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

No edit summary
No edit summary
Line 68: Line 68:
* Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.
* Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.
'''Biopsychological factors'''
'''Biopsychological factors'''
These factors includes the complex interaction of biological, psychological and social factors to understand health. The biological factors are brain damage/genetics, social factors are life traumas and stress and psychological is how the patient interprets life events.


* 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.<ref>Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.</ref>
* 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.<ref>Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.</ref>

Revision as of 11:26, 7 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 consists of history, objective and subjective examination, chief complaints in order to confirm the diagnosis. The toolkit will even include differential diagnosis, the process of identifying causes/risk factors of lateral epicondyle tendinopathy and functional examination.

Risk factors[edit | edit source]

Risk factors are the ones which increase the chances of developing this condition. There are two types of risk factors, modifiable and non modifiable.

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 limbs.

SpA (SCREEND’EM)[6] – 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 and measures can be taken to change them. They are the exposures /behavior's which lowers or increases the person's risk of lateral elbow epicondylitis.

Lifestyle

  • Smoking – current and past history[1]
  • Active Group – Overuse from repetitive and forceful recreational and occupational activity
    • Sport[1]
      • Grip strength weakness
      • Equipment (eg improper tennis grip size)
      • Technique (eg poor backhand swing)

Only 10% of LET are associated with racquet sport.[5]

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

These symptoms are perceptible only to the patient. Typical subjective symptom is pain.

  • 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

These factors includes the complex interaction of biological, psychological and social factors to understand health. The biological factors are brain damage/genetics, social factors are life traumas and stress and psychological is how the patient interprets life events.

  • 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.[7]

Objective Signs

  • Local Examination
    • Palpate the Extensor carpi Radialis Brevis tendon insertion at lateral epicondyle. May include ECRL + EDC insertion.
  • Special tests :
    • Mills test : Passive stretch of extensor group.
Technique. Start position : Shoulder neutral, elbow 90 degrees, forearm pronated, wrist fully flexed. Operator gradually passively extends elbow towards zero degrees, maintaining forearm pronation or wrist flexion. Monitor pain over lateral elbow.[8]
  • Maudsley's test: isometric resistance test for extensor group.

Technique. Start position: Shoulder neutral, elbow 90 degrees, forearm pronated, wrist neutral. Resist middle finger extension. Monitor pain over lateral elbow.[8]

  • Cozen test: Isometric resistance test for extensor group.

Technique. Start position: Shoulder neutral, elbow 90 degrees, forearm pronated, wrist neutral. Combined resistance of extension, radial deviation. Monitor pain over lateral elbow. [8]

  • Thomsen test: Isometric resistance test for extensor group. (variation of cozen test)

Technique. Shoulder 60 degrees flexion, elbow zero degrees ,forearm pronated, wrist extended 30 degrees. Isometrically resist wrist extension at dorsum of hand . Monitor pain over lateral elbow.[9]

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]

Intra-articular synovial plica of radial-capitular joint[9]

Radio-capitular arthritis[9]

Osteochondritis dessicans[9]

Instability[edit | edit source]

  • Posterolateral rotary instability due to laxity of collateral ligaments[9]

Neural[edit | edit source]

  • Radial tunnel entrapment of posterior interosseous nerve (Arcade of Froshe)[10]
  • Cervical radiculopathy
  • Abnormal neural tension neurodynamics (radial nerve bias)[9]

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.[1]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Watts A, Robinson P. Epicondylitis. BMJ Best Practice. (2021). Available from: https://bestpractice.bmj.com/topics/engb/978. [cited 2022Nov4].
  2. ↑ Shiri R, et al. Prevalence and determinants of lateral and medial epicondylitis: A population study. Amer Jour Epidemiology. (2006). 164(11):1065-1074.
  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. ↑ 5.0 5.1 Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
  6. ↑ Zytoon A, et al. Ultrasound assessment of elbow enthesitis in patients with seronegative arthropathies. Jour Ultrasound. (2014). 17:33-44.
  7. ↑ Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.
  8. ↑ 8.0 8.1 8.2 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.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 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.
  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.
Retrieved from "https://www.physio-pedia.com/index.php?title=Lateral_Epicondyle_Tendinopathy_Toolkit:_Section_B_-_Clinical_Assessment&oldid=319828"