12/3/2018 Unlocking the Course Objectives Mysteries of At the completion of this 2-hour session, the participant will be able to: 1. Plan a focused systematic differential evaluation of the elbow based Diffuse Elbow on patient history and location of symptoms. Pain 2. Interpret examination results to establish primary and provisional diagnoses related to the elbow pain. Ann Lucado, PT, PhD R. Barry Dale, PT, PhD 3. Evaluate examination findings to distinguish which interventions Joseph M, Day PT, PhD should be used for physical therapy management. Sponsored by the Academy of Hand and Upper Extremity Physical Therapy Conflict of Interest Disclosure Primary Care Algorithm for Elbow Pain No presenter has association or financial involvement with any organization having a financial interest in or financial conflict with the subject matter presented in this educational session. Two of the presenters (AML and JMD) are members of the Clinical Practice Guideline Development group for the APTA. Considerations in differential diagnosis Elbow/Forearm Physical Exam •Inspection •Edema measures •Sensation assessment •AROM/PROM •Stress or resisted testing •Palpation •Special Tests 1 12/3/2018 Posterior Elbow Structures Posterolateral Differential diagnosis considerations: ➢ Olecranon fracture Elbow ➢ Bursitis ➢ Triceps tendinitis Ann Lucado, PT, PhD ➢ Snapping triceps Certified Hand Therapist Mercer University ➢ Valgus Extension Overload ➢ MTrPs Olecranon/ Bursitis Triceps Tendinitis Snapping Triceps https://orthoinfo.aaos.org/en/diseases--conditions/elbow-olecranon-bursitis Triceps Valgus Extension Overload Seen in overhead throwing athletes Related to hyperextension and valgus forces at the elbow https://youtu.be/_TLkvYVRye4 https://musculoskeletalkey.com/valgus-extension-overload/ 2 12/3/2018 Lateral Elbow Structures Radiocapitellar joint - Traction Stresses ➢ Pulled elbow syndrome Pulled elbow syndrome ➢ Radial head fracture ➢ Posterolateral rotatory instability ➢ Posterolateral plica ➢ Radiocapitellar chondromalacia Radiocapitellar Joint- Compressive Stresses Other Radiocapitellar Sources of Pain ➢ Radial Head Fractures Posterolateral plica Interosseous Membrane Tears ➢ Radiocapitellar chondromalacia Posterolateral Rotatory Instability Posterolateral Rotatory Instability Lateral Elbow Structures Attenuation/rupture of lateral ulnar ➢ Lateral elbow tendinopathy collateral ligament ➢ Radial tunnel syndrome Symptoms may include ➢ Fibrotic edge of supinator ● pain, snapping, clunking, or locking when elbow extended ➢ Medial edge of ECRB and supinated ➢ Fibrous bands anterior to radial head ➢ Leash of Henry vasculature ➢Proximal tests to r/o cervical or shoulder involvement Green’s Operative Hand Surgery 3 12/3/2018 Lateral Elbow Tendinopathy Radial Tunnel Syndrome Most common cause of elbow pain1 High recurrence rate Consider proximal sources of pain Consider Primary or Associated TrPs https://www.epainassist.com/hands/neck-and-arm-pain Medial epicondylalgia – <1.0% of population Anteromedial •45-54 yo Elbow •Repetitive wrist flexion and pronation with elbow extension •Golfers and overhead throwers R. Barry Dale, PT, PhD •Forceful work Professor and Chair, Department of Physical Therapy •Smokers University South Alabama •Diabetes •Obesity 4 12/3/2018 Medial epicondylalgia Medial epicondylalgia –Pain with resisted wrist flexion •Examination tests: Active resisted •Dull ache common at rest –Golfer’s elbow –Examination tests •Pt places elbow in slight flexion, makes a fist and attempts to keep •Golfer’s elbow test the wrist in neutral •Polk’s test •PT applies extension force to wrist (pt attempts wrist flexion) while palpating medial epicondyle •Positive: pain at medial epicondyle Medial epicondylalgia Medial epicondylalgia •Examination tests: Active resisted •Treatment –Polk’s test –Sclerosing therapy using polidocanol •Resistance applied by having patient hold a book –Eccentric training of the forearm muscle over 12 weeks •Positive: pain at medial epicondyle can result in complete resolution of wrist pain. Cubital tunnel •Ulnar nerve entrapment or compression •Examine sensation in distribution of the dorsal cutaneous branch of the ulnar nerve Branches proximal to the Guyon canal in the wrist If decreased, compression of ulnar n. is proximal to wrist 5 12/3/2018 Cubital tunnel Cubital tunnel •Ulnar nerve entrapment or compression •Common in 30-60 yo •Parathesias –Manual laborers •Muscle weakness (C8-T1) –Athletes •Hypertrophy •Usually gradual onset –Forearm •Dull ache after activity –Triceps Cubital tunnel Cubital tunnel •Examination test •Examination test –Elbow flexion test –Tinel’s (at elbow) »Pt sitting with bilateral elbow flexion »Pt sitting with elbow flexion »Holds for 3-5 minutes »PT taps proximal to cubital tunnel »Positive test: reproduction of pain, » tingling, or numbness along ulnar nerve Positive test: reproduction of pain, distribution tingling, or numbness along ulnar nerve distribution »Sensitivity: 75-93 »Sensitivity: 70 Specificity: 99 »Specificity: 98 Cubital tunnel Ulnar Collateral Ligament •Intervention •UCL consists of 3 bands –Ergonomic assessment –Anterior, posterior, and transverse –Postural education –Neural mobilization –Anterior band provides most stability –ULTT ulnar nerve bias stretches during valgus stress –Surgery 6 12/3/2018 Ulnar Collateral Ligament Ulnar Collateral Ligament •Valgus stress test •Moving valgus stress test Valgus load applied at 70 degrees of flexion ● Valgus applied during throwing motion ● If positive, pain occurs between 70-120 degrees of Pain: 65% sensitivity; 50% specificity flexion Laxity: 100% specificity Ulnar Collateral Ligament Lymphatic Tissue •Milking Maneuver Lymph nodes ● Clustered at the medial elbow ● Valgus applied at 90/90 ● Inflamed nodes may be an alternative source of ● If positive, pain occurs between 70-120 degrees of symptoms-palpable and tender upon palpation flexion ● Requires referral. Rehabilitation Strategy Outline Considerations for implementing a regional motor control rehab strategy 1 2 3 Joseph M. Day, PT, PhD Orthopedic Clinical Specialist University of Dayton 7 12/3/2018 Motor Control in Elbow Rehabilitation: An Integrative Model (Coombes, Bisset, Vicenzino. BJSM, 2011) Introduction and Theory Motor Control in Elbow Rehabilitation: The Control of Movement: Theories of Motor Control Letter to the Editor; Role of Proprioception in lateral elbow tendinopathy. Journal of Motor Control; Translating Research Into Clinical Practice 4th Edition Shumway-Cook 2016. Hand Therapy, 2018. ● Reflexive – stimulus yields a response ○ Proprioceptive rehabilitation appears to be ignored and may be the missing link to improving outcomes. ● Hierarchical – high centers are in charge of lower centers ○ Treatment activities may include external bracing, taping, weight bearing exercises, and isometric contractions ● Motor program theory – relearning the correct rules for action – progressing from isolation to a whole Response ● Systems – synergies allow for a variety of movements – variability of movement ● Ecological – developing multiple adaptive solutions as part of the environment ○ Is reduction in elbow joint proprioception a symptom of sensorimotor incongruence? ○ Therefore, we should address *No one theory is best; propose using an integrative approach ■ Muscle recruitment and force production ■ Coordination and accuracy training ■ Reaction training and variable speed of movement ■ Task specific activities OPTIMAL Theory of Motor Learning Wulf and Lewthwaite. Psychonomic Bulletin and Review, 2016 Motivation Attention Increased focus on the goal of the task Literature Promote Patient Autonomy External Focus of Therefore, we increase motor Goal setting Movement performance and increase motor learning. Positive Augmented Feedback 8 12/3/2018 Dynamic motor control of the glenohumeral joint and scapula is an important component of conservatively treating shoulder pathologies and has been shown to be an effective rehabilitation strategy Some evidence exist that fine motor control, Evidence for using Motor Evidence for using Motor muscle firing patterns during grip tasks, and force Coordination of the Scapula control of wrist muscles are altered in patients with elbow pain compared to control groups. Control in Upper Extremity Quality of shoulder elevation and Range of motion Control in Upper Extremity *while incorporating principles of loading Burns, E., Chipchase, L. S., & Schabrun, S. M. (2016). Altered function of intracortical networks in chronic lateral epicondylalgia. Eur J Pain, 20(7), 1166-1175. Rehabilitation Strategies Rehabilitation Strategies Skinner, D. K., & Curwin, S. L. (2007). Assessment of fine motor control in patients with Jaggi, A., & Alexander, S. (2017). Rehabilitation for Shoulder Instability - Current Approaches. Open occupation-related lateral epicondylitis. Man Ther, 12(3), 249-255. Orthop J, 11, 957-971. Manickaraj, N., Bisset, L. M., Devanaboyina, V., & Kavanagh, J. J. (2017). Chronic pain Roy, J. S., Moffet, H., Hebert, L. J., & Lirette, R. (2009). Effect of motor control and strengthening alters spatiotemporal activation patterns of forearm muscle synergies during the exercises on shoulder function in persons with impingement syndrome: a single-subject study design. development of grip force. J Neurophysiol, 118(4), 2132-2141. Man Ther, 14(2), 180-188. Mista, C. A., Monterde, S., Ingles, M., Salvat, I., & Graven-Nielsen, T. (2018). Reorganized Savoie, A., Mercier, C., Desmeules, F., Fremont, P., & Roy, J. S. (2015). Effects of a movement training