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Medial and lateral epicondylitis elbow presentation
- 1. Dr Manvir SinghSekhon 29/10/2024 MEDIAL EPICONDYLITIS
- 2. What is medialepicondylitis? • Medial epicondylitis is also known as golfer's elbow. • It's characterized by pain from the elbow to the wrist on the inside (medial side) of the elbow. • The pain is caused by damage to the tendons that bend the wrist toward the palm
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- 5. Epidemiology Demographics - Affects menand woman equally - Dominant extremity in > 75% of the cases - Ages 30’s – 60’s ,
- 6. Causes of medialepicondylitis ? Medial epicondylitis is caused by the excessive force used to bend the wrist toward the palm. This can happen when swinging a golf club or pitching a baseball. Other possible causes of medial epicondylitis include: • Serving with great force in tennis or using a spin serve • Weak shoulder and wrist muscles • Using a too tightly strung, too short, or too heavy tennis racket • Carrying a heavy suitcase • Chopping wood with an ax • Operating a chain saw • Frequent use of other hand tools on a continuous basis • jobs involving lifting >20kg, forceful grip, exposure to constant vibration at elbow (plumbers, carpenters, construction workers)
- 7. Symptoms? • The mostcommon symptom of medial epicondylitis is pain along the palm side of the forearm, from the elbow to the wrist, on the same side as the little finger. • The pain can be felt when bending the wrist toward the palm against resistance, or when squeezing a rubber ball. • Decreased grip strength. • Tingling in your hand. • Numbness in your hand.
- 8. Physical examination Passive Technique •Position: The patient can be seated or standing for this test. • Procedure: The therapist palpates the medial epicondyle and supports the elbow with one hand, while the other hand passively supinates the patient’s forearm and fully extends the elbow, wrist and fingers. • Interpretation: If sudden pain or discomfort is reproduced along the medial epicondylar region, the test is considered positive.
- 9. Imaging Radiographs • usually unremarkable •25% have calcification of CFT or UCL • can identify posterior-medial osteophytes or degenerative changes • stress radiography used in some centers for assessing valgus instability MRI • standard of care • evaluate concomitant pathology (e.g. UCL injury in overhead thrower) • unclear source of medial elbow pain , evaluate for loose bodies • rule out rupture of flexor pronator origin findings • tendinosis / tendon disruption of CFT • increased signal on T2 images • peritendinous edema • UCL or osteochondral injuries EMG/NCS • may be used to further evaluate for ulnar nerve compression if identified on history and physical • Angiofibroblastic hyperplasia, as described for lateral epicondylitis
- 10. Treatment SURGICAL VS NONSURGICAL
- 11. Non Surgical • rest,ice, activity modification (stop throwing x 6-12wks), PT (passive stretching), bracing, NSAIDS • indications • first line of treatment • prolonged trial of conservative management appropriate due to less predictable success of operative treatment (compared to lateral epicondylitis) • technique • counter-force bracing / kinesiology taping • ultrasound shown to be beneficial • multiple corticosteroid injections should be avoided extracorporeal shockwave therapy (ESWT) • no definitive recommendations at present • promotes angiogenesis, tendon healing, short term analgesia • corticosteroid injections into peritendinous tissue • acupuncture
- 13. Surgical open debridement ofPT/FCR, reattachment of flexor-pronator group • up to 6 months of nonoperative management that fails in a compliant patient • symptoms severe and affecting quality of life • clear diagnosis outcomes • good to excellent outcomes in 80% (less than lateral epicondylitis) • worse outcomes when ulnar nerve symptoms present pre-operatively • degree of ulnar neuropathy correlates directly with worse clinical outcome
- 14. Rehabilitation • short periodof immobilization x 1-2 weeks in sling • avoid volar flexion of wrist immediately postoperatively • ROM exercises after 2 weeks • strengthening at 6-8 weeks • return to sport at 3-6 months
- 15. Prevention • Strengthen forearmmuscles. Use light weights or squeeze a tennis ball. Even simple exercises can help your muscles absorb the energy of sudden physical stress. • Stretch before your activity. Walk or jog for a few minutes to warm up your muscles. Then do gentle stretches before you begin your game. • Fix your form. Whatever your sport, ask an instructor to check your form to avoid overload on muscles. • Use the right equipment. If you're using older golfing irons, consider upgrading to lighter graphite clubs. If you play tennis, make sure your racket fits you. A racket with a small grip or a heavy head may increase the risk of elbow problems. • Lift properly. When lifting anything — including free weights — keep your wrist rigid and stable to reduce the force to your elbow. • Know when to rest. Try not to overuse your elbow. At the first sign of elbow pain, take a break.
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- 18. Dr Manvir SinghSekhon 29/10/2024 LATERAL EPICONDYLITIS
- 19. What is LateralEpicondylitis? • Tennis elbow (lateral epicondylitis) is swelling of the tendons that bend your wrist backward away from your palm.
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- 22. Epidemiology Incidence • most commoncause for elbow symptoms in patients with elbow pain • affects 1-3% of adults annually • commonly in dominant arm Demographics • affects up to 50% of all tennis players risk factors • poor swing technique ,heavy racket ,incorrect grip size ,high string tension • common in laborers who utilize heavy tools • workers engaged in repetitive gripping or lifting tasks • most common between ages of 45 and 64 years old • men and women equally affected
- 23. Causes of LateralEpicondylitis • Caused by the force of the tennis racket hitting balls in the backhand position. Your forearm muscles, which attach to the outside of your elbow, may become sore from excessive strain. When making a backhand stroke in tennis, the tendons that roll over the end of your elbow can become damaged. Tennis elbow may be caused by: • Incorrect backhand stroke • Weak shoulder and wrist muscles • Using a tennis racket that is too tightly strung or too short • Other racquet sports, like racquetball or squash • Hitting the ball off center on the racket
- 24. • Many peoplewho suffer from tennis elbow don't play tennis. The problem can be caused by any repetitive movement. Other causes of tennis elbow include: • Painting with a brush or roller • Working a chainsaw • Frequent use of other hand tools on a regular basis • Using repeated hand motions in various types of work. Some examples are butchers, musicians, dentists, auto workers, and carpenters.
- 25. Lateral Epicondylitis Stages •Stage 1: injury is probably inflammatory, is not associated with pathologic alterations, and is likely to resolve. • Stage 2: injury is associated with pathologic alterations such as tendinosis or angiofibroblastic degeneration. It is this stage that is most commonly associated with sports related tendon injuries such as tennis elbow, and with overuse injuries in general. Within the tendon, there is a fibroblastic and vascular response (tendinosis) rather than an immune blood-cell response (inflammation). • Stage 3: injury is associated with pathologic changes (tendinosis) and complete structural failure (rupture). • Stage 4: injury exhibits the features of a stage 2 or 3 injury and is associated with other changes such as fibrosis, soft matrix calcification, and hard osseous calcification. The changes that are associated with a stage 4 injury may also be related to the use of cortisone.
- 26. Symptoms • At firstyou may have pain, burning, or an ache along the outside of your forearm and elbow. Over time, the pain gets worse. If you keep doing the activity that caused your condition, the pain may spread down to your wrist, even at rest. Pain may also persist when you place your arm and hand palm-down on a table, and then try to raise your hand against resistance. You may also feel pain when you try to lift and grip small objects, such as a coffee cup. A weak grip is another symptom of tennis elbow.
- 27. Physical Examination • Cozen’stest is also known as the resisted wrist extension test. The elbow is stabilised in 90° flexion. The therapist palpates the lateral epicondyle and the other hand of the therapist positions the patient’s hand into radial deviation and forearm pronation. Then the patient is asked to resist wrist extension. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle • Mill's Test: The patient is seated with the upper extremity relaxed at the side and the elbow extended. The examiner passively stretches the wrist in flexion and pronation. Pain at the lateral epicondyle or proximal musculotendinous junction of the wrist extensors is a positive
- 28. Imaging Radiographs • usually normaland very rarely change management • may reveal calcifications near the lateral epicondyle (up to half of patients) • may reveal signs of previous surgery MRI • not necessary for diagnosis • may be helpful to rule out other potential sources of pain if diagnosis is unclear • increased signal intensity at ECRB tendon origin may be seen (up to 90% of cases) • thickening or thinning • edema • tendon degeneration • findings are not associated with symptom severity and should not dictate management Ultrasonography • requires experienced operator (variable sensitivity/specificity) • most useful diagnostic tool in experienced operator hands • Extensor Carpi Radialis Brevis (ECRB) tendon appears thickened and hypoechoic
- 29. Treatment Nonoperative Activity modification, ice,NSAIDS, physical therapy, ultrasound • first line of treatment • may have short-term benefit, but increased risk of GI side effects • tennis modifications (slower playing surface, more flexible racquet, lower string tension, larger grip) • counter-force brace (strap) Steroid injections • controversial after an RCT compared steroids versus placebo and found equivalent pain, grip strength, and patient-reported outcomes. • may have detrimental effects on muscle and skin • physical therapy regimen
- 30. Non Surgical • outcomes •80-90% improve with nonoperative treatment at 1 year • only 2-4% eventually undergo surgical intervention • no nonoperative protocol has proven superior to observation or placebo
- 31. Surgical Release and debridementof ECRB origin Indications • if prolonged nonoperative (12 months) fails • clear diagnosis (isolated lateral epicondylitis) Technique -may be performed open or arthroscopic Contraindications • inadequate trial of nonsurgical treatment • patient noncompliance with the recommended nonsurgical treatment Outcomes • no difference in outcomes between open and arthroscopic procedures (patient satisfaction, return to work, and complications) • 90-100% of patients have improvements in symptoms, but up to 40% have persistent pain
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