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Download evaluation and treatment of lateral elbow pain
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EVALUATION AND TREATMENT OF LATERAL ELBOW PAIN A MOVEMENT IMPAIRMENT BASED APPROACH Brenda Boucher, PT, PhD, CHT, OCS, FAAOMPT Pieter Kroon, PT, DPT, OCS, FAAOMPT Objectives 1. Describe the relationship between movement impairment syndromes and pain in the lateral elbow. 2. Demonstrate clinical examination skills necessary for treating patients that present with lateral elbow pain. 3. Demonstrate appropriate intervention strategies based on current evidence for patients with complaints of pain and/or dysfunction of the lateral elbow. 4. Select appropriate home exercises that match the objectives identified in managing patients with lateral elbow pain and dysfunction. Financial Disclosure There are no financial disclosures in this presentation Lateral elbow pain: difficult to treat • Reticent to treatment • Seemingly similar complaints do not respond well to the same treatment • Regional interdependence: many elbow problems are caused by movement impairments in wrist and shoulder • Different structures reproduce similar complaints Guiding Principles • Painful conditions of the upper extremity are often a response to faulty mechanics and overuse. • Faulty alignment, inadequate muscle length/strength/motor recruitment, and impaired movement can result in cumulative stresses that lead to pain and dysfunction. • This presentation will focus on examining the upper extremity with emphasis on alignment, tissue status, and movement patterns to identify factors that contribute to lateral elbow pain. • Intervention will emphasize manual techniques and specific exercises to address impairments and correct faulty movement patterns. APTA Vision Statement for the Physical Therapy Profession (beyond 2020) Transforming society by optimizing movement to improve the human experience. The physical therapist will be responsible for evaluating and managing an individual’s movement system across the lifespan to promote optimal development; diagnose impairments, activity limitations, and participation restrictions; and provide interventions targeted at preventing or ameliorating activity limitations and participation restrictions. The movement system is the core of physical therapist practice, education, and research. Movement System Impairment * Faulty alignment *Impaired movement • Underlying Cause * Sustained postures * Repeated movements • Provocative factors * Cumulative stress * Pain & dysfunction • End Result Faulty Alignment Repeated Use Faulty alignment Repeated use Example of long-term effects of faulty alignment/movement Neer’s Staged Classification • Stage I: Edema & Hemorrhage < 25, reversible, conservative treatment • Stage II: Fibrosis & Tendinopathy 25-40, recurrent pain, consider SAD • Stage III: Bone Spurs & Tendon Rupture >40, progressive disability, sx repair Movement System Impairment * Faulty alignment *Impaired movement Underlying causes . . . further up, or down the chain Examination “When I pick up a a cup of coffee.” Patient Body Diagram & Subjective Report “When I try to open a jar” “When I swing a bat or racquet.” “When I play sports.” Dull ache, Can be sharp “When I use hand tools such as a hammer or screwdriver.” Differential Diagnosis • ECRB tendonopathy • Radial nerve ANT • Radiohumeral joint dysfunction Impaired Movement Pattern Extension with Radial Deviation Syndrome •Dominant ECRB & ECRL •Dominant thumb & digit extensors Muscle Imbalance Imbalance Patterns Forearm, Wrist & Hand Strong & Dominant •ECRL & ECRB •EPL, EPB, APL •ED, EDM Muscle Imbalance Imbalance Patterns Forearm, Wrist & Hand Weak •ECU •Lumbricales •Interossei Muscle Length Muscle Length Restrictions Forearm, Wrist & Digits Short •Radial wrist extensors •Digit extensors (extrinsic) •Thumb extensors Joint Accessory Mobility Joint Mobility Forearm & Wrist Hypomobility/Hypermobility •Radio-ulnar joints (radial head) •Ulno-triquetral joint •Scapholuno-radial joint •1st CMC joint Example: long-term effects of faulty alignment/movement Diagnosis Referrals Radial-dorsal-sided wrist pain: • Lateral elbow pain • Radial tunnel syndrome • Intersection syndrome • DeQuervain’s syndrome Ulnar-sided wrist pain: • TFCC dysfunction FAULTY ALIGNMENT – IMPAIRED MOVEMENT Non-weight bearing assessment Weight bearing assessment Alignment Assessment Front View Clavicle alignment - optimal •Lateral clavicle approximately 15-20° higher than medial clavicle Humerus alignment - optimal •Cubital fossa oriented anteriorly •Palmar hand oriented medially Alignment Assessment Back View Scapula alignment - optimal • • • • • Superior angle aligned with T2 Inferior angle aligned with T7 Axillary border vertically aligned Axillary border 3” lateral to SP 10° anterior tilt relative to thorax (sagittal plane) Humerus alignment - optimal •Olecranon process oriented posteriorly Alignment Assessment Side View Humerus alignment - optimal • • Humeral head positioned anteriorly </= 30% to acromion Proximal humerus vertically aligned with distal humerus Alignment Assessment Functional weight-bearing Scapula, Elbow, Forearm, Wrist, Palm •Scapula stability loss •Elbow hyperextension •Forearm hyperpronation •Wrist radial compression/ulnar distraction •Palm arch collapse Courtesy Brandi Smith-Young, PT Board Certified Orthopaedic Specialist Fellow, American Academy Orthopaedic Manual Physical Therapists Alignment Assessment Functional weight-bearing Cervical Spine, Scapula, Humerus, Wrist, Thumb •Cervical flexion •Scapula depression, abduction, downward rotation •Humeral anterior glide, medial rotation •Wrist extension/radial deviation •Thumb extension EXAMINATION Forearm, Wrist, Hand Special Tests: there are few well designed diagnostic accuracy studies assessing the elbow for pathology Resisted Tennis Elbow Test • Patient seated • Patient extends the wrist against a force applied by the examiner • Positive test is reproduction of pain along the lateral epicondyle Reliability Sensitivity Specificity +LR -LR NT NT NA NT NA No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test Cook C and Hegedus E. Orthopedic Physical Examination Tests, an Evidence Based Approach 2nd edition Pearson, NJ 2013 Passive Tennis Elbow Test • Patient seated, elbow placed in extension • Examiner passively pronates the forearm and flexes wrist to endrange • Positive test is reproduction of pain along the lateral epicondyle Reliability Sensitivity Specificity +LR -LR NT NT NT NA NA No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test Cook C and Hegedus E. Orthopedic Physical Examination Tests, an Evidence Based Approach 2nd edition Pearson, NJ 2013 Maudsley’s Test • Examiner resists 3rd digit extension, stressing the ECRB • Positive test is reproduction of pain along the lateral epicondyle Reliability Sensitivity Specificity +LR -LR NT NT NT NA NA No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test Cook C and Hegedus E. Orthopedic Physical Examination Tests, an Evidence Based Approach 2nd edition Pearson, NJ 2013 Physical Examination Muscle Strength Assessment Forearm, Wrist & Hand Weak •ECU •Lumbricales ECU Lumbricales Physical Examination Muscle Length Assessment Forearm, Wrist & Digits Short •Radial wrist extensors •Extrinsic digit extensors •Thumb extensors & abductor ECRB & ECRL EPL, EPB, APL ED, EI, EDM Physical Examination Joint Mobility Assessment Forearm & Wrist Hypomobility/Hypermobility •Humeroulnar joint •Radiohumeral joint •Ulno-triquetral joint •Scapholunate-radial joint •1st CMC joint Ulnotriquetral jt Scapholunoradial jt (flex & ext) DRUJ 1st CMC jt PRUJ (radial head mobility) Physical Examination Palpation to Palpation Tenderness •ECRB tendon insertion •ECRL tendon insertion •Extensor digitorum tendon insertion •Radiohumeral joint line •Radial nerve Physical Examination Palpation ECRL: Place tip of thumb just superior to lateral epicondyle against anterior aspect supracondylar ridge ECRB: Elbow 90 degrees flexion, forearm supinated. Thumb on edge lateral epicondyle. Move thumb slightly medial. For proximal tendon, flex elbow 45 degrees, fully pronate. In this position the tendon runs over radial head. Intervention Address primary impairments, movement dysfunction and provide external support as indicated. Local & Proximal Manipulations - Local • Radiohumeral joint Intervention Manipulations - Distal • Ulno-triquitral thrust • Scapholuno-radial thrust • 1st CMC 1st CMC Ulno-triquitral thrust Scapholuno-radial thrust Intervention Manipulations - Proximal • Upper thoracic • Cervical-thoracic T Spine • Glenohumeral Mobilization Scapula GH joint lateral CT junction GH joint posterior Intervention Small finger placement Neutral fist position NMT - Distal •Wrist extension strength training (ECU emphasis) Avoid excessive activity of: radial extensors thumb ext/abd extensor digiti minimi Intervention NMT - Local •Lumbrical hold •Lumbrical hold with movement Correct Incorrect Lumbrical hold with active wrist flexion-extension Thumb extensors & abductor Intervention Lengthen •Radial wrist extensors •Extrinsic digit extensors •Thumb extensors & abductor Wrist radial extensors & thumb extensors/abductors Radial wrist extensors Hand-heel rock Intervention Shoulder NMT • • • Hand-heel rock Standing pivot prone Shoulder-wrist dissociation Standing pivot prone Shoulder-wrist dissociation Thank you!
