccentric Strength Training

What shoulder exercises should be considered for Lateral Epicondylalgia as a treatment?

• Rotator Cuff Strengthening Exercises

• Scapular Muscle Strengthening Exercises

What two muscles showed improvements for DASH score and grip strength from a case report in 2013?

Middle and Lower Trapezius

How is the Mulligan’s Mobilization With Movement (MWM) performed for Lateral Epicondylalgia?

• Non-thrust technique

• Identifies painful activity (usually gripping or wrist extension)

• Applying lateral glide by stabilizing humerus and mobilize proximal forearm (can add ant/post/caudle glides)

How is Mulligan’s Mobilization With Movement dosed for Lateral Epicondylalgia?

• Below symptom threshold

• May add gripping motion w/ mobilization (pain-free)

• Re-assess after treatment

From literature on MWM for Lateral Epicondylalgia, what were the results…

A) after a single session?

B) comparing MWM and CS injection after 3 weeks?

C) comparing MWM and CS injection after 52 weeks?

D) MWM combined with exercise and cold therapy?

E) MWM vs US vs Control towards pain and grip strength?

F) from double blind RCT w/ pain-free grip strength and pain pressure threshold?

A) Decrease in pain & increased pain-free / max grip strength

B) Injection group was most improved

C) MWM group was most improved

D) Decreased pain, improved max grip strength, increased function

E) Improved pain on VAS and grip strength from MWM group

F) Improved pain-free grip strength by avg of 58% and increased pain pressure threshold by 10%

What clinical prediction rules are associated with Lateral Epicondylalgia?

• less than 49 years old

• Affected arm pain-free grip strength (PFGS) > 112 N

• Unaffected arm PFGS < 336 N

• Change in PFGS post first MWM >25%

What manipulation can be performed at the wrist as an intervention for Lateral Epicondylalgia?

Scaphoid Thrust Manipulation

What were the improvements using Scaphoid Thrust Manipulation for Lateral Epicondylalgia…

A) overall improvements?

B) @ 3 weeks?

C) @ 6 weeks?

A) Variances of pain, grip strength

B) Better overall improvements

C) No significant difference

From a 2007 study by Berglund on Lateral Epicondylalgia, there was a prevalence of pain in cervical / thoracic spine pain. What percentage reported cervical / thoracic spine pain?

70%

In a Coombes study on Lateral Epicondylalgia,

A) Where did 35% of patients have a positive joint mobility assessment at?

B) What percentage of people had a +radial nerve tension test?

C) Was there a decrease or increase in associated with +mobility assessment if they experienced long symptom severity?

D) Was there an increase or decrease association with +radial nerve tension test when there is an increase in resting symptoms?

A) C4-C7

B) 41%

C) Increased

D) Increased

Who would experience greater pain-free grip strength deficits in affected UE for Lateral Epicondylalgia?

• Patients who will benefit from treatment at the periphery

• Patients who will benefit from treatment at the spine

Patients who will benefit from treatment at the periphery

Who would experience greater pain pressure threshold differences in affected UE for Lateral Epicondylalgia?

• Patients who will benefit from treatment at the periphery

• Patients who will benefit from treatment at the spine

Patients who will benefit from treatment at the spine

What predictors are associated with worse prognosis for Lateral Epicondylalgia?

• Pain at baseline

• Higher intensities of pain with functional activities

• Being on paid sick leave

• Recurrence

What percentage of medial epicondylalgia make up ALL epicondylalgia diagnoses?

10-20%

What is another name for Medial Epicondylalgia?

Golfer’s Elbow

What muscles are involved with Medial Epicondylalgia?

• Pronator Teres

• Flexor Carpi Radialis

• Palmaris Longus

• Flexor Carpi Ulnaris

• Flexor Digitorum Superficialis

What are the clinical patterns associated with Medial Epicondylalgia?

• Gradual Onset (deep ache)

• Tenderness to palpation at the medial elbow

• Pain with specific motions

• May have edema and warmth at region

What causes the gradual onset and deep aching pain of medial epicondylalgia?

Repetitive wrist flexion / pronation activities

What age group is most common for medial epicondylalgia?

40-50s

Does Medial Epicondylalgia (ME) affect more men or women?

Equal

What sports is ME associated with?

Golf, baseball, bowling, javelin, weight lifting, football, ect…

What occupations is ME associated with?

Carpentry, Plumbing, Meat Cutting

Where would be the best place to palpate ME for tenderness?

5 mm distal and anterior to medial epicondyle

What resisted motions and stretches cause pain for ME?

• Resisted pronation, flexion, ulnar/radial deviation

• Stretching into wrist extension, supination, and radial deviation

Where can pain radiate to for ME?

Forearm

What may occur to people with chronic ME?

Lose ROM and lead to elbow flexion contracture

What differential diagnoses must be performed for ME?

• Cervical / Thoracic Junction

• Ulnar Neuropathy

• Ulnar Collateral ligament pathology

Are x-rays abnormal or normal with ME?

Normal

What percentage of cases would experience soft tissue calcification for ME?

20-25%

What radiology images would assist with diagnosing ME?

MRI and US

What treatment is ME similar to?

Lateral Epicondylalgia (LE)

For ME, What is the rehabilitation emphasis for…

A) Phase I?

B) Phase II?

C) Phase III?

A) DAPRE (Daily adjusted progressive resistance exercises)

B) Endurance and Hypertrophy

C) Strength and Power

For ME, What is the goals for…

A) Phase I?

B) Phase II?

C) Phase III?

A) Increase ROM (Passive, active, resistive) & Develop initial strength endurance

B) Continue with phase 1 exercises & Increase muscular endurance and mass

C) Continue with phase II exercises, increase strength and power, reintroduce movement skills for sport specificity & Functional sport movements and return to sport/activity

What is the most common arthritis at the elbow?

Rheumatoid Arthritis

What is the presentation at the elbow with someone experience rheumatoid arthritis?

• Bilateral presentation, inflammation, pain

• Decreased ROM into Extension>Flexion

T/F: The elbow is one of the last joints to be affected by Rheumatoid Arthritis.

False, it is one of the earlier joints

What is Rheumatoid arthritis at the elbow often associated with?

Bursitis or Neuropathy

Is Osteoarthritis more or less common at the elbow?

Less

Who is OA at the elbow more common in?

Middle aged men with manual jobs or post trauma

What impact does OA at the elbow have on function?

• Pain

• Decreased ROM

• Stiffness

• Joint locking

• Joint instability

What is the treatment for OA and RA?

• Joint protection

• Education

• Regular exercise

• Pain relief

• ROM

• Ex.

What is Osteochondral Lesion?

Separation of articular cartilage from bone

What is the etiology for Osteochondral lesion?

Not clear but may be related to prolonged overload or high compressive forces

What are two examples of Osteochondral lesion?

Panner’s Disease

Osteochondritis Dissecans

What is Panner’s Disease?

Osteochondrosis of Humeral Capitellum

What are some signs for Panner’s Disease?

Pain, Swelling, TTP over at lateral elbow

What can X-rays show for Panner’s Disease?

• Flattening of Capitellar Epiphysis

• Fragmentation of bone

Who is at risk for Panner’s Disease?

Male athletes under 10 years old

What is the treatment for Panner’s Disease?

Activity modification, rest, anti-inflammatory medication

How does Panner’s disease resolve usually?

Growth, imaging demonstrates reossification

What population is Osteochondritis dissecans commonly presented in?

Adolescent overhead athletes

What is the primary symptoms of Osteochondritis Dissecans?

Pain

How is pain described for Osteochondritis Dissecans?

Dull and poorly localized

For Osteochondritis Dissecans, what impact does it have on ROM?

Decreased especially in Extension

What can indicate fragmentation of cartilage for Osteochondritis Dissecans?

Clicking, Popping, Locking

What population is susceptible to Ulnar Collateral Ligament injuries?

Throwing atheltes

What are other names for Ulnar Collateral Ligament injuries?

• UCL insufficiency

• Valgus extension overload syndrome

  • Olecranon overload

What part of the UCL is most affected for injuries? Why?

Anterior Bundle of the UCL b/c it is the main stabilizer of the elbow

What degrees of elbow flexion is the anterior bundle of the UCL seen as the main stabilizer of?

30-120 degrees

Where is the greatest valgus force experienced in throwing?

Late cocking / early acceleration phase

How much force can the UCL withstand?

40lb

What protects the UCL?

• Triceps

• Anconeus

• Flex / Pronation

• Internal Rotation

How much compressive force can be placed on humeral capitellar (lateral impact)?

~500 N

What is the primary symptom of UCL injury?

Medial elbow pain with throwing at late cocking / early acceleration

Where can pain be presented for UCL injury?

Olecranon and over flexor / pronator mass

What is the best way to palpate UCL injury?

50-70 degrees of elbow flexion, move flexor mass anteriorly

What may a patient report with movement if they have a UCL injury?

Popping, snapping sound

Are you more likely to see a patient with acute or chronic episodic pain for UCL injury?

Chronic Episodic Pain

Is there an increased or decreased carrying angle?

Increased

Is instability a common complaint for UCL injury? Why?

No because muscle stabilizers compensate for instability

For people with UCL injury, what percentage of patients may also have ulnar neuritis / cubital tunnel syndrome?

40%

What type of contracture is common in elite athletes for UCL injury?

Flexion contractures

What special tests are performed to assess UCL injury?

Valgus Stress Test

Moving Valgus Stress Test

Milking Test

What should taken into account for the Milking Test for UCL injuries?

Often will only have pain, but not laxity with testing

What imaging can assist with diagnosing UCL injury?

X-rays, MRI, CT arthrograms

What should be included in the subjective exam for UCL injuries?

• Timing of pain during throw

• Training practice or recent changes

• Participation level

• Pitch type

• Changes noted in quality of throw or endurance

What conditions do we have to perform differential diagnosis for when seeing a pt with UCL injury?

• Coronoid fossa osteophytes

• Olecranon osteophytes

• Olecranon Stress Fracture

• Medial or Lateral Epicondylalgia

• Muscle Strains

• Biceps or Triceps Tendinopathy

• Radiocapitellar Chondral Injury

• Posterolateral synovial plica

• Nerve Injury

• Vascular Injury