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Dx Bilateral Lat Epicondylitis
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Dx Bilateral Lat Epicondylitis - March 22, 2006 3:16:00 PM
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cpagePT
Posts: 8
Joined: March 17, 2004
From: Boardman, OH
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Any help here would be greatly appreciated:
Pt 46 y/o male office job. Woke up last april with "Bilateral Epicondylitis". Was injected with near elimination of sx's for about 6 months. Pain returned bilaterally and was injected again with improvements again for another 5 months. Now... injected a third time by an ortho this time and both elbows are worse than ever. I tried treating his elbows (ecc wrist ext, us, tfm) no luck. I began doing mobs and focusing more on the neck and acute pain is nearly gone but he continues to have pain directly ove the lat epi and insertion and is often unable to flex his elbows in the morning. Guess my question is- are there any specific mobs that work best- any other manual techniques- i think i'm on the right track but am getting a little frustrated. Thanks
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Clint Page MPT, CSCS
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 3:49:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Clint,
The fact that the corticosteroid injections worked in the past indicates that at least for those times, inflammation was the major issue, and he's just doing something to kick it back up again. After a few start/stop episodes, some time, and a few injections, the tissue can/will degenerate.
Some will suggest to screen and rule out the neck, but with resolution via injection, odds are it is the elbow.
Most important is to get him to quit doing whatever causes pain. Make sure ROM is full, especially extension of the elbow. Rule out any radial nerve issues via neural tensioning, get him into a tennis elbow strap (minor reduction in forces, and reminder not to do anything dumb).
Consider pulsed focal US, deep TFM, iontophoresis, wrist extensor stretches with elbow straight. You can perform Mills manipulation, or a muscle energy technique that I use for these patients:
1. Take supinated forearm and provide posterior glides of the radial head/proximal radius
2. Flex elbow to 90 degrees, and firmly place your hand on top of their supinated wrist, and tell them to attempt flexing their elbow at maximal intensity, while you provide no ability for it to move. Odds are, you will hear a "click" or "crunching" sound as the biceps manipulates the radius. You may also see improved elbow extension ROM.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 3:51:00 AM
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PTupdate.com
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And by the way...just saw a woman who is a recurrent patient from Boardman. We went there last year to buy some cool southwestern dishes at Dillard's, and she wanted us to go eat at some popular Italian restaurant on the main drag.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 12:12:00 PM
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ginger
Posts: 660
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From: Melbourne Victoria
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John, seems you have yet to come to terms with referred pain and its interesting manifestations . It is not difficult to eliminate referred pain at the site of pain with various injections, modalities , sometimes acupuncture etc. The effect localy of antiinflammatory drugs is , as you say , to reduce the possibility of inflammation . This is however , not proof , by the relief, that a local event has been modified.
Clint is onto the source as his attempts strongly suggest, just not finished.
It is difficult Clint, with referred C567 T1 pain to resolve . But persistance and strong mobs done continuously for long periods will do It . Don't forget to release Subscapularis and as many tight shoulder muscles as may be found. Poor shoulder movements because of dural and soft tissue tightness play a role in maintaining the facet joint irritation.
Forget the elbows, thats just for the learners.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 1:55:00 PM
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PJM
Posts: 25
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From: Australia
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This man would most likely benefit from an office workstation ergonomic assessment.
His technique or work posture may be playing a role in his ongoing symptoms.
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 1:55:00 PM
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nari
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From: Australia
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I will endorse "forget the elbows"..the condition has never really been an 'elbow' problem, empirically.
Look closely at radial nerve, and exclude median, and concentrate on the cervical spine if nothing useful happens with radial and median nerves.
Nari
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 4:47:00 PM
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rodgere
Posts: 49
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From: Linden
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I agree with NARI. bilateral elbow pain. when you wore out your tires unevenly its not the tires its a central problem. have you tried to see what cervical movment patterns effect comparible signs. I would say look at the neck more.
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 4:56:00 PM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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ditto Mr. Evans. I do admire all those shiny initials after your name! (truthfully, not being sarcastic for a change, way to go..what setting do you work in? private practice? teaching? just curious! Congrats on your dedication to the realm of orthopedics!!)
Ben Galin, MPT, OCS
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 5:11:00 PM
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PTupdate.com
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I don't know guys. I see quite a few of these patients, and there is still a high percentage that are actual elbow problems.....resolved by treating the elbow. There are numerous studies regarding the efficacy of injection and/or surgery, with very good outcomes. There is no way someone is going to tell me that they were all neck problems. Throw on top the histological examination of the tissue that is removed from the ECRB. When I had mine, it was plain and simple...injured doing overhand curls with more weight than the wrist extensors could handle. I am quite glad I treated the elbow.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 6:13:00 PM
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cpagePT
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From: Boardman, OH
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Thanks for all of your replies. A couple more things. Cervical ROM limited @ endrange all planes but relatively pain-free. MRI bilat elbows showed nothing. You guys ever seen anyone with this complaint-- this morning, pt was unable to straighten elbow because he felt like something was "going to rip in half" until 11:00- but after he was able to his pain was less than it has been in a month. Does that sound like severe neural tension? One more quick one- pt's doc is a DO- manipulation c-spine a good idea in something like this? Thanks
PS Duff- you know the name of that restaurant?
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Clint Page MPT, CSCS
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 6:16:00 PM
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cpagePT
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From: Boardman, OH
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Ginger- any specific mobs you've found to work best? I've been doing side glides/PA's-- just general jt mobs to c5,6,7. Thanks, CLint
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Clint Page MPT, CSCS
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 8:45:00 PM
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ginger
Posts: 660
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From: Melbourne Victoria
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When I mobilise facet joints I do so with a specific interest in releasing the paravertebral small muscles holding them in what i describe as a protected state.
To provide the optimum stimulus for this lowering of tone , continuously moving facet joints, (usually PA though sometimes AP )through a range that produces pain at that joint, will usually see reductions in tone that is able to be felt by therapist as change, and by patient as a reduction in pain , within about 45 seconds. It sometimes takes 5 minutes. When this change has taken place, a further reduction in tone(and pain ) can be expected for at least as long as it took for the first reduction to begin.
As that facet joint can then be seen actively and passively to be more mobile, it may then take a further 24 hours for any inflammatory events of joint and nerves to dissipate. After that time , the optimum relief of both local joint symptoms and referred symptoms will be experienced.
In cases of the so called 'epicondylitis' where referred pain is created by inflammatory events of C5 all the way to often include t345, the problem is often confounded by a series of tight structures as mentioned above.
Traps scalenes rhomboids, subscap etc all play their own role in biomechanical disadvantage for freedom at shoulder and scapulothoracic joints. Expecting full resolution then with mobs alone will delay best effect. Get stuck in to those tight structures.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Dx Bilateral Lat Epicondylitis - March 23, 2006 10:12:00 PM
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nari
Posts: 1568
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From: Australia
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cpage
Your example of the guy who could move his elbow and feel much less pain - what happened at 1100 hrs?
Severe neural tension can resolve in mere minutes - if the right thing is done. If not, then pain can get worse. Especially if everyone's having a go at it. People with 10 years of neural (central) pain can be painfree within minutes. It may not stay that way for long, because of confounding factors, of which there are many with chronic pain. But it can be done if those factors are addressed (education on the origin of pain. etc etc)..and everyone needs individual management, which makes chronic pain such a challenge.
Nari
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Re: Dx Bilateral Lat Epicondylitis - March 24, 2006 10:02:00 AM
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PTinFLA
Posts: 14
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From: Florida
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Spank,
I would say try having this person hit some squeeze balls around the clinic with a standard cane. :)
But seriously, I wish I could help you out on this one but I've got nothing. Seems like all the good suggestions have already been taken and I've been in the land of stenosis and joint replacements for too long.
Give me a call sometime, same number.
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Re: Dx Bilateral Lat Epicondylitis - March 24, 2006 6:06:00 PM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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If he is truly waking up with this, and it isnt brought on by something else, I would look into just how he is sleeping. Is he flexing his wrists to end range and beyond for prolonged time periods? This could stretch muscle, tendon, nerve, etc beyond a reasonable length for a long period, creating pain from mechanical strain. OR, maybe he is sleeping with his head cranked to extremes. I am a firm believer that you need to figure out what he is doing that prevents himself from getting better, and/or causes the problem in the first place. Its not always easy, and cause/effect is difficult to prove, but somehow his problems keep coming back......
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Steve Hill PT
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Re: Dx Bilateral Lat Epicondylitis - March 25, 2006 3:28:00 AM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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Clint: Wife and I can't remember the name, but when we got off the turnpike and took that 4 lane road to the mall where Dillards was, it was on the left, just next to a huge lot they were performing construction on. Same side as the fireworks store.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Dx Bilateral Lat Epicondylitis - March 25, 2006 5:48:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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I agree with Shill and Mr. Evans (hi there) that you must look for the aggravating factor(s). Sleeping position makes sense because his worst complaint is in the morning upon waking. I also agree with Ginger that you should focus proximally and work your way down to the elbow. I would get a sense of tissue glide along the entire path of the radial nerve and gently loosen any adhesions felt (need a very soft touch for this). Also, have you done nerve tension tests aka Butler or Shacklock? The fact that this is bilateral is a very big clue that the cause is more central, however. I mean, unless this guy is extremely ambidextrous, it doesn't make sense to blame the elbow. What does he do for a living? Also, don't ignore the thoracic spine. Mobilize it. Good luck!
Sarah
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Re: Dx Bilateral Lat Epicondylitis - March 25, 2006 6:01:00 AM
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drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
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I know this wont go over very well here, but I have had some success treating epichondylitis with low level laser therapy. I am amazed how quickly it responds and how much it improves in only a couple of visits. I wish I was close enough to one of your clinics so I could visit for a day and let you use it on a few patients because I know I sound like a whackjob when I talk about how well it works.
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Re: Dx Bilateral Lat Epicondylitis - March 25, 2006 6:21:00 AM
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rwillcott
Posts: 435
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From: Canada
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Sarah, why do you recommend mobilizing the t-spine?
I agree to look at the c-spine since it's bilateral. I'd take a close look at C4/C5. Is this person in a HFP. Possibly an anterior shear at this level that would benefit from some deep neck flexor retraining.
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Re: Dx Bilateral Lat Epicondylitis - March 25, 2006 10:40:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Because of postural issues that may be affecting the thoracic outlet. Mobilizing the T-spine will allow better alignment of the nect, scapulae and shoulders.
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