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Re: How do you treat lat. epicondylitis
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Re: How do you treat lat. epicondylitis - January 7, 2006 7:36:00 AM
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MPT
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I forgot to mention that one should r/o nerve tension with the mills manip. Even without positive ULTT I have the pt sidebend their neck toward the treatment side just to take the system off tension alittle.
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Re: How do you treat lat. epicondylitis - January 7, 2006 7:36:00 AM
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TLB
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Duffy,
That reminds me I need to renew my subscription to PTupdate.com and for you guys who are not members he has some great photos and movies of different techniques like the one mentioned above. Check it out if you haven't already, it's well worth the price.
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Re: How do you treat lat. epicondylitis - January 7, 2006 9:06:00 AM
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PTupdate.com
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Todd...you don't have to renew......membership was switched to lifetime for everybody, so get back on and enjoy!!
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
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www.PTupdate.com
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Re: How do you treat lat. epicondylitis - January 7, 2006 10:54:00 AM
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MPT
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I just signed up for the site. I have been meaning to do this for awhile now. I look forward to hours of fun!!!!
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Re: How do you treat lat. epicondylitis - January 7, 2006 2:11:00 PM
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clydesdale6
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No problem Ptupdate, Thanks. I am going to read this article and if it sounds like a sensible idea, I will be my own experiment and ask the ortho to give it a try. At this time I will hold off on cortisone.
Someone please clear up these eccentrics for me. Today I did eccentrics with a 5 and then a 10lb dumbell. I passively did the concentric and the lowered to a pace of 6 seconds. I have no clue what the article suggested and then i read here that you guys have them do the concentric also. So it sounds like just regular dumbell extension of the wrist, or do you have a specific method???
Jason, I respect you perspective, but I still don't think our examples are the same. You had a car ride and it sounds like it didn't give you the symptoms right away and later that night you had a problem. Plus usually with radiculopathy you don't get palpatory pain on the referred area. I can't remember ever really palpating pain in a calf that I was then able to centralize and turned out to be a spinal problem. In this case it was instant or atleast within a few seconds. I knew I made a booboo and when I touch the same spot I know I still have a problem. I am still not ready to take the leap off of the obviuos. But lets see how I feel after I have exhausted everything else.
I do have one question slightly off topic with regards to the referred pain theory. Do you guys get a script for the neck before you do the mobs? If I think it is coming from somewhere else, I will get a script for that area. From a legal standpoint, I can't take the risk of going for the spine if the script says shoulder or elbow. God forbid the patient wakes up the next day sore and says "what did you do", I don't want to worry about it. Plus the referring Doc might get a little upset or think I am getting quacky. I would get the script before I did it.
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Re: How do you treat lat. epicondylitis - January 7, 2006 2:33:00 PM
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Alex Brenner PT MPT OCS
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Duffy,
Will you list the Achilles article that you trashed? I am curious if it is the one that I reference often. Thanks!
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Re: How do you treat lat. epicondylitis - January 7, 2006 4:00:00 PM
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srcase
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Clydesdale,
I'm pretty sure you can get palpatory tenderness at referred sites due to inflammation of the nerve itself and it's termination at the motor unit. Don't have my Shacklock book sitting here, so I can't quote the exact mechanism.
Do I get a script to treat centrally? I try to make sure I'm covered that way, yes, but sometimes you just do a trial treatment and if the patient improves, the doctor is usually more than willing to sign off on it.
Sarah
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Re: How do you treat lat. epicondylitis - January 7, 2006 4:09:00 PM
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PTupdate.com
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Alex, you are a member of PTupdate.com, and the first article is under the DAILY UPDATES section, and the second is in Archives 9:
This article was reviewed on 5/23/05:
ECCENTRIC TRAINING IN PATIENTS WITH CHRONIC ACHILLES TENDINOSIS: NORMALIZED TENDON STRUCTURE AND DECREASED THICKNESS AT FOLLOW UP. The British Journal of Sports Medicine, Vol. 38, 2004.
This is the one I really did not like, and it was reviewed and critiqued on 8/11/04
SUPERIOR SHORT-TERM RESULTS WITH ECCENTRIC CALF MUSCLE TRAINING COMPARED TO CONCENTRIC TRAINING IN A RANDOMIZED PROSPECTIVE MULTICENTER STUDY ON PATIENTS WITH CHRONIC ACHILLES TENDINOSIS. Knee Surg, Sports Traumatol, atrhsoc 9: 42-47, 2001
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 7, 2006 4:13:00 PM
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pt_davey
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The way I look at it if i'm asked to treat elbow pain it doesn't matter if I work on their neck, scapula or their eardrum as long as the elbow pain goes away. Even if it doesn't as long as I can justify my treatment I don't worry about it.
ps. Duffy, on lonely friday nights I alternate hands to avoid RSI
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Re: How do you treat lat. epicondylitis - January 7, 2006 7:27:00 PM
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FLAOrthoPT
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sick joe, sick
but funny
then again I was toasting the new england patriots soon to be super bowl champs again a bit too much tonight, I will look in AM to see if still funny-
Ben
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Re: How do you treat lat. epicondylitis - January 7, 2006 8:51:00 PM
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TLB
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You go Duff, Alex check the site!
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Re: How do you treat lat. epicondylitis - January 8, 2006 5:37:00 AM
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dosrinc
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Clyedsdale,
regarding do I get a script to treat the neck, no-way but I do include manual therapy techniques as part of my treatment plan that the docs sign off on and if cervical pathology is found on the eval it is included in the report to the physician, most of my referrals come in as eval and treat, most without true dx, maybe neck pain, lateral elbow pain, referrals like that require that you do a complete exam and I would say you are more subject to liability if you DONT screen and treat the cervical spine when any upper ext dysfunction is given as the dx than if you DO, It is part of the Guide to PT practice and should be the expected course of a PT eval to fully evaluate, to just treat the elbow without at least screening the C-spine may be seen as negligent behavior if the pt. is later found to have a mid cervical disc problem contributing to the elbow pain and you "missed" it. Maybe I am wrong but that is how I feel.
Rick
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Re: How do you treat lat. epicondylitis - January 8, 2006 11:45:00 AM
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clydesdale6
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Rick, I think we agree but are on different pages. Lets use me as an example. I come into the clinic and tell you my wheel barrow story and I have a script that says lateral epicondylitis. You then start treating and determine you want to mobilize my c-spine, which is a far cry from screening it. YOu now decide to treat the c-spine in order to treat my elbow pain. What have you done to cover yourself. Do you send up your plan of care to all M.D.s before you tx? If you do, do you specifiy that manual tech. will be done to c-spine. For all of our medicare pts we have to send a plan of care and we can check off man. tech and the M.D. will sign off on it. But if it doesnt state otherwise, I can see where the M.D. would think the manual tech is being applied to the elbow. I am not arguing at all that you should always screen proximally and do a thorough eval. But if i find something in that screen that i want to address, I will no doubt get a script. I cant see mobilizing a spine in order to treat a patient that has a script for tennis elbow, unless I have cleared it with the MD. The simple fact is that many MDs do not buy into that and God forbid you get put on the stand, I don't think you will have much support for your theories. I have been to one deposition, not for something I did, and have a coworker who has been sued twice for bogus things. Bottom line is MD. vs PT. is very ugly and the MD carries much more weight. I am not debating the idea of screening. But in my case, I would be clear to the MD what I plan on doing and make sure he signs off on it. Thanks
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Re: How do you treat lat. epicondylitis - January 8, 2006 11:58:00 AM
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ginger
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To chris adams ( and others who have enquired about my hands), Yes actually my hands are rather gnarled and wretched, but not from mobilisations. I had a few other careers before physio, farming, fishing,teaching dance, film making, to name a few. My hands bear the scars and marks of honest toil. Bilateral dupytrons as well. I do credit my hand strength in some way to having milked by hand as a boy, morning and night. I remember that was the only time my hands ever ached. It was also the only time I allowed a female to **** in my bucket, but thats another story.
I don't use a "knob", or any other device. My thumbs are perfect for the job. As mentioned here previously, most newcomers to continuous mobs last about five minutes, improvements to tolerance can be expected over a few weeks and months of persistant practice. The rewards are too high not to have your thumbs be strong and fatigue resistant.
Cheers
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The Grand Pediculator
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Re: How do you treat lat. epicondylitis - January 8, 2006 12:07:00 PM
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dosrinc
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Maybe it is just me or maybe that I have been doing this for 15 years but if I get a referral from a physician with a dx of lateral epicondylitis I treat it as a referral with a suggestion of what the physician thinks the problem is not as a "treat this and only this doctrine"
It is fully within our scope of practice to evalute and treat, we have direct access in our practice act in Florida so I am covered from that standpoint. The only reason I need a signed treatment plan from a physician is to get paid, not to treat whatever I think needs treating.
You seem to suggest that by treating a c-spine with mobilizations if I deem they are necessary puts me at risk for litigation, I ask you what is the risk of that, where in the literature have you ever seen someone harmed by having joint mobs performed on them by a knowledgeable clinician? I would again argue that there is greater risk (although also very negligable) in not treating the cervical spine in someone who presents with appropriate findings. Lets take this scenario, say you come to me with your complaints of elbow pain, I exhaust your benefits treating your elbow unsuccessfully, you end up going back to your physician or another clinician who says hey, maybe we should look at your neck, you get an MRI that shows a C56 foraminal stenosis with nerve root impingement, wouldnt you be awfully pissed at me for spending all of your rehab dollars treating your elbow?
I try and eval and treat on the same day so if I think your neck is part of the problem I am certainly going to treat it and the eval will make it clear as to why. If you can explain the scientific rationale behind your treatment and if you know what you are doing you wont have any issues. The docs that refer to me EXPECT that I am going to be screening the spine and applying the appropriate treatment, that is why they send to me.
Rick
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Re: How do you treat lat. epicondylitis - January 8, 2006 12:10:00 PM
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SJBird55
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Clyde, with my plan of care, I change the Dx if need be or add a secondary Dx... I specifically state what I plan on treating - if you were to attend PT and I planned on treating your cervical spine - well, I'd state it in my plan of care. Since I also send my evaluative findings with the plan of care, something would have been found within that typed evaluation page that lead me to the treatment plan. I fax both pages to the referring physician and request a signature, date and for the plan to be faxed back to me. I have only had one time that a surgeon refused to sign my plan and called me up, chewed my butt out, put me in my place that he controls what is done in PT. Almost all of the time, the referring physician signs it (and 99.9% of my referrals state "treat per evaluation"). I've wondered if the referring physicians even read the plans of care. I don't clear a treatment plan prior to treating a patient if I plan on treating the patient - my view is that physical therapists are THE neuromusculoskeletal specialists. Now if there is a huge difference in the referred Dx or if I have some major red flag concern that is a different story (in those cases the patient is put on hold until the situation is resolved).
Clyde, an MD may not buy into it, but there is published evidence in peer-reviewed literature that can be a framework in which to base your rationale. There has been more and more published evidence on treating the cervical spine with elbow complaints. There has been more and more evidence published on treating the cervical and the thoracic spine with shoulder complaints.
Rick, our posts crossed - I ditto your post. I have no fear of litigation. Fear doesn't motivate or disincline me in my decision-making process.
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Re: How do you treat lat. epicondylitis - January 8, 2006 1:58:00 PM
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clydesdale6
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I hope you guys realize that I agree with your clinical reasoning, just not with the process. Bird the example of myself is an instance where diagnosis could be VERY different from what you tx. If the ortho gives you the Lat epi. script and you tx for a radiculopathy, that is VERY different. If this was not the type of patient, ie medicare, that i send a plan of care for every single time, i certainly would send one this time if i thought it was radiculopathy. I would not start treating for a cervical diagnosis if the script says lat epi. I would get on the phone and explain my position to the MD. If the MD say no way and I consider explaining my position to the patient and let them make the decision to seek a second MD opinion. But I cant tx a spinal condition with a SPECIFIC limb diagnosis. Now If I get "LEG PAIN" from a GP that is a different story. But lat epi from an ortho?? We are all shaped and influenced by our experiences, my experiences tell me pick up the phone and cover my ass.
Now back to my **** elbow- anybody want to explain the EXACT method of the eccentrics?? Is there a time or length of contraction that was recommended in the study?
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Re: How do you treat lat. epicondylitis - January 8, 2006 2:41:00 PM
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VagusX
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Does anybody give patient's wrist spicas?
I tend to start chronic patient's wearing them early to see if I can reduce their symptoms by elimianting/reducing wrist extension. It seams to work with about 50% of my patients. It may be worth a try for you Clyde since you are exausting many options.
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Re: How do you treat lat. epicondylitis - January 8, 2006 3:21:00 PM
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dosrinc
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Clydes, I would agree with you that if you are not comfortable treating without running it by the doc first then you are better of not treating, now we need to get you comfortable with it.
Rick
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Re: How do you treat lat. epicondylitis - January 9, 2006 5:44:00 AM
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JLS_PT_OCS
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I think Rick nailed the "cover your rear" end.
We are 100% Direct Access in the military, so sometimes I forget the silly games the legislatures make you guys on the outside play.
Clydes - for my radiculopathy, my calf was painful, which is why I thought DVT. Once again, you can't sort out referred pain just becuase there's a hx of trauma. But take your case for a moment. You have passed all the known thresholds for soft tissue healing. Why would this pain persist?
Like many patients, if you were working with me I would let you know that it is not so much the original injury, but the changes and compensations that have happened since that we are dealing with.
If you don't think referred pain can cause local tenderness, then you should pick up Michael Shacklock's Clinical Neurodynamics, and update yourself on the science behind nerve tension and injury. It certainly opened my eyes.
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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
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