Lateral Epicondyle Tendinopathy Toolkit: Section B - Clinical Assessment: Difference between revisions

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'''Lifestyle'''
'''Lifestyle'''


* Smoking – current and past history
* Smoking – current and past history<ref name=":2" />


'''Active Group –''' Overuse from repetitive and forceful recreational and occupational activity.
'''Active Group –''' Overuse from repetitive and forceful recreational and occupational activity.
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* Only 10% of LET are associated with racquet sport.<ref>Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.</ref>
* Only 10% of LET are associated with racquet sport.<ref>Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.</ref>


'''Occupation:'''
'''Occupation'''<ref name=":2" />''':'''


* Repetition, Ergonomics, Tools (forceful grip, vibration)  
* Repetition, Ergonomics, Tools (forceful grip, vibration)  
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=== Subjective Assessment ===
=== Subjective Assessment ===
'''History'''
* Lateral elbow pain which is related to over use.
'''Subjective symptoms'''
* Symptoms increases during activity.
* Extensor muscles weakness and reduced grip strength
* Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.
'''Biopsychological factors'''


* '''Subjective symptoms'''
* Persistent LET pain may involve behavioral and psychosocial factors contributing to nervous system sensitivity (peripheral and central). There is evidence that psychological variables (catastrophization, signs of distress) can increase LET symptoms. In patients with psychosocial drivers, treatment programs should consider providing pain neuroscience education, as well as addressing cognitive and behavioral barriers.
** Symptoms increases during activity.
** Extensor muscles weakness and reduced grip strength
** Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.       
* '''History'''
** Lateral elbow pain which is related to over use.
* '''Biopsychological factors'''
** It may involve behavioral or psychosocial factors which in turn contributes to neural sensitivity.
** The evidence states that psychological involvement can increase the symptoms of tennis elbow.<ref>Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.</ref>
* '''Objective Signs'''


'''Objective Signs'''
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!Upper quadrant Screening Exam
 
!Contributing Factors
 
!Upper quadrant examination
!Factors of contribution
|-
|-
|Cervical
|Cervical
|Neuropathy, Radiculopathy
|Radiculopathy, Neuropathy
|-
|-
|Shoulder
|Shoulder
|Weakness of rotator cuff, Neuopathic tender points, Myofascial trigger points
|Rotator cuff weakness MTrP, Neuropathic tender points
|-
|-
|Elbow , Forearm
|Elbow , Forearm
|Weak grip strengh, Neuropathic tender points, Myofascial trigger points
|Grip weakness MTrP, Neuropathic tender points
|-
|-
|Neurodynamics
|Abnormal Neural Tension(Neurodynamics)
|Radial bias
|Peripheral nerve – Radial bias
|}
|}


Revision as of 10:50, 4 November 2022

Original Editor - Kim Jackson uploaded for the BC Tendinopathy Task Force Dr. Joseph Anthony, Paul Blazey, Dr. Allison Ezzat, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates and Alison Hoens

Top Contributors - Nupur Smit Shah, Cindy John-Chu, Kim Jackson, Rishika Babburu and Vidya Acharya  


Introduction[edit | edit source]

The purpose of this document is to summarize the clinical assessment of the patient diagnosed with lateral epicondyle tendinopathy.

Initially , the assessment consist of history, objective and subjective examination, chief complains in order to confirm the diagnosis. The tool kit will even include differential diagnosis, the process of identifying causes/risk factors of lateral epicondyle tendinopathy and functional examination.

Risk factors[edit | edit source]

Non-modifiable risk factors[edit | edit source]

These are the factors which cannot be changed.

Age Typically occurs > 40 years [1]

Gender Weak evidence for female >male[1][2]

Metabolic disorder Generally, metabolic factors are weakly associated with LET compared to mechanical overuse (modifiable) factors.[3]

  • Diabetes[1][3]/Hyperglycemia[3]
  • Cardiovascular disease risk factors[4]

Familial Disorder Genetics – variants in connective tissue health more likely to be susceptible to LET[5]

Systemic Inflammatory Disease

Spondyloarthropathy (SpA) is generally associated with enthesis disorders, more commonly in the load bearing tendons of lower limbs compared to upper limb.

SpA (SCREEND’EM)9 – acronym for a useful screening tool to assist in identifying individuals that would benefit from further medical investigation for SpA.

Modifiable risk factors[edit | edit source]

These are the factors which can be worked on.

Lifestyle

  • Smoking – current and past history[1]

Active Group – Overuse from repetitive and forceful recreational and occupational activity.

Sport:

  • Grip strength weakness
  • Equipment (eg improper tennis grip size)
  • Technique (eg poor backhand swing).
  • Only 10% of LET are associated with racquet sport.[6]

Occupation[1]:

  • Repetition, Ergonomics, Tools (forceful grip, vibration)

Inactive/Sedentary Group

  • More likely to have overuse response to unaccustomed loads from ADLs, or decline in tendon load capacity (age, activity, or lifestyle factors). Previous shoulder injury Rotator cuff weakness ipsilateral side

Assessment[edit | edit source]

Things to look out during the assessment of tennis elbow patient is complete history, subjective examination, objective examination, biopsychological factors and differential diagnosis.

Subjective Assessment[edit | edit source]

History

  • Lateral elbow pain which is related to over use.

Subjective symptoms

  • Symptoms increases during activity.
  • Extensor muscles weakness and reduced grip strength
  • Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.

Biopsychological factors

  • Persistent LET pain may involve behavioral and psychosocial factors contributing to nervous system sensitivity (peripheral and central). There is evidence that psychological variables (catastrophization, signs of distress) can increase LET symptoms. In patients with psychosocial drivers, treatment programs should consider providing pain neuroscience education, as well as addressing cognitive and behavioral barriers.

Objective Signs

  • Local Examination
    • Palpate the Extensor carpi Radialis Brevis tendon insertion at lateral epicondyle.
  • Special tests :
    • Mills test[7]
    • Maudsley's test[7]
    • Cozen test[7]
    • Thomsen test[8]
Upper quadrant Screening Exam Contributing Factors
Cervical Radiculopathy, Neuropathy
Shoulder Rotator cuff weakness MTrP, Neuropathic tender points
Elbow , Forearm Grip weakness MTrP, Neuropathic tender points
Abnormal Neural Tension(Neurodynamics) Peripheral nerve – Radial bias

Differential Diagnosis[edit | edit source]

Articular[edit | edit source]

  • Radiocapitular arthritis
  • Intraarticular synovial plica of radial capitular joint
  • Osteochondritis Dessicans[9]

Instability[edit | edit source]

  • Posterolateral rotatory instability because of laxity of collateral ligaments[9]

Neural[edit | edit source]

  • Abnormal neuro dynamics[10]
  • Cervical nerve bias
  • Radial tunnel entrapment of posterior interosseus nerve[11]

Imaging[edit | edit source]

  • It is done only when the conservative management is not working on the patient.
  • Ultrasound and MRI are usually preferred
  • It helps to diagnose the extra and intra articular conditions.[12]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Epicondylitis [Internet]. Epicondylitis - Symptoms, diagnosis and treatment | BMJ Best Practice US. [cited 2022Nov4]. Available from: https://bestpractice.bmj.com/topics/en-us/978
  2. ↑ Shiri R, et al. Prevalence and determinants of lateral and medial epicondylitis: A population study. Amer Jour Epidemiology. (2006). 164(11):1065-1074. DOI:10.1093/aje/kwj325
  3. ↑ 3.0 3.1 3.2 Park HB, Gwark JY, Im JH, Na JB. Factors associated with lateral epicondylitis of the elbow. Orthopaedic Journal of Sports Medicine. 2021 May 12;9(5):23259671211007734.
  4. ↑ Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, Shishido H, Fukuhara S, Kikuchi S, Konno S. Chronic hyperglycemia increases the risk of lateral epicondylitis: the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS). Springerplus. 2015 Dec;4(1):1-9.
  5. ↑ Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
  6. ↑ Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
  7. ↑ 7.0 7.1 7.2 Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. British journal of sports medicine. 2017 May 1;51(9):743-8.
  8. ↑ Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, Tsepis E, Gioftsos G. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)–A systematic review. Journal of Hand Therapy. 2021 Feb 27.
  9. ↑ 9.0 9.1 British Medical Jpurnal.Available from https://www.jhandtherapy.org/article/S0894-1130(21)00039-9/fulltext.(accessed 29th October 2022)
  10. ↑ Hegmann KT, Thiese MS, Kapellusch J, Merryweather A, Bao S, Silverstein B, Wood EM, Kendall R, Foster J, Drury DL, Garg A. Association between epicondylitis and cardiovascular risk factors in pooled occupational cohorts. BMC musculoskeletal disorders. 2017 Dec;18(1):1-0.
  11. ↑ The Knee Resource .Available from https://thekneeresource.com/wp-content/uploads/2018/12/Screendem-P-KIrwan-Spondyloarthropathy.pdf. Accessed on 29th October 2022.
  12. ↑ Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, Tsepis E, Gioftsos G. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)–A systematic review. Journal of Hand Therapy. 2021 Feb 27.
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