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Re: How do you treat lat. epicondylitis
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Re: How do you treat lat. epicondylitis - January 6, 2006 12:51:00 PM
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clydesdale6
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Charles, I did not take the UE and LE course. I think McKenzie is excellent, just did't fully believe in the extremity portion. So my thought was to wait it out on that. What is the specific difference in definition of tendonosis and tendonitis?
Steve, I have started strengthening and will focus on the eccentrics. Any good exercise examples? Thanks for your help folks. I am sure the problem is right at the elbow and would love to avoid the injection. Not too many have commented on the injection. Would you get it???
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Re: How do you treat lat. epicondylitis - January 6, 2006 12:53:00 PM
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PTupdate.com
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jaymango42, I do not see this as a PROBLEM with the PT profession, but rather one of our assets.
Our discussions above are diagnostic and differential, as we are not looking at this elbow, and only making suggestions as to what else it could be. Plus, if the full first line of treatment for lateral epicondylosis does not work, "here are some other things it could be and how to address them"
I too have a problem when someone puts the cart before the horse, and addresses many obscure issues instead of what appears to be obvious, but none of us are implying that here.
Clydesdale6...are you a PT?
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 1:17:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]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![/QUOTE]Cortisone tatoos, sweet.
Clydes,
I think some of the best evidence based advice given above is with the eccentrics. It makes sense and has been shown to be effective in the literature with similar problems in other areas of the body. I would start here.
I am an Army physical therapist and a lot of guys I see are on direct access, meaning that I am the first guy to see them, no referral. As far as the cortisone injection, I say go for it. Many times, for whatever reason, it is the "magic silver bullet". One shot and the symptoms are gone. For a long time I was in a single therapist clinic so I worked very closely with our Army PA's. I would bring guys over who were not responding to the conservative PT and the PA's injected them. I personally have never seen anyone get the injection and get worse. On some it seems to be magical, on others it works for 1 week, others 6 months, and some not at all. But again, I have never seen anyone get worse from one cortisone injection.
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Alex Brenner, PT, MPT, OCS
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Re: How do you treat lat. epicondylitis - January 6, 2006 1:21:00 PM
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JLS_PT_OCS
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Clydes-
I would get an anti-inflammatory injection if I had chemical pain from an inflammatory process. For me, this has some hallmarks - chemical pain does not vary much with movement, is present often regardless of activity or position, tends to be worse in the morning upon rising, and is easily irritable.
Of course people can have both mechanical and chemical pain, but if you have no hallmarks of chemical pain, then I wouldn't bother with the cortisone. It probably won't work, as your NSAIDs didn't either. It sounds as if you have a mechanical pain problem. Though certainly the needle entry and the fluid bolus of the cortisone might be helpful for tendonosis. But in your case it seems the autologous blood or saline might be a better option.
If you have mechanical pain, I would not expect the "anti-inflammatory" to help, and I would decline the injection. Or ask for saline as I mentioned. However, the sort of artificially induced inflammation of things like friction massage, eccentric exercise, or autologous blood injection into your tendonosis/noninflammatory tendon degradation is an intervention that makes a lot more sense. Don't you think?
I would start the eccentrics (eccentric wrist ext with dumbbell) in a position of elbow flexion, and progress toward full extension as the weeks go by, always looking for painfree eccentric contraction, but mild pain (i tell patients maybe 4/10 for what that's worth) at concentric contraction. High volume, low load, say 3 sets of 15 reps twice per day?
That's to just focus on the presumed tendonosis.
I have had people with what seemed like slam-dunk tendonosis who did not improve until I started mobilizing C5-C7 and worked their C/T junction with a few manips, and a radial nerve glide here and there. Sounds crazy, but low cost-benefit and they did improve. I can't infer causation, but surely it is worth a try in the spirit of exploration and weighing of options.
Or you can do as jaymango suggests, say "yes doctor" to the well-meaning Orthopod and behave as a technician. But I don't recommend this. :)
J
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"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 3:00:00 PM
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PTupdate.com
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Why are we all such losers and sitting here talking about tennis elbow on a Friday night!!!!!!!! Are we THAT DULL? Surprised we don't all have tennis elbow from something else.
Duffy
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Re: How do you treat lat. epicondylitis - January 6, 2006 3:17:00 PM
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clydesdale6
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ok, I think I am getting some good ideas. I thank all for the input. I have a good relationship with this Doc and I am going to hold on the cortisone and ask for a saline injection. I have already ordered the autologous blood article from our hospital library. Can someone please take a second though and explain the theory behind this for me. Excuse my ignorance on this but do they draw blood from me and then inject it???? I have not heard of this treatment and would love to bring it up to the Doc.
Jason thanks for the eccentrics, I will definitely start there.
Alex, thanks for the input, I will still consider the injection of cortisone if my current plan doesnt work. My ortho is very good and is in an office that has legends and I trust their protocols and they believe the injection for this is also the "magic bullit".
I have to stay away from the other ideas for now. I know the mechanism of injury and I have no proximal symptoms or deficits so I can't look at the neck right now. If this was a patient of the street I would ask all the usual questions, but in this case i know where the problem is. I bet the ortho there was a tear and there was a mech of injury and acute pain so I am sold the problem is there.
Talk to me about this blood injection. Why blood? Just to take up volume in the tendon and promote natural inflamation? Do you even need anything or would a dry needle and the mechanics of it be enough?
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Re: How do you treat lat. epicondylitis - January 6, 2006 3:31:00 PM
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clydesdale6
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PTupdate, yes I am a P.T., been doing ortho for 8 years, but still suck at treating lat epi. But No, I have not heard of Mills manipulation. Are you a P.T.?
Just kidding.
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Re: How do you treat lat. epicondylitis - January 6, 2006 4:48:00 PM
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Jeffre
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Clyde,
From the abstract:
An injection of autologous blood might provide the necessary cellular and humoral mediators to induce a healing cascade.
I guess that is why blood and not some other Kool-Aid.
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Re: How do you treat lat. epicondylitis - January 6, 2006 4:51:00 PM
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Synergy
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[QUOTE]Why are we all such losers and sitting here talking about tennis elbow on a Friday night!!!!!!!! Are we THAT DULL? Surprised we don't all have tennis elbow from something else.
Duffy [/QUOTE]ROFL Duff!
Clydes,
You seem to have opened a 'virtual' Pandora's Box. Everyone has provided great ideas for you to consider. I have had good results from having patients perform the eccentric exercises coupled with, as Jason pointed out, radial nerve 'clean up' using STM/DTM and good ol' nerve glides. Rarely have I mobilized the lower cervical segments, but it sounds very plausible. I even like to use some soft tissue mobilization with active patient movement, i.e. active patient wrist or elbow flexion/extension while you perform the soft tissue work.
I came across [URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12671860&query_hl=2&itool=pubmed_docsum]this[/URL] article and thought you may find it useful/informative.
Good luck! :)
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Re: How do you treat lat. epicondylitis - January 6, 2006 5:34:00 PM
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MPT
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Clyd: I also find lat ep hard to treat. I have not talked to many PTs who can honestly say they have a lot of luck with it.
Mills Manip: The pt sits in front of you. Stand behind the pt on the side you want to manip. Grab the pt's arm just below the elbow and with your other hand control the wrist. Internally rotate the shoulder and pronate the forearm. Flex the elbow to about 25 degrees and fully flex the pt's wrist. Hold the wrist in full flex and manipulat the elbow into extension. The pt needs to have full elbow extension and be careful not to over do it and hyperextend the elbow. The theory is it tears the adhesions and restarts the healing process.
The blood injections are for tendonosis. The theory (as I understand it) is you are introducing cells that restart the healing process. If you get the article it talks about the theory behind it.
I still do not totally grasp the eccentric theory. Bottom line they have done studies with patellar tendonosis and Achilles tendonosis that show eccentric work improves tendon histology and improves outcomes. They say you should not do both eccentric/concen which I don't totally understand. I think there was a discussion on RE before about eccentric exercises. I do them a lot but can't say I have much luck.
I also try cerv manip/mob, wrist ext manips/mobs, elbow adduction mobs, XFM,n. glides, splints, taping, animal sacrifice and amputation. I have the best results with the last option.
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Re: How do you treat lat. epicondylitis - January 6, 2006 7:27:00 PM
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ginger
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Referred pain and other altered sensations arising in limbs is very common.It is not possible from the POV of the complainer of pain, to assert any pain is . or isn't, referred , on the basis of the sensations themselves. When the brain attempts to make sense of altered information arriving from a distal structure , it will do so in a pattern appropriate to the degree and specifics of both the information itself and the degree to which it has been altered. The altered neural data is most often provided by inflammatory events, of nerves as they are associated with other structures. The most likely of which are joints.
Clydesdale ( are you big and hairy or what ), you have a pain in your elbow and insist it is not referred because you 'feel' it . This is not a way to know one way or the other.
I am still reading of people who have trouble with so called tennis elbow( epicondylitis osis etc etc). This problem , when not the effect of direct trauma, is a referred event from inflammatory activity at c567. For you to prove this would be usefull don't you think?.
Have someone mobilise C567 one joint at a time, for the time required for each joint to be relieved of pain at each joint when mobilising pressures are applied. This can be done either in prone( recommended) or supine , ( more painfull , though more likely to reproduce the referred pain as pressures are applied to C6.)
This may take several minutes to achieve at each facet joint.
Assess pain with active and passive movements and palpation before commencing, and after about twenty minutes of continuous mobs. The pain picture will immediately improve, second treatment after 24 hours, third should clear it up.This is the standard I have come to expect with this problem. I truly don't see why those of you who have so much trouble with epicondylitis can't just give it a go. Go at it with persistance, firm pressures mixed with sensitivity and you really can't lose.
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Re: How do you treat lat. epicondylitis - January 6, 2006 7:43:00 PM
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Synergy
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Ginger (Geoff right?),
20 minutes of mobilizations? I have to know...do your fingers look wretched and deformed from all of your mobilizations, or do you use a tool of sorts...perhaps a knob? I'm just curious.
By the way, I found this in Clydes' profile. :)
[IMG]http://www.imh.org/imh/bw/images/clconf.jpg[/IMG]
He does appear to be rather large and hairy. :)
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Chris Adams, PT, MPT
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Re: How do you treat lat. epicondylitis - January 7, 2006 1:38:00 AM
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clydesdale6
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Ginger, like you said yourself, when not the direct effect of direct trauma,I would look into other potential problems. But there is a clear event, the wheel barrow was very heavy, very wobbly and I corrected it and "wham". I had pain in the elbow almost immediate. In addition, I get pain with resisted wrist extension and with concontraction like a handshake. There is a positive MRI as well. We are not talking about MRI results in the spine which I take with a grain of salt, unless something scary is on there. There are just too many factors pointing to clear cut extensor tendon issues for me to believe referred. When I say referred though, I mean something like coming from c-spine or shoulder girdle. I like the idea of the neural ingrowth and having to try to initiate a proper inflammatory response.
Chris, I have already ordered that article from our library and will bring it to my ortho. Thanks
By the way, you have to admit, I do look studly. :D
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Re: How do you treat lat. epicondylitis - January 7, 2006 2:01:00 AM
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clydesdale6
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AR15, thanks for the Mills manip guide. I will check it out.
By the way, I am at work here this early on a sat morning so I feel a little better about my social life. I couldn't believe how many responses I got on a Friday night.
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Re: How do you treat lat. epicondylitis - January 7, 2006 2:40:00 AM
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dosrinc
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Jason, why no pain with the eccentrics? my understanding from the treatment approach by Karim Kahn and colleauges was not to avoid pain with eccentrics when treating the Achilles tendon. What are your thoughts?
Clydesdale, the one thing I might add is that despite the mechanism of injury a chronic C5C6 pathology may result in atrophy of the tonic muscle of the elbow, the ECRB, thus predisposing you to the injury and also inhibiting your recovery, you might try what Ginger suggests though I will admit that my outcomes with the addition of this type of treatment to what others have suggested are nowhere near as fast as Ginger's. Good luck!
Rick
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Re: How do you treat lat. epicondylitis - January 7, 2006 3:02:00 AM
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Alex Brenner PT MPT OCS
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AR15, Chris and others,
Has anyone worked with a patient that has undergone the autologous blood injection? It sounds promising from the abstract and I look forward to reading the entire article.
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Alex Brenner, PT, MPT, OCS
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Re: How do you treat lat. epicondylitis - January 7, 2006 3:11:00 AM
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FLAOrthoPT
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that manip would cause sooooooooooooooooo many problems if it were really a peripheral nerve injury. I mean a double or triple crush syndrome with that manip would make the patient throw up i would imagine. And whoever said this:
"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. "
Are you freakin kidding me...just this week alone: ahilles tendonitis on a 5 year old (she had talar dome fracture), RTC tear (OA of shoulder), CVA (BPPV), knee pain and weakness (proximal neuropathy), radiculopathy left leg (maralgia parasthetica from tight jeans). But you are soooooooo right, we should listen to the orthos because they want to take the extra 20 minutes to find the diagnossi when the patient has no longer become profitable for them because they are no longer requiring surgery. What world do you wake up in, is there a rainbow and and a butterfly outside everyday, does the sun say good morning and ask how many scoops of raisins, what an idiotic statement, sorry, it hink I am just grumpy, but man, that was one of the worst statements i have ever seen on a PT board, unless you are not a PT and then it makes tremendous sense.
Ok back to the lati. epi. I have clinically found that most people with this who are not doing something like laying cable with just a terrible lat. epi. almost have to have some peripheral nerve irritation. If this is so, I found that treating as such, with neurofascial mobs, treating the neck and shoulder and brachial plexus, and no one has mentioned how scap strengthening (proximal stability to reduce the excess compensatory motion at the elbow) can help too. I had one really bad bilateral epic. that all I did was ionto and scap strengthening and have her avoid ANY activity with elbow at full extension and it went away gradually over like 3 weeks. But I have seldom seen a lat epi that is only a lat epi mainly b/c most people who get it never still have it by time the see the doc, get the rx, take some meds, come and see you. Anyway, go Pats, go Steelers so then you can play Indy and beat them and then the Pats can eventually play you and beat you.
Happy Playoff Wildcard Weekend,
Ben
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Re: How do you treat lat. epicondylitis - January 7, 2006 5:40:00 AM
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JLS_PT_OCS
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Rick-
I guess with the eccentrics, I have found clinically that telling the patient they should have pain on the CONcentric part of the contraction (per that article in BJSM about volleyball players last year) and not the eccentric contraction, works for me.
That study did show that those who pushed through some tendon pain did better than those who avoided it.
So I use the painfree eccentric portion/painful concentric portion as a guide. I readily admit that my use of this paradigm to prescribe and progress eccentrics is anecdotal. But it seems to work, for what my unsubstantiated claim is worth.
And (I can't believe I'm about to say this) I agree with Ginger/Geoff that just because something feels a certain way doesn't mean the tissue of origin can be immediately identified.
Once, after a long car trip of multiple days I awoke at 3am with terrible calf pain. Not a cramp. I was idly wondering about the admittedly low likelihood of DVT when I rolled over on my stomach to get out of bed. Suddenly, in lumbar extension, the pain immediately went away. So much for being SURE it is a local thing, huh?
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 7, 2006 6:50:00 AM
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PTupdate.com
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Sorry clydesdale6, I just wanted to make sure I was not teaching a manipulation to someone NOT a PT, and then having to deal with some legal bullsh_t.
The Mills manipulation is perfectly noted above, and probably either tears adhesions or even detaches the remaineder of the ECRB, and thus the pain reduction. But, also as noted, if a neural restriction, you will have a very unhappy person!
The muscle energy technique is as follows:
1. Flex elbow and relax the persons arm, and then apply AP glides to the radius to loosen up
2. Flex persons elbow to 90 deg, put your hand on their supinated wrist, and tell them to try and flex the arm as hard as they can. You will hear a "crunch" sound or a "click" as the radial head gets repositioned via the muscular contraction. When I get that "crunch", which does happen most of the time, I end up with more elbow extension and the people get better much faster.
As far as the eccentric/concentric theories, many seem to base their opinion on an article that was done on Achiles tendonitis. It was full of horrible research methodology, and those on my site may remember how I trashed it.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: How do you treat lat. epicondylitis - January 7, 2006 7:34:00 AM
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MPT
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Alex
I have not seen any pt's s/p blood injection. I did talk with one ortho who has a colleague who has tried it and reports good results.
Ginger: I really do plan on trying your techniques. I just got a pt on thurs with lat ep and maybe I will give it a go. I am just concerned that I won't be able to stay awake for 20 min of mobs. It is much harder to sleep at night with a 4wk old around.
FlaPt: Thats one hell of a week!!!
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