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Lateral Epicondylitis

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I - Upper Extremity Conditions. Pathological frequently diagnosed ... Fibromyalgia. II Lateral Epicondylitis 'Tennis Elbow' Most common overuse syndrome? ... – PowerPoint PPT presentation

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Title: Lateral Epicondylitis


1
Lateral Epicondylitis Custom Counter Force Brace
  • Presented by Robert Barbosa, D.O

2
I - Upper Extremity Conditions
  • Nonpathological
  • Aches and pains
  • Myofascial tightness
  • Strains
  • Benign exertional myalgia

3
I - Upper Extremity Conditions
  • Pathological frequently diagnosed disorders that
    may require either medical or surgical treatment
  • Sprains
  • Trigger digits
  • Cubital tunnel syndrome
  • Lateral epicondylitis
  • De Quervains

4
I - Upper Extremity Conditions
  • Pathological frequently diagnosed disorders that
    may require either medical or surgical treatment,
    cont…….
  • Carpal tunnel syndrome
  • Medial epicondylitis
  • Ganglia
  • Radial tunnel syndrome

5
I - Upper Extremity Conditions
  • Frequently misdiagnosed disorders
  • Unspecified tendinitis (ex. Intersection
    syndrome)
  • Reflex sympathetic dystrophy (complex regional
    pain syndrome)
  • Thoracic outlet syndrome
  • Cervical disc disease

6
I - Upper Extremity Conditions
  • Frequently misdiagnosed disorders, cont….
  • Cervical myofascial pain
  • Cervical spondylosis
  • Synovitis of the radiohumeral joint
  • Posterior interosseous nerve palsy

7
I - Upper Extremity Conditions
  • Subjective variable terms
  • Cumulative trauma disorder?
  • Repetitive motion disorder?
  • Overuse syndrome?
  • Work-related myoskeletal disorder
  • Fibromyalgia

8
II Lateral Epicondylitis
  • Tennis Elbow
  • Most common overuse syndrome?
  • Effects 1 - 3 of the population
  • Occurs in patients 40 to 60 years of age (over 35
    years)
  • In clinical practice, less than 5 is related to
    tennis. Tennis players get the problem because of
    backhand swing

9
II Lateral Epicondylitis
  • Tennis Elbow, cont….
  • Effects 50 of tennis players over 50 years of
    age
  • Occurs 10X more frequently than medial
    epicondylitis (golfers elbow)

10
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinitis implies an inflammatory condition and
    diagnosis should be limited to
  • Anatomical location
  • Specific muscle tendon unit
  • Symptoms provoked by mechanically stressing the
    involved muscle tendon units
  • Increase in temperature at the affected site
  • Tenderness to palpation
  • Swelling

11
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis
  • Aging equals degeneration
  • Degeneration means wear and tear in the tendon
  • Tendon becomes weaker than normal. It may also be
    caused by a decreased blood supply to the tendon,
    attritional changes (ex. rotator cuff Achilles
    tendon or patellar tendon)

12
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Degeneration in the same tendon. There is a loss
    of normal arrangement of the fibers of the tendon
  • Tendons are made up of collagen. The individual
    strands become jumbled due to degeneration
  • Other fibers lose elasticity, break and the
    tendon loses strength

13
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Healing process causes the tendons to become
    thickened as the scar tries to repair the tendon.
    This condition is called tendinosis
  • One theory on the cause of tendinosis is
  • Aging tendons sustain small tears
  • The tendon begins to heal, but when it is
    re-injured, the tendon has difficulty healing and
    is further scarred
  • Scar tissue is unable to reach maturity and
    develops a condition called angiofibroblastic
    degeneration

14
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Other causes and factors contributing to the
    lateral epicondylitis (tendinosis)
  • Decompensation from
  • Loss of strength secondary to decrease in
    conditioning. Patients now perform athletic-like
    activity at work that was tolerated at an early
    age (ex. Age 20), but now over 35 years of age
  • Increased body mass
  • Obesity
  • Increase in the of fat content

15
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Other causes and factors contributing to the
    lateral epicondylitis (tendinosis), cont…..
  • Smoking?
  • Poor nutritional habits
  • Poor body posture (ergonomic factors at workplace)

16
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Scope of the problem
  • The Bureau of Labor Statistics reported 73,195
    repetitive motion injuries, including tendinosis
    and carpal tunnel syndrome in private industry in
    1999
  • That translates to 1 in every 1,250 full-time
    workers
  • The AFL-CIO stated that 1.8 million suffer from
    repetitive motion injuries on the job each year
    (this included all back injuries)

17
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Tendinosis, cont…..
  • Scope of the problem, cont…..
  • The true figure lies somewhere between that
    reported by the Bureau of Labor Statistics and
    the AFL-CIO
  • The division with the most repetitive injuries
    was manufacturing. The most common occurrence was
    in assemblers
  • Interestingly enough, women sustain only 33 of
    the total injuries. They sustain 65 of the total
    tendinosis and carpal tunnel syndrome injuries

18
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Diagnosis of lateral epicondylitis (tendinosis)
  • Pain over the lateral elbow with a gradual onset
  • Maximum discomfort at the extensor carpi radialis
    brevis less commonly over the extensor carpi
    radialis longus rare over the extensor digitorum
    communis and rarely over the extensor carpi
    ulnaris

19
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20
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Diagnosis of lateral epicondylitis (tendinosis),
    cont…..
  • History
  • Aching pain and elbow pain over the lateral
    epicondyle with increased activity
  • Simple activities increase pain lifting a cup or
    coffee or gallon of milk
  • Pain may be present at night
  • Symptoms are typically unilateral

21
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22
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Diagnosis of lateral epicondylitis (tendinosis),
    cont…..
  • Exam
  • Pain is increased with resisted extension with
    the elbow in full extension and resisted
    extension of the wrist with pain being reproduced
    directly at the origin of the extensor carpi
    radialis brevis
  • Pain increased with resisted extension of the
    middle finger (middle finger sign)
  • Pain is increased with palpation over the lateral
    epicondylar area, generally at the origin of the
    extensor carpi radialis brevis

23
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Diagnosis of lateral epicondylitis (tendinosis),
    cont…..
  • Exam, cont…..
  • Pain increases with resisted supination at the
    origin of the extensor carpi radialis brevis
  • Decreased hand grip is noted by Jamar readings
  • X-rays are generally normal. A CT arthrogram may
    be of some benefit if one suspects a tear fo the
    lateral collateral ligament in conjunction with
    pathology of the lateral epicondylar area. An MRI
    also may be of some benefit since it will
    demonstrate evidence of degeneration

24
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Diagnosis of lateral epicondylitis (tendinosis),
    cont…..
  • Exam, cont…..
  • EMG to rule out any other nerve problems, such as
    a cervical radiculopathy or nerve compression
    syndrome, such as posterior interosseous nerve
    syndrome
  • Laboratory tests of no help

25
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment
  • In the majority of patients, it is a
    self-limiting problem generally treated by a
    primary care physician or by the patient
    themselves
  • Counterforce bracing plus rest and modifying
    their work and consideration can be given to
    utilizing oral nonsteroids

26
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Physical therapy to include numerous modalities
  • Ultrasound
  • Phonophoresis
  • Acupuncture?
  • Wait and see program. Treat the patient
    symptomatically and just instruct them in
    ergonomic use of their elbow

27
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Modalities, cont…..
  • Exercise
  • Isometric
  • Eccentric
  • Concentric?
  • Ice Massage
  • Heat
  • Electromuscle stimulation
  • Laser?

28
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Modalities, cont…..
  • Sonocur Machine. This is an extracorporeal
    ultrasound device (outside the body), where the
    ultrasound is 100X the normal
  • This was approved by the FDA in July of 2002
  • Treatments once weekly X 3 weeks. Treatment takes
    about 8-10 minutes. May take 6-8 weeks
    post-treatment to see the best results, according
    to the manufacturer
  • A German study done on lateral epicondylitis
    noted no difference between shockwave therapy and
    placebo treatment for tennis elbow

29
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30
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Modalities, cont…..
  • Sonocur Machine, cont…..
  • An Australian study done by treating palmer
    fascitis also demonstrated no difference between
    placebo and shockwave treatment
  • Average cost for treatment is between 1,000 and
    3,000 in the United States

31
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Nonsteroidals
  • Why do they help if it is not an inflammatory
    condition?
  • It may help to control pain
  • The mechanism of action is not known
    specifically, but may inhibit cyclo-oxygenase
    (COX) activity and prostaglandin synthesis

32
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Cortisone injections
  • Unknown why injection of steroid helps. It may be
    that steroid reduces pain with similar action to
    the nonsteroidals

33
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34
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Manipulation of elbow
  • Results, in my experience, are extremely variable
    and appear to give short term relief in the
    majority of patients
  • Several patients that I have treated with
    manipulation have returned to regular work
    without further treatment

35
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Future treatment
  • Stem cell injection
  • I have personally used blood taken from the
    patient and injected it into the elbow. Have not
    reproduced the results reported in the published
    literature

36
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Several interesting papers combine treatment
  • Utilizing injections Naprosyn and placebo
    utilizing Vitamin C
  • 164 patients were divided into three groups. The
    first group was given a steroid injection. The
    second group was given Naprosyn. The third group
    was given Vitamin C
  • At four weeks, the injection group did much
    better with 92 improvement in their pain,
    Naprosyn was at 57 and placebo was at 50

37
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Several interesting papers combine treatment
  • Utilizing injections, cont…..
  • At six months, the Naproxine group and the
    placebo group were similar in their outcome
  • At 12 months, there appeared to be no difference
    in the outcome of all patients

38
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Another study combined treatment with therapy and
    brace
  • A group was divided into three
  • The first group was treated with therapy
  • The second group was treated with a brace
  • The third group was treated with therapy and a
    brace

39
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Another study combined treatment with therapy and
    brace, cont….
  • After analysis of the results, no statistical
    difference was noted with the treatment of the
    brace and therapy or the brace or the therapy
    alone. Short-term, it was noted that the brace
    and therapy was best to decrease pain. Patients
    were also most pleased with the brace that the
    brace with therapy. They did not like the idea of
    having to go to therapy and have that prolonged
    waiting period. Also, the brace appeared to
    benefit them in that the patient was able to
    perform most activities with the brace in place
    and reduce the overall pain pattern

40
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Surgical Treatment
  • A select group of patients
  • All patients were selected who failed all forms
    of non-operative treatment
  • Minimum of six months duration with the diagnosis
    of lateral epicondylitis
  • The technique is simple. Release of the origin of
    the extensor carpi radialis brevis at the level
    of the origin at the epicondylar area. The
    patients rarely underwent release of the extensor
    carpi radialis longus and extensor digitorum
    communis

41
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Surgical Treatment, cont…..
  • 62 patients were reviewed. Average age was from
    32 to 50 years of age. There were 40 females and
    24 males
  • Several had radial tunnel syndrome release in
    conjunction with the lateral epicondylar release.
    Three of the females had bilateral release. One
    female had both medial and lateral epicondylar
    release.
  • One failure. In essence, the patient was unable
    to progress with her elbow due to her concomitant
    injury to her rotator cuff. The rotator cuff
    injury started during the course of vigorous
    physical therapy

42
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Surgical Treatment, cont…..
  • Two patients required they be operated on twice
  • Re-operation occurred one year after the first
    surgery
  • Post-operative treatment consisted of cast
    immobilization for one week
  • The cast was then removed and active range of
    motion was started
  • The patient was then placed into a structured
    exercise program under the care of the therapist,
    and the patient was progressed to a strengthening
    exercise program with the goal of returning him
    back to a regular work status

43
III Is Tennis Elbow a Tendinitis or Tendinosis?
  • Treatment, cont…..
  • Surgical Treatment, cont…..
  • Poor Outcome? On two patients…
  • One developed rotator cuff symptoms
  • The second patient has not returned to regular
    work since second surgery in April 2004
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