DPTD 853 - elbow & iontophoresis

tennis elbow aka

lateral elbow tendinopathy

LET non-modifiable risk factors

• female

• dominent hand involvement

• h/o smoking

• RTC injuries

• De Quervains

• CTS

• oral corticosteroid therapy

LET modifiable risk factors

• low job control

• low social support

• handling tools > 20 kg

• repetitive elbow/wrist flx/ext for > 2 hrs per day

• repetitive forearm twisting/rotating/screwing movements

LET symptoms

• local tenderness over lateral epicondyle, can refer to forearm

• aching to sharp pain

• pain w strong or repeated gripping, tool use, sports

LET objective findings

• MAY have ROM deficits

• pain with resisted wrist ext and wrist ext w/ radial deviation

• decreased grip strength

• decreased pain pressure threshold

• + Mill’s, Cozen’s, Maudsley

Mill’s test

• pt supine

• stabilize olecranon while palpating ext bundle

• move arm into passive elbow ext and wrist flx

Cozen’s test

• pt forearm pronated

• pt performs radial deviation and ext of wrist, stabilize olecranon as PT applies force into wrist flx

Maudsley’s test

• stabilize distal forearm/ wrist

• downward force at 3rd DIP, pt resists motion

• + if pain in lateral elbow

LET CPG best evidence interventions (level B)

• multimodal - wrist ext strengthening & manual therapy

• ther ex

  • low load high rep concentric & eccentric to fatigue

• manual

  • trigger point

  • joint mob

• rigid taping

LET DO NOTS…

• US as standalone tx

• iontophoresis > 4 weeks from onset

• forearm counterforce or wrist support orthoses

• deep transverse t cross friction massage

• cryotherapy for pain in irritable LET

LET & corticosteroid injections…

• not beneficial - specifically in chronic LET → worse outcome 1 year out

• may be beneficial in acute phase, but still may have long term negative affect and greater recurrence rate

golfers elbow aka

medial epicondyle tendinopathy (MET)

MET symptoms

• pain over medial epicondyle

• dull, deep, achy pain - may be sharp - can radiate to to medial forearm

• weak grip

• *worsens in late cocking phase

MET contributing factors

• new activity w/ high frequency

• poor training, lack of warm up

• ipsilateral arm injuries

• *more common on dominant side

MET objective findings

• TTP

• pain with resisted pronation, wrist flx, ulnar, and radial deviation

• pain w/ stretching into wrist ext, supination, radial deviation

• + golfer’s elbow test = + familiar pain w/ passive forearm supination while ext elbow, wrist, and fingers

• may have ROM deficits

MET intervention recommendations

• activity modification

• multimodal interventions

• stretching w/out pushing into pain

• low load high rep wrist flexor strengthening

surgical indications LET vs MET

• LET = persistent pain and symptoms after >6 months of conservative management

• MET = persistent pain and symptoms 3-6 months of conservative management

ulnar collateral ligament injury MOI

• excessive valgus force - occurs in late cocking phase

  • medial aspect is stretched, lateral aspect is compressed

• common in OH athletes - forceful elbow ext and forearm pronation

• anterior portion at greatest risk

little league elbow

inflammation at growth plate - avulsion fx are common

UCL injury objective findings

• medial elbow pain

• increased carrying angle

• pain w/ palpation over UCL (palpate in 50-70° elbow flexion) and medial epicondyle

• feeling of instability with pronation

• + Moving valgus stress test, valgus stress test

moving valgus stress test

• pt seated, shoulder at 90° ABD w/ max elbow flexion

• PT applies valgus force and quickly moves elbow into extension

• + if familiar pain between 120-70° elbow flexion

valgus test

• pt supine w elbow in slight flexion

• stabilize distal humerus and apply valgus force to proximal forearm

• + in increased laxity compared to uninvolved side and familiar pain

milking maneuver

• pt seated elbow flexed >60° w/ forearm supinated

• apply down and out force on thumb

• allegedly tests posterior band of UCL

UCL injury PT management

• gradual progression of strengthening w/ focus on biomechanics

• flexor-pronator strength for dynamic stability

• must address strength & mechanics at trunk and shoulder as well

posterolateral rotatory instability stages

• stage I = disruption of lateral ligament complex

• stage II = disruption of anterior & posterior capsule

• stage III = may also involve MCL

PLRI MOI

usually trauma - may be due to chronic microtrauma from varus deformity and hyperlaxity

PLRI clinical findings

• lateral elbow pain, may be vague

• clicking, popping, snapping, locking

• dimple at site of radial head dislocation

• ROM usually WFL

• + posterolateral rotatory drawer test

PLRI test

• pt supine w arm supported by PT, shoulder in full ER and flexion > 90°

• elbow begins in ext, axial compression and valgus stress applied

• + = familiar pain and elbow subluxes at 40-70° flexion

PLRI PT management

• low severity - avoidance, strengthening & stabilization exercises, bracing

• typically requires surgery

elbow fracture objective findings

• neurovascular assessment

• ROM - limited to post op protocol

• MMT of uninvolved side & proximal m that do not attach to elbow if post op

heterotopic ossificans

• abnormal formation of bone in soft tissue

• progressive ROM loss

• bone scan will detect sooner than x-ray (x-ray cannot see until 4-6 weeks)

complex regional pain syndrome

• pain disproportionate to injury

• non dermatomal distribution

osteochondritis dissecans pathology

• inflammatory pathology of subchondral bone & articular cartilage

• often due to repetitive compression injury that leads to vascular insufficiency and microtrauma

• results in localized necrosis and fragmentation of bone and cartilage

osteochondritis dissecans objective findings

• visible swelling, tenderness of lateral or posterolateral elbow

• loss of flexion and extension ROM

• crepitus, popping, locking, giving way

• strength may be normal but limited to pain

• pain w/ valgus stress test

osteochondritis dissecans PT management

• 6-12 weeks = pain management, pt ed, activity mod; possible bracing

• then pain free ROM and strengthening

nursemaid’s elbow pathology/MOI

• dislocation of radial head - damages to annular ligament

• traction force at elbow w/ outstretched arm & forearm pronation

• fall

• insidious element

what is iontophoresis

electrical modality that uses charged ions that deliver meds transdermally into tissues for localized ther effect (+ charged med on + electrode, - charged med on -electrode)

iontophoresis common indications

pain, edema & inflammation, scar management

iontophoresis contraindications

• open wounds or immature tissue

• standard electrical modality precautions

• steroid allergies

• adhesive sensitivity

• early tendon/ligament repairs

• skin conditions, infections

iontophoresis side effects

• slight tingling sensation during treatment

• redness

• minor dryness/irritation

• tiny white blisters

• pt w DM should monitor blood sugar changes

common med used with iontophoresis…

dexamethasone (corticosteroid) - placed on NEGATIVE electrode