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How do you treat lat. epicondylitis
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How do you treat lat. epicondylitis - January 6, 2006 2:08:00 AM
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clydesdale6
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This is something that my coworkers and I have extreme difficulty with making consistent positive results. I know have had it for the past 3 months. It is the result of bracing a wheel barrow that had a very large section of tree in it. The barrow almost fell, I corrected it and.... sting. I have taken oral NSAIDs, which have not helped much if at all. I have tried two rounds of ionto with dex for 6 treats at a shot. I have tried resting it. But this thing isn't going away. I have had an MRI, which showed a slight tear. According to the ORTHO it shows that all the time with lat. epi.
So what have you found that works?
He wants to do a cortisone injection. I am mixed on this. One of my coworkers is married to an MD who has the same problem, just had an injection and he advised me not to waste my time and potentially make things worse. What are your thoughts? Thanks
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Re: How do you treat lat. epicondylitis - January 6, 2006 2:34:00 AM
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PTupdate.com
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Now that you are in the chronic stage, and a tear found on MRI, it is more a tendinosis issue, not an "itis", and thus the lack of good reponse with your anti-inflammatory treatments.
Obviously rest is one best option, and preventing anything that causes pain or irritates it will help...simple idea, but skipped by most.
Have you tried deep friction massage? I highly recommend in order to break down fibrotic scar tissue and all the other connective tissue crap that is found during surgery to this area. Who knows, it may be that with deep TFM, a weak ECRB might just detach on it's own, and the good results we see are because we did a non-surgical release of the tendon?!?
Do you have full elbow extension? Have you tried either muscle energy to reseat the radial head, or even Mill's manipulation?
Stretching of the wrist extensors and gentle, non-painful strengthening? Even tennis elbow strap to reduce some of the strain at the origin. Also, make sure you are not suffering from a radial nerve entrapment syndrome.....as it can mimic lateral epicondylosis very well and miss detection.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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Re: How do you treat lat. epicondylitis - January 6, 2006 3:11:00 AM
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JLS_PT_OCS
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Of course John D always covers all the bases well, I second everything he said.
Plus I would attend to the neck as well, and look for neurodynamic issues re: radial nerve.
If we think of this narrowly as a traumatic event, is there an explanation (other than the tendonosis John mentioned) for why it still would hurt?
Referred pain or nervous tissue deformation seems the most likely candidate for that.
If engaging in strengthening, I would do eccentrcs just like we do for achilles and patellar tendonosis.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: How do you treat lat. epicondylitis - January 6, 2006 3:47:00 AM
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clydesdale6
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I did the NSAIDS initially when not chronic. The orhto stated that the tears are always there with lat. epi. I have full elbow extension. It gets a little painful at times for full extension, but I wont allow a ROM loss to set in. I have just started strengthening against the jugdgemet of some. I just don't know what else to do so I will go back to basics and start a little stregthening. I have tried the elbow stap and was suprised at how little it did (nothing). My ortho is eager to do the injection and really believes it will go away. What are your thoughts on the cortisone.
As far as looking at the neck to treat my elbow- I usually have a hard time buying into that kind of stuff. I have no "neural tension". None of the symptoms are increase by tightening the nerve. But if you give me a description of what you want me to try, I will do it with an open mind. I dont believe in ionto and I tried that.
I think it isn't healing because there is a small tear and even with "rest", we are talking about my arm and my hand, I dont think true rest exists. I am considering waiting it out. What would you like me to try? Would you go for the injection?
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Re: How do you treat lat. epicondylitis - January 6, 2006 5:28:00 AM
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drbuddy
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It would be an interesting case for low level laser therapy. I had a pro horse rider (penning) really st/sp his right groin, I mean his entire groin and inner thigh was black and blue to the knee and the scrotum and pubis area was even black. He was back riding in two weeks with only minimal pain (even though I advised agaisnt it). In pre vs post treatment there was a big difference in strength and pain levels.
Other than that, I would try some sort of soft tissue therapy to break down the scar tissue and any adhesions that might be present. Neural tensioning tests might be worth checking too. I dont know about the validity of such tests, but I am finding it is present in most of my patients with extremity pain. (just read Shacklock's text - good stuff).
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Re: How do you treat lat. epicondylitis - January 6, 2006 5:37:00 AM
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Sean Weatherston
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Clydesdale,
Don't discount the thought that the prolonged pain might be coming from the neck. Jason didn't say that the cause of your pain was from your neck, just that there might be something going on there that might be prolonging your symptoms.
Yes, you can trace the origin of your elbow pain to a specific event, but does that preclude any other areas from having anything to do with why you got hurt in the first place?
An example: Is there anything wrong in thinking your elbow may have taken the brunt of the force because your scapular stabilizers were too weak to steady the wheelbarrow when it went out of control? Check them and see..... not going to hurt anything.
Sean
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Sean Weatherston, PT, OCS, CSCS
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Re: How do you treat lat. epicondylitis - January 6, 2006 5:45:00 AM
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PTupdate.com
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As Jason says, look at the neck, especially if there appears to be any radial nerve involvement. Not sure why you do not agree with that, but there are good articles related to radial nerve entrapment/tension acting as lateral epicondylitis, along with tons of anecdotal stories by PT's. Plus, if indeed radial nerve, the fact that there are double and triple crush syndromes, and they are proven, one MUST look at the neck as a possible "first cause".
As for injection? Sure, there may be some inflammatory cells present, and their histochemical processes are causing some pain, so it may work. However, I am currently working on a 40-something guy who has had multiple injections and now had pigmentation changes at both elbows...not real pretty, and permanent!
And, as Sean says you may need to look more proximal to the girdle musculature (but always after you addressed the local issues first, and had no luck). If not trauma induced, and the patient just can't figure out what the heck caused it, you do need to dig deeper and look for the cause.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: How do you treat lat. epicondylitis - January 6, 2006 5:47:00 AM
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SJBird55
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Is lateral epicondylitis always lateral epicondylitis?
A factor that strikes me as different in your scenario, clydsdale, is the mechanism of injury. A very quick reflexive action with a lot of gripping force generated with the elbow in a flexed position and fighting either a pronation or supination force (depending on which way the wheel barrow was tipping). The forces would be a strong concentric grip with a large eccentric rotational force. Your mechanism of injury is not the typical lateral epicondylitis "story" that subjectively would be told by the majority of patients.
Because of your mechanism of injury, if you were a patient of mine, I'd be more inclined to search for literature based on traumatic lateral elbow pain and combining a mental image of you acting out what happened with consideration of what really bothers it.
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Re: How do you treat lat. epicondylitis - January 6, 2006 6:32:00 AM
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jaymango42
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This is the problem with the profession of physical therapy. An ORTHOPEDIST diagnosed Clyde with lateral epicondylitis, and the physical therapists are looking for an obscure reason for Clyde's elbow pain (ie the neck or scapular stabilizers??? - come on people). Why don't we start with the basics by treating the elbow when a patient has elbow pain.
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Re: How do you treat lat. epicondylitis - January 6, 2006 7:28:00 AM
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MPT
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Autologous blood injections seem to work well.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12671860&dopt=Abstract]Autologous blood injections for refractory lateral epicondylitis[/URL]
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Re: How do you treat lat. epicondylitis - January 6, 2006 7:28:00 AM
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pt_davey
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Jaymango,
Are you a PT?
Sounds like you need to learn a little about the many causes of elbow pain.
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Re: How do you treat lat. epicondylitis - January 6, 2006 8:21:00 AM
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clydesdale6
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Thanks AR15. I will get that article and bring it to my ortho. We happen to have a meeting with him coming up where we discuss some research articles.
As far as the neck and the elbow discussion, my hang up with that is simple. I am fairly strong, work out regularly, and have a side job that requires manual labor. I have trained my scapular stabilizers and RTC in my shoulder routine for the past 10+ years. I am no stranger to work. I can't possibly buy that it was because of a weak muscle group. I think I did something that required absolute maximal contraction and grip and then "wham", I felt the problem. I have full cervical ROM and neural tension tests are negative. There is no peripheralization. I have pinpoint pain in the elbow, right on the bone. I think going further into the neck than what i just said would be going down a long dark road searching for a needle in a hay stack. I hope and believe it is not that complicated. But, what the hell, tell me what you want me to do. I hear the idea about TFM, I have gotten into it a little and it does seem to aggravate it temporarily. I am doing stretches and will step up the strengthening.
I think what Jaymango might be trying to say is that we often try to over complicate things. Correct me I am wrong Jaymango. I
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Re: How do you treat lat. epicondylitis - January 6, 2006 8:34:00 AM
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clydesdale6
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John (ptupdate), walk me through the Mills manip. and the muscle engery technique you describe. What is the theory with the muscle engery idea and the radial head. On another note, we also already tried the common mulligan technique for tennis elbow. Let me know. THanks
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Re: How do you treat lat. epicondylitis - January 6, 2006 8:57:00 AM
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steve
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Clydesdale,
I think lateral epicondylitis suffers from much of what non specific low back pain does clinically. There are likely a multitude of causes and not a reliable system for classifying patients into a treatment approach that will work. This leads to the ecclectic treatment approaches and people offering a wide variety of treatments. Thankfully, we are making progress with respect to LBP.
I spoke to Dr. Alfredson who did much of the initial research on tendonosis in the achilles. He noted that there were no markers of inflammation at time of surgical intervention with achilles tendonosis. What they did find was misaligned collagen with neovascular and neural ingrowth. Eccentric exercise caused a visible change in the tendon that was still visible at two years. Interestingly, pain during the exercise was correlated with a successful outcome and those patients who followed the protocol had as high as 90% successful outcomes. Theoretically, he believes that the eccentric exercise causes a shearing effect on the neovascular/neural in growth and that this is responsible for the pain. He stated that they had performed a similar pilot trial with lateral epicondylitis that had the same outcome.
Hope that is helpful.
Steve
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Re: How do you treat lat. epicondylitis - January 6, 2006 10:05:00 AM
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ehanso
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Has anyone thought through or considered the recent article epicondylitis vs. epicondylosis. Are we treating the inflammation or the consequences of the inflammation? I have a tendency to treat both since they both seem present, if not initially surely after a few weeks. Also I usually don't see then in the truely acute phase. They are more early to mid chronic.
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Re: How do you treat lat. epicondylitis - January 6, 2006 10:30:00 AM
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drbuddy
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Jay,
That's part of the problem too, some clinicians will treat a diagnosis just because an MD said that's what it is. MD's tend to give a vague "diagnosis" such as bursitis, epichondlylitis, lumbalgia, cervicalgia, etc. Their through process is ruling out cancer, infection, fractures, tears, or anything else they might be able to surgically repair (or solve with an injection).
I learned very early on not to trust a diagnosis from another provider. I dont care if they are the chief of staff at the Mayo Clinic. Most recently I had a AAA dissection walk in to the office that had been seeing his MD for low back and groin pain for 2 months. If I would have said, "Oh, ok, your MD says you have a low back sprain/strain, we'll treat you for that," he'd be dead by now.
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Re: How do you treat lat. epicondylitis - January 6, 2006 10:39:00 AM
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JSPT
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Could someone please briefly elaborate on what is meant by "eccentric exercise" for this condition?
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Re: How do you treat lat. epicondylitis - January 6, 2006 11:08:00 AM
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certMDT
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Since everyone is just throwing out their favorite diagnosis (and there are a few relevant signs)...clydesdale - you said you are McKenzie certified, have you ruled out a derangement at the elbow?
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: How do you treat lat. epicondylitis - January 6, 2006 11:13:00 AM
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certMDT
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JSPT - there is a good article on this in Manual Therapy:
Lateral epicondylalgia: a musculoskeletal physiotherapy perspective Manual Therapy, Volume 8, Issue 2, May 2003, Pages 66-79
B. Vicenzino
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Charles Sheets PT OCS Dip MDT
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Re: How do you treat lat. epicondylitis - January 6, 2006 12:50:00 PM
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dosrinc
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Jaymango, have you ever seen how an Orthopod diagnosis lateral epicondylitis?
I have, it went something like this, "Where is your pain?, in your lateral elbow, How did you hurt it?, playing tennis, oh yes, you have lateral epicondylitis, take these and rest, if it is not better in two weeks we may take an xray and send you to PT"
Try and learn something from the posts here, you may actually learn something
Rick
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