Mentoring Minutes

Mentoring Minutes: "Tennis Elbow"

REFERENCES & NOTES:

Cohen M, da Rocha Motta Filho G. LATERAL EPICONDYLITIS OF THE ELBOW. Revista Brasileira de Ortopedia. 2012;47(4):414-420. doi:10.1016/S2255-4971(15)30121-X

- 1-3% of population; word suggest inflammatory process, but histological analysis on tissue fails to show any inflammatory process, but more a form of tendinosis with fibroblastic and vascular response (angiofibroblastic degeneration)

- even tough called tennis elbow, only 10% of patients with dx play tennis, 4th -5th decades of length,

-most common is origin of tendon ECRB, with overload mechanism.    

- In general, the pain arises through activities that involve active extension or passive flexion of the wrist with the elbow extended.

- Pain located in the lateral epicondyle and at the origin of the extensor musculature

- The test known as Cozen's test is done with the elbow flexed at 90° and with the forearm in pronation. The patient is asked to perform active extension of the wrist against the resistance imposed by the examiner

- Mill's test, is performed with the patient's hand closed, the wrist in dorsiflexion and the elbow extended. The examiner then forces the wrist into flexion and the patient is instructed to resist this movement.

- pain control is the main objective of the initial treatment, but not splinting.

-main treatments include correcting technique , and modifications to limit gripping (using a larger handle with tools and sporting, and straps for heavy lifting.

-  some short term benefits for pain include NSAIDS and a strap brace, but not long term. And US and laser only have shown placebo effect benefits.

Buchanan BK, Hughes J. Tennis Elbow (Lateral Epicondylitis) [Updated 2017 May 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431092/

Cullinane FL et al., Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clinical Rehabilitation, 2014. 28: 3-19

- Twelve studies met the inclusion criteria. Three were deemed ‘high’ quality, seven were ‘medium’ quality, and two were ‘low’ quality. Eight of the studies were randomized trials investigating a total of 334 subjects. Following treatment, all groups inclusive of eccentric exercise reported decreased pain and improved function and grip strength from baseline.

- elbow ext, wrist ext, forearm on table, opp side holds for 6-8 sec; another article used TB on foot, 4 sec lowering

Randal GlaserJiten B. BhattAndre ChavezEmmanuel Yung. (2016) Management of Lateral Epicondylalgia Targeting Scapular Muscle Power Deficits: A Case series. Journal of Hand Therapy 29:2, e5-e6. 
 

Joseph M. DayHeather BushArthur J. NitzTim L. Uhl. (2015) Scapular Muscle Performance in Individuals With Lateral Epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy 45:5, 414-424. 
Online publication date: 30-Apr-2015.

- Twenty-eight patients with symptomatic LE and 28 controls matched by age and sex were recruited to participate in the study. Strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) was measured with a handheld dynamometer. A scapular isometric muscle endurance task was performed in prone. Changes in muscle thickness of the SA and LT were measured with ultrasound imaging. 

- The involved side of the group with LE had significantly lower values for MT strength (P = .031), SA strength (P<.001), LT strength (P = .006), endurance (P = .003), and change in SA thickness (P = .028) when compared to the corresponding limb of the control group. 

 

 

Mentoring Minutes: Cubital Tunnel Syndrome

PART 1:

PART 2:

REFERENCES & NOTES:

- Wojewnik B, Bindra R. Cubital tunnel syndrome — Review of current literature on causes, diagnosis and treatment. Journal of Hand and Microsurgery. 2009;1(2):76-81. doi:10.1007/s12593-009-0020-9.

- most don’t need surgery, unless traumatic injury to elbow structure

- SOL: bone spur, ganglions, callus,

- Froment sign: weakness of adductor pollicus muscle, pt given a piece of paper and holds it together between the thumb and index finger (key pinch) with flexion of the thumb IP joint (because weakness of add poll muscle.

-Positive flexion sign at the elbow with supination and wrist extension reproducing the symptoms up to 60 seconds and ulnar nerve subluxation with elbow flexion can also be seen.

- treatment: braces, to limit flexion

- Cutts S. Cubital tunnel syndrome. Postgraduate Medical Journal. 2007;83(975):28-31. doi:10.1136/pgmj.2006.047456.

- 2nd most common peripheral nerve entrapment

- The cubital tunnel is formed by the cubital tunnel retinaculum which straddles a gap of about 4 mm between the medial epicondyle and the olecranon

- intraneural pressure associated with elbow flexion are believed to be key issues

-shape of the tunnel changes from an oval to an ellipse with elbow flexion. narrows the canal by 55%. , this compression can hinder blood flow;

-Elbow flexion, wrist extension and shoulder abduction increases intraneural pressure by six times.

- persons at risk_ holding prolonged flexion, prolonged position (tools, phones), pitchers at late cocking phase stresses nerve and tend to have mild boney changes at the elbow;

- 4th and 5th fingers parasthesia, or motor changes (clawing or abduction of little fingers

- elbow flexion test, tinnel, ULTT ulnar

-treatments: avoid prolonged flexion, nerve mobility,


 

-Cent Eur Neurosurg. 2011 May;72(2):90-8. doi: 10.1055/s-0031-1271800. Epub 2011 May 4.

Cubital tunnel syndrome - a review and management guidelines.

Assmus H1, Antoniadis GBischoff CHoffmann RMartini AKPreissler PScheglmann KSchwerdtfeger KWessels KDWüstner-Hofmann M.

-J Hand Ther. 2014 Jul-Sep;27(3):192-9; quiz 200. doi: 10.1016/j.jht.2014.02.003. Epub 2014 Feb 27.

Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain.

Day JM1, Willoughby J2, Pitts DG2, McCallum M2, Foister R2, Uhl TL3.

- J Manipulative Physiol Ther. 2010 Feb;33(2):156-63. doi: 10.1016/j.jmpt.2009.12.001.

Neurodynamic mobilization in the conservative treatment of cubital tunnel syndrome: long-term follow-up of 7 cases.

Oskay D1, Meriç AKirdi NFirat TAyhan CLeblebicioğlu G.

Mentoring Minutes: Cubital Tunnel Syndrome

Cubital Tunnel Syndrome:Part 1

Cubital Tunnel Syndrome: Part 2

REFERENCES & notes: 

Wojewnik B, Bindra R. Cubital tunnel syndrome — Review of current literature on causes, diagnosis and treatment. Journal of Hand and Microsurgery. 2009;1(2):76-81. doi:10.1007/s12593-009-0020-9.

- Most don’t need surgery, unless traumatic injury to elbow structure

- SOL: bone spur, ganglions, callus,

- Froment sign: weakness of adductor pollicus muscle, pt given a piece of paper and holds it together between the thumb and index finger (key pinch) with flexion of the thumb IP joint (because weakness of add poll muscle.

-Positive flexion sign at the elbow with supination and wrist extension reproducing the symptoms up to 60 seconds and ulnar nerve subluxation with elbow flexion can also be seen.

- Treatment: braces, to limit flexion

Cutts S. Cubital tunnel syndrome. Postgraduate Medical Journal. 2007;83(975):28-31. doi:10.1136/pgmj.2006.047456.

 - 2nd most common peripheral nerve entrapment

- The cubital tunnel is formed by the cubital tunnel retinaculum which straddles a gap of about 4 mm between the medial epicondyle and the olecranon

- intraneural pressure associated with elbow flexion are believed to be key issues

-shape of the tunnel changes from an oval to an ellipse with elbow flexion. narrows the canal by 55%. , this compression can hinder blood flow;

-Elbow flexion, wrist extension and shoulder abduction increases intraneural pressure by six times.

- persons at risk_ holding prolonged flexion, prolonged position (tools, phones), pitchers at late cocking phase stresses nerve and tend to have mild boney changes at the elbow;

- 4th and 5th fingers parasthesia, or motor changes (clawing or abduction of little fingers

- elbow flexion test, tinnel, ULTT ulnar

-treatments: avoid prolonged flexion, nerve mobility,

-Cent Eur Neurosurg. 2011 May;72(2):90-8. doi: 10.1055/s-0031-1271800. Epub 2011 May 4.

Cubital tunnel syndrome - a review and management guidelines.

Assmus H1, Antoniadis GBischoff CHoffmann RMartini AKPreissler PScheglmann KSchwerdtfeger KWessels KDWüstner-Hofmann M.

-J Hand Ther. 2014 Jul-Sep;27(3):192-9; quiz 200. doi: 10.1016/j.jht.2014.02.003. Epub 2014 Feb 27.

Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain.

Day JM1, Willoughby J2, Pitts DG2, McCallum M2, Foister R2, Uhl TL3.

- J Manipulative Physiol Ther. 2010 Feb;33(2):156-63. doi: 10.1016/j.jmpt.2009.12.001.

Neurodynamic mobilization in the conservative treatment of cubital tunnel syndrome: long-term follow-up of 7 cases.

Oskay D1, Meriç AKirdi NFirat TAyhan CLeblebicioğlu G.

 

Mentoring Minutes: Elbow Stiffness

References & Notes

Filh GM, Galvão MV. POST-TRAUMATIC STIFFNESS OF THE ELBOW. Revista Brasileira de Ortopedia. 2010;45(4):347-354. doi:10.1016/S2255-4971(15)30380-3.

- stiff elbows presented a thin capsule with a disorganized collagen matrix, increased inflammatory cytokine levels and fibroblastic infiltration, thus characterizing a fibrotic and inflammatory condition

- combination of loss of extension associated with loss of forearm supination represents a severe limitation on certain activities 

- functional arc of the elbow is defined as a range of flexion-extension motion of 30° to 130° and pronosupination of 50° to –50. (10)On the other hand, loss of 50% of the mobility of the elbow represents a functional loss of 80% of limb function. Likewise, contracture of flexion greater than 45° gives rise to severe dysfunction regarding the capacity to position the hand in space

-treatment: mobs, stretches, and splints

Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Rehabilitation of the Overhead Athlete’s Elbow. Sports Health. 2012;4(5):404-414. doi:10.1177/1941738112455006.

- if the patient continues to have difficulty achieving full extension using ROM and mobilization techniques, a low-load, long-duration (LLLD) stretch may be performed to produce a deformation (creep) of the collagen tissue, resulting in tissue elongation.

- The patient lies supine with a towel roll or a foam pad placed under the distal brachium to act as a cushion and fulcrum. Light-resistance exercise tubing is applied to the wrist of the patient and secured to the table or a dumbbell on the ground (Figure 1). The patient is instructed to relax as much as possible for 10 to 15 minutes per treatment. The resistance applied should enable the patient to stretch for the entire duration without pain or muscle spasm. This technique is intended to impart a low load during a long-duration stretch. Patients are instructed to perform the LLLD stretches several times per day, totaling at least 60 minutes of total end range time. We typically recommend a 15-minute stretch, 4 times per day. This program has been referred to as a TERT program (total end range time)

- Open pack:

            - HU joint: 70 deg flexion, 10 deg supination

                        - Distraction treatment

            - HJ joint: Full ext and supination

                        -Radial treaction treatment

                        - Post glide for ext

                        - Ant glide for flexion

            - PRU joint: 70 deg flexion, 35 deg supination

                        - post glide for pronation

                        - Ant glide for supination

A prospective randomized control Trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. JBJS. 2012:94 694-700