Hand Works Occupational Therapy
Lateral Epicondylitis
By Sath Segran
Outline of presentation • What is Lateral Epicondylitis • Anatomy • Epidemiology • Aetiology • Definitions • Symptoms and presentation • Assessment of Lateral Epicondylitis • Goals of Treatment • Available treatments • Outcome measures • Conclusion
What is Lateral Epicondylitis? • Also known as Tennis Elbow
• First used in 1883
• Most common Upper Extremity Tendonitis
• Overuse phenomenon of the wrist extensor muscles during repetitive upper extremity motions.
Pathological changes occurring at the common extensor tendon origin which attaches to the lateral epicondyle.
Muscles involved
• Number one culprit = ECRB
• ECRB has a small origin
• Vulnerable to shearing stress during all movements of the forearm.
• Changes can also occur at the Common Extensor tendon origin, EDC and ECRL.
Epidemiology • 1:1 male to female
• 30-50 years old
• Tennis players = 5%
• Majority are work related injuries
Repetitive movements of the wrist and forearm
into supination /pronation
Micro trauma/
tears to the tendon at
the common extensor
origin
Microtearing stimulates
inflammation
Repetitive micro
trauma leads to
incomplete healing
Tendon degeneration
Aetiology
Tendon Degeneration
• This tendon degeneration is characterized as angiofibroblastic hyperplasia.
Definitions
• Tendonitis : Acute inflammatory response to injury of a tendon that produces the classical signs of heat, swelling and pain.
• Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon.
Definitions Tendinosis= The term Tendinosis has been used to describe the histopathologic findings identified in Tennis Elbow. The findings included : •Absence of inflammatory infiltrates and tenocyte •Fibroblast hyperplasia – Collagen synthesisation •Endothelial cell hyperplasia •Disorganised collagen •Cell necrosis •Calcification
Hand Works Occupational Therapy
• Pain over the lateral epicondyle of the humerus or during movements: – gripping, resisted wrist extension, supination,
digital extension and wrist radial deviation. • May present with referred pain. • Reduced grip strength with elbow extended • Mild stages: Symptoms will develop after completion
of an activity. • Severe stages: Symptoms will occur with minimal
activity such as brushing teeth and shaking hands.
Symptoms/Clinical presentation
• Initial Interview
– Patient’s history on symptoms.
– Previous Treatment
– Work duties
– Patient’s hobby and interest
Assessment
• Wrist AROM: Secondary to pain, ROM may be limited in wrist extension or flexion and elbow extension.
• Grip strength: Patient is instructed to squeeze the handle to the point where the pain starts and then stop.
– In elbow flexion/extension
Clinical Assessment
Coven’s test:
I. Examiner’s thumb stabilizes the client’s elbow at the lateral epicondyle.
II. With forearm pronated, the client makes a fist and then actively extends and radially deviates- with examiner resisting this motion.
Positive: Severe sudden pain in the area of the lateral epicondyle.
Mill’s tennis elbow test • Originally described as a manipulation maneuver,
but can be used as a clinical test.
I. Examiner palpates the the lateral epicondyle.
II.Elbow pronated, the examiner fully flexes the wrist while moving the elbow from flexion to extension.
Positive: Pain at Lateral Epicondyle.
*Test should not be used on patients with significant muscular pain in the region.
Resisted Middle Finger Extension Test
• A positive test is pain with resisted middle finger.
• May elicit pain due to the extensor digitorum sharing a common tendon with the ECRB.
Pain on palpation over the common extensor tendon origin.
• Patient Rated Tennis Elbow Evaluation
• Easy to use
• 15 Questions
• 2 subscales: Pain and Function.
• High test-retest reliability.
Assessment
Assessment/Questionnaire
• Disability of the Arm, Shoulder and Hand:
– Self-report questionnaire
– Measures physical function and symptoms
– Scored out of 100
– Higher score indicating a greater level of disability
• Visual analogue scale
Assessment/Questionnaire
These two written assessment are useful:
• It allows clinician to quickly assess pain and function in patients with LE.
• Identify jobs/tasks that could be changed to decrease pain.
• Occupation focused.
Imaging • Determines the severity of injury.
• Can show thickening of the ECRB tendon and degenerative tendinosis.
• Demonstrates increased signal intensity of the origin of the ECRB.
MRI Findings
Goals of Treatment
• Reduce pain
• Reduce inflammation (for acute conditions)
• Regain muscle strength and AROM
• Return to normal ADL and Occupation
Treatment Options • Little evidence out there
• More than 40 types of available management.
• Occupational Therapy key treatment’s:
– Educating patient regarding their injury.
– Ergonomic counselling
– Activity modifications
– Other lifestyle changes to reduce aggravating activities.
Example of Activity Modifications • Avoid lifting with palm turn down.
Hand turned up is better.
• Avoid lifting with a straight elbow. Maintain a bent elbow and keep item close to body when lifting.
Orthotic Intervention
• Can be used in the acute phase. • Can be a custom made or prefabricated.
Purpose of splinting: Unload and rest muscles to promote tendon recovery.
Significant reduction in electrical activity with wrist in
extension during lifting activities.
Counter- force brace • Prevents full muscular expansion • Applied distal to ECRB origin • Provides a compressive force • Significant reduction in ECRB and EDC muscle
force • Creates a secondary origin of the extensor
tendons • Thus unloading the true origin at the Lateral
Epicondyle.
Hand Works Occupational Therapy
Kinesio Tape
• Provides increased low-threshold excitement to somatosensory receptors, thereby increasing somatosensory input to CNS.
• Applied on a pronated arm, with wrist flexed.
• Not stretching the tape, apply from the origin to the insertion of ECRB.
• K-tape is believed to have therapeutic benefits:
– Gather fascia to align the tissue in its desired position
– Lift the skin over areas of inflammation, pain and oedema.
– Decrease pressure over the lymphatic channels that provide a path for the removal of exudates.
Eccentric Exercises
• Remodelling at the
musculotendinous junction.
• Increase fibroblast activity
• Facilitate tendon remodelling and healing.
• Evidence suggests that exercise programs can reduce pain, but the improvement in grip strength is still unclear.
Myofascial Release • Low load pressure and stretch to a muscle unit.
• Pressure is applied on restricted fascia.
• Using thumb to slowly sink into fascia, contacting the restricted fascia.
• Fascial restrictions undue tension in the other parts of the body due to fascial continuity.
Myofascial Release • Resulting in stress on structures that
are enveloped, divided, or supported by fascia.
• By restoring length, pressure can be relieved on pain sensitive structures.
• Significantly more effective than a placebo treatment.
Laser treatment • Widespread but controversial treatment.
• Not carried out by Occupational Therapist.
• Produces clinically meaningful improvements in a variety of soft tissue injuries.
• Alteration at cellular function occurs in absence of significant heating in cells after irradiation.
Acupuncture
• Treatment of musculoskeletal conditions in Western countries.
• Thought to confer an analgesic effect
• By increasing the release of b-endorphins in the lumbar spine.
Acupuncture • Overriding of the pain stimulus by the biochemical
lines of acupuncture in the transmitting process of the CNS.
• Significant longer duration of pain relief compared to a placebo treatment.
• Also not carried out by OT’s however they are some who perform dry needling.
Non- streroidal anti-inflammatory drugs
• Proven to relief pain
• Temporary solution
• No literature evidence on long term benefits
Corticosteroid Injections
• Greater perception of benefit at 4
weeks than receiving oral NSAIDs
• Short term benefits in:
-Pain reduction
-Grip strength
Long term effectiveness and advantages over other conservative management are still uncertain.
Medical Management
Medical Management cont. Autologous blood injection • May trigger the inflammatory cascade and initiate
healing.
No significant differences in pain, grip strength and general improvement between ABI and placebo.
Platelet Rich Plasma Injection
• Slightly similar to the ABI.
• Difference = Blood is placed in a centrifuge.
• Platelets are then selectively removed and used for injection.
Platelet Rich Plasma Injection cont. • A greater concentration of platelets delivered
into the damaged body part
• Platelets play a significant role in the repair and regeneration of connective tissue.
No scientific research documenting this benefit at the moment
• Option ONLY after 6 to 12 months of conservative management.
• 8% will require surgery. • Excision of abnormal tissue
within the CETO, release and/or reattachment of the tendon
• Still no consensus on which operative procedure offers the best results.
Surgical Management
Due to the lack of methodological sound studies, researchers have been unable to identify a single treatment that has provided significant improvements for patients with Lateral Epicondylitis.
Key points:
• LE is usually not an inflammatory condition, it involves tendinosis and tendon degeneration.
• Imperative to provide patient education on appropriate lifting techniques and other activity modifications to prevent exacerbation and re-injury.
• Our role is to facilitate healing, increase or maintain patient’s function and return patients to their daily occupations.
Conclusion
Questions?
References • Ajimsha, M. S., Chithra, S., & Thulasyammal, R. P. (2012). Effectiveness of Myofascial Release in the Management of Lateral
Epicondylitis in Computer Professionals. Archives of physical medicine and rehabilitation, 93(4), 604-609. • Blanchette, M.-A., & Normand, M. C. (2011). Augmented Soft Tissue Mobilization vs Natural History in the Treatment of Lateral
Epicondylitis: A Pilot Study. Journal of Manipulative and Physiological Therapeutics, 34(2), 123-130. doi: 10.1016/j.jmpt.2010.12.001
• Coleman, B., Quinlan, J. F., & Matheson, J. A. (2010). Surgical treatment for lateral epicondylitis: A long-term follow-up of results. Journal of Shoulder and Elbow Surgery, 19(3), 363-367. doi: 10.1016/j.jse.2009.09.008
• Derebery, V. J., Devenport, J. N., Giang, G. M., & Fogarty, W. T. (2005). The Effects of Splinting on Outcomes for Epicondylitis. Archives of physical medicine and rehabilitation, 86(6), 1081-1088. doi: 10.1016/j.apmr.2004.11.029
• Dorf, E. R., Chhabra, A. B., Golish, S. R., McGinty, J. L., & Pannunzio, M. E. (2007). Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis. The Journal of Hand Surgery, 32(6), 882-886. doi: 10.1016/j.jhsa.2007.04.010
• Greco, S., Nellans, K. W., & Levine, W. N. (2009). Lateral Epicondylitis: Open Versus Arthroscopic. Operative Techniques in Orthopaedics, 19(4), 228-234. doi: 10.1053/j.oto.2009.09.005
• Green Sally, Buchbinder Rachelle, Barnsley Les, Hall Stephen, White Millicent, Smidt Nynke, & Assendelft Willem Jj. Acupuncture for lateral elbow pain. Cochrane Database of Systematic Reviews.
• Greenfield, C., & Webster, V. (2002). Chronic Lateral Epicondylitis: Survey of current practice in the outpatient departments in Scotland. Physiotherapy, 88(10), 578-594. doi: 10.1016/s0031-9406(05)60510-x
• Hong, Q. N., Durand, M.-J., & Loisel, P. (2004). Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine, 71(5), 369-373. doi: 10.1016/j.jbspin.2003.05.002
• Lattermann, C., Romeo, A. A., Anbari, A., Meininger, A. K., McCarty, L. P., Cole, B. J., & Cohen, M. S. (2010). Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. Journal of Shoulder and Elbow Surgery, 19(5), 651-656. doi: 10.1016/j.jse.2010.02.008
• Smidt, N., Assendelft, W. J. J., van der Windt, D. A. W. M., Hay, E. M., Buchbinder, R., & Bouter, L. M. (2002). Corticosteroid injections for lateral epicondylitis: a systematic review. Pain, 96(1–2), 23-40. doi: 10.1016/s0304-3959(01)00388-8
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• Trudel, D., Duley, J., Zastrow, I., Kerr, E. W., Davidson, R., & MacDermid, J. C. (2004). Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy, 17(2), 243-266. doi: 10.1197/j.jht.2004.02.011
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• Wuori, J. L., Overend, T. J., Kramer, J. F., & MacDermid, J. (1998). Strength and pain measures associated with lateral epicondylitis bracing. Archives of physical medicine and rehabilitation, 79(7), 832-837.