HighVelocity Thrust for Traumatic Onset Lateral Elbow Pain

1
High-Velocity Thrust for Traumatic Onset Lateral
Elbow Pain

• Manipulation of the elbow in the acute
• pain case
• Brett Windsor, PT, OCS, FAAOMPT
• February 15, 2006
• Boston Massachusetts

2
Lateral Elbow Pain

• Recognized for more than a century
• Cyriax
• Primary Impairment
• Grip strength
• Pain
• Epidemiology
• Signs and Symptoms

3
Lateral Elbow Pain

• Signs and symptoms
• Pain
• Palpation
• Mechanism of Injury
• Usually chronic overuse
• Acute traumatic cases do occur

4
Acute Traumatic Cases The Abducted Ulna

• Fryette (1980)
• Described an abducted ulna lesion
• Abduction at elbow
• Medial separation
• Radial head shunted distally
• Olecranon shifts medially (abducted ulna)
• Mechanical Distortion
• Fall onto outstretched elbow
• Fixed hand..valgus force

5
Acute Traumatic Cases The Abducted Ulna -
Effects

• UCL increases tension
• Forces hand into ulna deviation
• Muscle length changes
• Increased Tension in ECRB
• Causative factor in lateral elbow pain
• Friden (1994, 1999, 1999)
• Lee (1986)
• Increased tension ulna nerve
• Par aesthesia
• Lower motor neuron signs

6
Acute Traumatic Cases The Abducted Ulna -
Resolution

• Reverse Mechanical distortion
• Initial force valgus?
• Restore with a varus force?

7
Manipulation in the elbow?

• Fryette
• Manipulative varus technique for chronic cases of
  abducted ulna
• Cyriax
• Initially championed use of varus technique.
• Later abandoned in favor of Mills maneuver
• Kusher and Reid
• Kaltenborn technique
• Stoddard
• Fixation over knee.momentum into adduction

8
Manipulation in the elbow?

• Mills manipulation (Kaufman, 2000)
• Positive outcomes in lateral elbow pain of
  non-traumatic origin
• Struijs et al (2003)
• Repetitive thrusts to the wrist
• Sustained lateral glides
• Vincenzino 2001
• Paungmali 2003
• No literature found on manipulation in cases of
  traumatic onset elbow pain.

9
Abducted Ulna - Findings

• Subjective
• Traumatic onset of pain
• Usually fall onto outstretched hand
• Pain immediate, sharp and constant
• Pain localized to the lateral elbow
• May extend into common extensor origin
• May or may not develop paraesthesia
• Initial pain decreases after initial injury, may
  or may not become chronic

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Abducted Ulna - Findings

• Subjective
• Aggravating factors
• Elbow extension
• Wrist extension
• Gripping
• Imaging
• Radiological examination negative initially
• Radial head

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Findings

• Objective
• Carrying angle
• Upper Quadrant Screen negative
• Decreased active elbow extension and supination
• Decreased active wrist extension and radial
  deviation

• Pain with UCL (valgus) test
• RCL test (varus) negative
• Strong and painful elbow and wrist extensors

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Findings

• Extension and adduction combined movement
  demonstrated hard (pathological) end feel
• Passive Accessory testing
• Decreased posterior, lateral humeroulnar glides
• Pathomechanical end feel lateral glide
• Decreased anteromedial superior RU joint glide
• Decreased palmar radocarpal glide

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Findings

• Palpation
• TOP at Tenoperiosteal junction of the ECRB origin
• Minimal TOP over medial collateral ligament
• No effusion
• No trophic changes
• Tuning fork negative

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Findings

• RU Ligament Stress Tests
• Valgus testing
• Field and Atcheck
• Anterior bundle of medial collateral ligament
  released prior to noticeable joint opening.
• Best visualization at 60-75 deg flexion
• Lee
• Full extension/30 degrees flexion
• Significant valgus opening.false positive

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RU Ligament Stress Tests

• ODriscoll
• Moving valgus stress test
• Constant moderate valgus force to fully flexed
  elbow.quickly extend
• Positive test pain at MCL at max 70-120 deg
  flexion
• Found to be highly sensitive versus arthroscopy
• Varus testing/Shear testing
• ?????? Data ??????

16
Elbow ligament stress tests

• Test grade for pain stability
• Ulnar collateral
• Ant band
• Post band

Medial epicondyle
Post. band
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Elbow ligament stress tests

• Test grade for pain stability
• Radial (lateral) collateral
• Lateral ulnar band

lateral epicondyle
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Assessment Clinical Reasoning

• No red flags
• No neurological findings
• No fracture
• No cervical involvement
• No indication of shoulder or wrist involvement
• No upper limb tension

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Assessment Clinical Reasoning

• Traumatic onset
• Symptoms localized to the elbow
• Carrying angle
• Movement and accessory findings consistent with
  abducted ulna

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Treatment

• High Velocity, low amplitude thrust in a varus
  direction to the ulnohumeral joint
• Indications
• One joint, one direction movement restriction
• Contraindications
• Fracture, neurological involvement, significant
  muscle tear, ligament disruption, frank
  instability

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Lateral Glide technique
22
Elbow Tennis elbow manip 2
23
Elbow Mills per Cyriax
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Discussion

• Lack of Scientific evidence supporting PT Rx of
  lateral elbow pain
• No data to prove existence of Abducted ulna
  lesion
• Theoretical based on knowledge of how we think
  the elbow moves
• No data validating assessment
• No data validating treatment
• This case shows a positive outcome

25
Discussion

• How did we get a positive outcome?
• Test clusters
• Look at cases individually
• Not all cases are chronic
• Manipulation is effective in some cases

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Further Study

• Can we identify the lesion?
• Why is manipulation effective in the elbow?
• Is the manipulation effective?
• What would have happened to this patient if this
  treatment had not been performed?

27
References

• Cyriax J. Textbook of Orthopaedics Medicine
  Volume One Diagnosis of Soft Tissue Lesions. 8th
  ed. London, England BailliereTindall, 1982 176.
• Cyriax J. Pathology and treatment of tennis
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• Vicenzino B. Lateral epicondylalgia A
  musculoskeletal physiotherapy perspective. Man
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• Labelle H, Guibert R, Joncas J, et al. Lack of
  scientific evidence for the treatment of lateral
  epicondylitis of the elbow An attempted
  meta-analysis. J Bone Joint Surg Br
  199274646-651.
• Dimberg L. The prevalence and causation of tennis
  elbow (lateral humeral epicondylitis) in a
  population of workers in an engineering industry.
  Ergonomics 1987 30573-579.
• Vincenzino B, Wright A. Effects of a novel
  manipulative physiotherapy technique. Man Ther
  1995130-35.
• Fryette H. Principles of Osteopathic Technique.
  Colorado Springs, CO Academy of Osteopathy, 1980

28
References

• Friden J, Liber RL. Physiologic consequences of
  surgical lengthening of extensor carpi radialis
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• Friden J, Liber RL, Ljung BO. Sarcomere length
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• Lee D. Tennis elbow A manual therapists
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29
References

• Stoddard J. Manipulation of the elbow joint.
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• Abbott JH, Patla CE, Jensen RH. The initial
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• Vincenzino B, Paungmali A, Buratowski S, Wright
  A. Specific manipulative therapy treatment for
  chronic lateral epicondylitis produces uniquely
  characteristic hypoalgesia. Man Ther
  20016205-212
• Paungmali A, OLeary S, Souvlis T, Vincenzino B.
  Hypoalgesic and sympathoexcitatory effects of
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  epicondylalgia. Phys Ther 200383374-383.
• Kaufman RI. Conservative chiropractic care of
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• Struijs PA, Damen PJ, Bakker EW, et al.
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30
References

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