Lateral Epicondylitis dnbid lecture 2012

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Lateral Epicondylitis and Physiotherapy:

Lateral Epicondylitis and Physiotherapy Dr. Dibyendunarayan Bid [PT] Senior Lecturer Sarvajanik College of Physiotherapy, Rampura, Surat

Lat Epicondylitis:

Lat Epicondylitis Lat epicondylitis, or tennis elbow, is the most common overuse injury of the elbow and is observed up to 10 times more frequently than medial epicondylitis. Lat epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity. Early conservative management is the key to symptom resolution, which eventually allows return to vocational and avocational activities without restriction.

Pathophysiology :

Pathophysiology Lat epicondylitis is a result of inflammation, or enthesitis , at the muscular origin of the extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon, with subsequent fibrosis and, ultimately, tissue failure. Less commonly , the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved.

Epidemiology :

Epidemiology Sex The condition affects men and women with equal frequency. Age lat epicondylitis most often occurs between the third and fifth decades of life.

History :

History The patient usually describes a gradual onset of lat elbow pain, which is characterized as follows: The aching pain generally increases with activity. The patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk. Pain may be present at night. Symptoms are typically unilateral.

Physical Examination :

Physical Examination Most commonly, the examination reveals localized tenderness to palpation just distal and anterior to the lat epicondyle. Other symptoms include the following: Pain increases with resisted wrist extension, especially with the elbow in extension. The patient may have a weakened grip on the affected side. Elbow range of motion (ROM) is typically normal. In chronic, refractory cases, be sure to fully assess shoulder integrity and scapular stability. Weakness or instability of the scapular stabilizers may perpetuate lat epicondylitis by leading to overuse of the wrist extensors.

Causes :

Causes Lat epicondylitis is an overuse syndrome generally caused by repetitive use of the wrist extensors or sustained power gripping. Lat epicondylitis can be associated with an imbalance secondary to muscle weakness and soft-tissue inflexibility.

Differentials :

Differentials Cervical Disc Disease Cervical Myofascial Pain Cervical Radiculopathy Cervical Spondylosis Fibromyalgia Medial Epicondylitis

Laboratory Studies :

Laboratory Studies Laboratory studies generally are not indicated for the diagnosis of lat epicondylitis.

Imaging Studies :

Imaging Studies Imaging studies usually are not necessary, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with ultrasonography .

Staging of Lat Epicondylitis:

Staging of Lat Epicondylitis Nirschl defined the following progressive stages: Stage 1 - Inflammatory changes that are reversible Stage 2 - Nonreversible pathologic changes to origin of the ECRB muscle Stage 3 - Rupture of ECRB muscle origin Stage 4 - Secondary changes such as fibrosis or calcification

Physiotherapy Assessment:

Physiotherapy Assessment Cozen’s test Mill’s test Resisted middle finger extension Assess muscle power of wrist extensors Assess mobility of cervical spine especially C5C6 Assess mobility of wrist joint Assess power of scapular muscles.

Rehabilitation Program :

Rehabilitation Program

Physical Therapy :

Physical Therapy Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasonography , and iontophoresis . Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain. The use of iontophoresis with corticosteroids is not supported.

Physical Therapy :

Physical Therapy A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching.

PowerPoint Presentation:

Counter-force Brace

Physical Therapy :

Physical Therapy Deep-tissue and friction massage help to release underlying adhesions and promote improved circulation to the area. In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation / supination should be achieved prior to proceeding with a strengthening program.

PowerPoint Presentation:

Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors. Kinesio -taping is also gaining popularity.

Physical Therapy :

Physical Therapy In chronic refractory cases of lat epicondylitis, scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.

Occupational Therapy :

Occupational Therapy As activities are resumed, the patient's vocational and avocational pursuits must be considered. Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required. Gradual resumption of activities is recommended to improve tolerance and prevent recurrence.

Kinesio taping :

Kinesio taping Kinesio taping is a unique form of taping that encourages tissue healing while not limiting movement or athletic performance. The tape is applied along injured muscles or across joints to encourage lymphatic drainage, increase tissue sensation, and speed recovery.

Kinesio Taping Video:

Kinesio Taping Video

Mulligan Taping video:

Mulligan Taping video

Exercises for Lat Epicondylitis:

Exercises for Lat Epicondylitis

Surgical Intervention :

Surgical Intervention For cases of refractory lat epicondylitis, surgical resection of the lat extensor aponeurosis might be considered.

Surgical Intervention :

Surgical Intervention Most surgical procedures involve debridement of the diseased tissue of the extensor carpi radialis brevis (ECRB) muscle with decortication of the lat epicondyle. This procedure has been performed through open, percutaneous , and arthroscopic approaches. While the classic open approach provides excellent reproducible results, the mentioned minimally invasive approaches are reported to allow earlier rehabilitation and resumption of activities.

Postoperative Details :

Postoperative Details Surgical treatment of lat epicondylitis is an outpatient surgical procedure. If the open approach is used, the elbow is usually protected initially with a splint or brace at 90°.

Follow-up :

Follow-up Early motion in a brace may be initiated at 3-5 days after surgical treatment of lat epicondylitis, with strengthening exercises usually started by 3 weeks, depending on the patient's symptoms. Return to racquet sports can be expected by 4-6 months. Depending on the specific job requirements, patients can return to work in 6-12 weeks, although job modification or persistent use of a counterforce brace during work activities may be necessary.

Medical Therapy:

Medical Therapy The goal of drug treatment in cases of lat epicondylitis is pain control, in order to facilitate the performance of ADL. NSAIDs Corticosteroids Analgesics

Other Treatment :

Other Treatment Most lat epicondylitis is degenerative rather than inflammatory, and injecting steroid around a tendon can inhibit collagen repair; therefore, steroid injections should be used on a limited basis. Additionally, injecting a corticosteroid directly into a tendon can be deleterious. Nonetheless, steroid injections in some cases can bring about dramatic, albeit short-term, relief.

Other Treatment :

Other Treatment Platelet-rich plasma has been used to treat chronic epicondylitis and has been shown to be more efficacious than corticosteroid injection. Local anesthetics and botulinum toxin injection > not recommended. Other types of treatment have included acupuncture and extracorporeal shockwave therapy> not effective.

Complications :

Complications Aggressive surgical debridement for lat epicondylitis causes lat elbow instability. The proximity of the lat collateral ligaments and the annular ligament makes them susceptible to injury. In addition, when the arthroscopic technique is used, the radial nerve is at risk. Other complications include recurrence or incomplete relief of pain.

Deterrence/Prevention: :

Deterrence/Prevention: To avoid a recurrence of lat epicondylitis, the etiology of the condition must be considered. Job modifications may be necessary and may be facilitated by a job site evaluation. Investigation into avocational activities also is necessary, because contributing factors to this condition may be identified. In addition, adherence to a home exercise program is important in preventing a recurrence of lat epicondylitis.

Outcome and Prognosis :

Outcome and Prognosis Patients who present acutely (< 3 mo) generally respond well to treatment. Chronic cases that are refractory to treatment may take months to resolve. Surgical treatment of lat epicondylitis has yielded predictably favorable results, with approximately 85% of patients reporting complete pain relief. Some patients may have persistent symptoms despite surgical treatment, and these patients may benefit from a more aggressive debridement.

Patient Education :

Patient Education Education regarding: the proper use of tools, good body mechanics, and the importance of flexibility and strength of the involved musculature should be emphasized to the patient.

PowerPoint Presentation:

Lat Epicondylitis Protocol 1 Lat Epicondylitis Protocol 2 Lat epicondylitis rehabilitation

Thanks for your attention…..:

Thanks for your attention…..

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