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

• Struijs Peter Aa, Smidt Nynke, Arola H, van Dijk C N, Buchbinder Rachelle, & Assendelft Willem Jj. Orthotic devices for the treatment of tennis elbow. Cochrane Database of Systematic Reviews.

• 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

• Wolf, J. M., Ozer, K., Scott, F., Gordon, M. J. V., & Williams, A. E. (2011). Comparison of Autologous Blood, Corticosteroid, and Saline Injection in the Treatment of Lateral Epicondylitis: A Prospective, Randomized, Controlled Multicenter Study. The Journal of Hand Surgery, 36(8), 1269-1272. doi: 10.1016/j.jhsa.2011.05.014

• 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.