7. • Convex surface of bone fits in concave surface of
2nd bone
• Unixlateral like a door hinge
• Examples:
- Knee, elbow, ankle, interphalangeal joints
• Movements produced:
- flexion
- extension
- hyperextension
8. • Rounded surface of bone articulates with
the ring formed by the 2nd bone & ligament
• Monoaxial since it only allows rotation
around longitudinal axis
• Examples:
- proximal radioulnar joint
- supination
- pronation
- atlanto-axial joint
- Turning head side to side “no”
31. Definition
• • “A pathologic condition of the common
• extensor muscles at their origin on the
• lateral humeral epicondyle. Epicondylitis
• suggests an inflammation at one of the
• epicondyles of the elbow.”
32.
33. Lateral Epicondylitis (tennis elbow)
• Pathology
– 30 – 50 years old
– Repetitive micro-trauma
– Chronic tear in the origin of the extensor
carpi radialis brevis
34. Lateral Epicondylitis (tennis elbow)
• Mechanism of Injury
– Overuse syndrome caused by repeated
forceful wrist and finger movements
– Tennis players
– Prolonged and rapid activities
37. Common Complaints
• Diffuse pain
• • Morning stiffness
• • Occasional night pain
• • Dropping of objects/ weak grip strength
• • Pain w/ palpation of lat. epicondyle
• • Pain w/active or resisted extension
• • Pain w/ grasping objects with the effected
hand
38. Symptoms
Lateral Arm / elbow /forearm pain
Increased with use(holding/picking up items)
If popping / clicking present, consider
problem within joint(loose bodies,
osteochondral lesions )
45. Special Tests
• Cozen’s Sign
– Elbow flexed; Forearm pronated
– Wrist extension and radial deviation against
resistance
– Positive when pain at lateral epicondyle
• Mill’s Test
– While palpating the lateral epicondyle
– The examiner pronates the patient’s forearm, flexes
the wrist, and extends the elbow
– Positive when pain at lateral epicondyle or lack of
full elbow extension
46.
47. Special Tests
• Grip Strength Measures
• Middle Finger Test
– Resistance just distal to PIP joint of the
middle finger with forearm in pronation
– Positive in tennis elbow with pain at lateral
epicondyle
50. 50
Spurling sign
• . Axial compression of
the spine and rotation
to the ipsilateral side of
symptoms reproduces
or worsens cervical
radiculopathy.
• Pain on the side of
rotation is usually
indicative of foraminal
stenosis and nerve root
irritation.
51. Radial Tunnel Syndrome
• Compression of
radial nerve under
extensors in forearm
• Deep, lateral
forearm pain, often
at night
• No sensory
component
• Often confused
with lateral
epicondylitis (they
co-exist 5% of the
time) pain is more
distal
52. Radial Tunnel Syndrome: Diagnosis
• Extended middle finger
test
• Pain with resisted
supination
• Electrodiagnostic tests
not helpful
• Injection of local
anesthetic into radial
tunnel completely
relieves symptoms and
is diagnostic
59. Management
• Key points
• It is a self limiting condition – no-one ever has it
forever.
• 90% of people are better after 1 year.
• Physiotherapy, activity modification and simple
exercises will control the symptoms in most people.
• Injections are reserved for very resistant cases.
• An operation is only considered as a last resort.
60. Management
• Non-operative
– successful in 95%
• Operative
– only after failed non-operative Rx
– usually successful
65. Physiotherapy
• At 6 weeks:
– better than ‘watch and wait’
– worse than steroid injection
• Long-term:
– better than steroid injection
– same as ‘watch and wait’
66.
67. Brace / elbow clasp
• Between 12 and 24 weeks:
– Pain reduction
– Improved functionality
– Improved pain-free grip strength
• No better at 12 months
68. Physical Therapy
• Ultrasound
– Limited low quality evidence
– Used as an adjunct; not independently
• Pulsed ultrasound to break up scar
tissue, promote healing, and increase
blood flow in the area
69. Manual Techniques
• Deep Transverse Friction Massage
– No benefit when combined with concurrent
physiotherapy modalities when compared
to control group
• Manipulation of the Wrist
– Scaphoid Thrust Manipulation
• Cervicothoracic Spine Manipulation
– Non-thrust manipulation and traction of
cervical spine
– Lateral Cervical Glide Technique
70. Steroid injection
• Good short-term relief for 6 weeks
• Poorer outcome in the longer term than
– watch and wait
– physio
71. Injections
• Short-term benefits (2-6 weeks)
• Greater perception of benefits (pain
reduction, global improvement, grip
strength) but did not persist long term
• Several studies have found that oral
NSAIDS and PT have greater benefits
than corticosteroid injections at both 6
weeks and 6 month follow-ups
72. Platelet Rich Plasma
Therapy
• A 2006 study looking at the treatment of lateral
epicondylitis with platelet rich plasma therapy
– Over 90% of the patients were completely satisfied
with their results and did not opt for surgery in the
weeks and months following a single treatment
• Eight weeks after the treatment, the platelet-rich
plasma patients noted 60% improvement in their visual
analog pain scores versus 16% improvement in control
patients (P =.001).
100. Lateral Epicondylar Release
Return to Work Protocol
• Week 0 – 1: off work
• Week 1 – 4: one-handed work
• Week 4 – 12: light duty work
• Week 12: regular duty work
101.
102.
103.
104.
105.
106.
107.
108. Arthroscopy
• 70% satisfactory to excellent
• 473 cases
– 4 deep infection
– 33 prolonged drainage
– 12 transient nerve palsies
Arthroscopic tennis elbow release. Kalainov D et al. Techniques in Hand and Upper Extremity
Surgery. 2007;11(1):2-7
• Arthroscopy leaves residual tendinopathy
– Gross and histological
– Results in poorer outcomes
Lateral Epicondylitis: In Vivo Assessment of Arthroscopic Debridement and Correlation With
Patient Outcomes. Cummins CA. Am J Sports Med Sep 2006, 34(9):1486
109.
110.
111. Conclusions
• Nirschl Mini techniques less risk, lower costs, best
success
• Tendinosis surgery is not a release operation
• Tendinosis surgery is resection of pain producing
tissue
• Direct vision clearly identifies pathological tissue
• No harm to normal tissue – rapid rehab
• Can do combined procedures (medial and lateral)
when indicated
112. Management summery
• Activity modification,stretching,tennis elbow strap
and cock up wrist splint
• NSAIDs
• Therapy (Iontophoresis)
• Corticosteroid injection
• Offer PRP injection in some individuals
• Surgery:
Open technique
Arthroscopic technique when intra-articular pathology suspected
or when more rapid recovery needed
Perform concomitant radial tunnel decompression in patients
with both conditions
Depending on the severity and number of small tendon injuries that build up, the ECRB may not be able to fully heal. Nirschl defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. The stages are:
1. Inflammatory changes that are reversible
2. Nonreversible pathologic changes to origin of the ECRB muscle
3. Rupture of ECRB muscle origin
4. Secondary changes such as fibrosis or calcification
Fedorczyk
Sensitivity and Specificity have not been determined
63 patients randomised
US:
Has thermal and mechanical effects on target tissue leading to increased metabolism, circulation, extensibility of connective tissue, and tissue regeneration
Provides modest pain reduction over 1-3 months
Combining US with deep transverse friction massage or corticosteroids is no better than US alone
Lundeberg et al. reported no significant difference in healing between groups; no difference between pulsed/continuous
Binder et al. reported significantly enhanced recovery in US group vs. placebo group
D’Vaz et al. found that very low intensity pulsed US using a home unit device to promote fracture healing was equivalent to placebo in reducing pain
*different parameters and stages of healing
CAT- used 6 studies
Low quality RCT 2b on Sackett level of evidence scale
DTFM:
Thought to realign abnormal collagen fiber structure, break up adhesions and scar tissue, and increase healing
Insufficient Evidence
Johnson et al.
Brosseau et al. – low sample size, lack of studies available, inconsistent pain scales, combination of several modalities
Wrist Manip. (Struijs et al.)
31 patients with symptoms ranging from 6 wks-6 mos.; 9 treatments over 6-week pd.
Random assignment manipulation group & therapy group
Manipulation group: wrist extended dorsally and scaphoid is manipulated ventrally
Therapy group: pulsed US, friction massage, HEP
Treatment group exhibited significantly less pain (VAS) but success rates of 2 groups were not significantly different
Cervicothoracic Spine Manip. (Gunn and Milbrandt)
50 patients, 5.3 weeks, non randomized study, low level of evidence
Many patients had unsuccessful treatment in past including surgery
Results = 86% patients reported a good or satisfactory improvement following treatment (persisted at 6 month f/u)
Similar Study (Cleland et al.)
10 patients, randomly assigned, 10 treatments over 6 weeks
Results = showed improvements in pain-free grip force and DASH but not on pain rating scale
Lateral Cervical Glide (Elvey/Vicenzino et al.)
Patient is supine and with head supported and involved UE placed in neurodynamic test position purported to preferentially stress or load the radial nerve; therapist applies lateral cervical glide toward contra-lateral side of symptoms
Results = Initially, improved ROM, reduced pain and increased pain threshold
F/u Study, significant improvements in pressure pain threshold and increase in pain-free grip force
*Long term f/u is needed
Corticosteroid Injections:
Uncertain long-term effectiveness and advantages over other conservative treatments
For short term relief, injections may be more effective than oral NSAIDS in decreasing pain and increasing function but for long-term relief, oral NSAIDS and PT have greater benefits
Johnson et al.
Mishra et al. 2006
Cohort Study
140 patients; all initially given a standardized physical therapy protocol and a variety of other nonoperative treatments
All patients were considering surgery
Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients
Final follow-up (range 12-38 months), the PRP patients reported 93% reduction in pain compared with before the treatment and did not opt for surgery following their treatment
60% of pts withdrew from study or sought other treatment after 8-wk period
