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Re: How do you treat lat. epicondylitis
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Re: How do you treat lat. epicondylitis - January 9, 2006 8:42:00 AM
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nari
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From: Australia
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I totally agree with Jason's last post...
Clydes, for your own benefit and confidence, read up on pain physiology. The whole world of therapy will change for you in how you regard 'injury' and what 'causes' pain.
David Butler's Explain Pain is also a good start, as is his Sensitive Nervous System.
Treating pain only where it is felt by the patient is outdated thinking.
Having to follow a dr's 'orders' is also outdated, but having no direct access is partly to blame for that. Hope that system changes across the USA - you guys won't know yourselves.
Happy reading.
Nari
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Re: How do you treat lat. epicondylitis - January 10, 2006 6:21:00 AM
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paulpt
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I must have been doing something more productive Firday night, rather than reading this interesting post.
I am currently treating a patient who had a reaction to cortisone injection #2 to the lateral elbow for 'tennis elbow'. First she had an absence of pigmentation and then she developped a darkening (as mentioned by someone else). Most significant was an atrphic change in the area in which she was missing a big chunk of the musculature. She lacked 30 degrees of extension, and each time I moboilized, got full ext... and she returned lacking 30 degrees. Did this four times before referring her back. Wish I had done the test for rotary instability - as the cortisone shot had also caused wasting of the ligamentous complex. She is now s/p repair of the lateral collateral complex.
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Re: How do you treat lat. epicondylitis - January 18, 2006 1:36:00 PM
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PJM
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From: Australia
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I'm not sure if anyone has asked this yet, but is your lateral elbow pain a 'spot only' or does it extend down into your forearm laterally?
Have you tested your painfree grip strength from to compare affected to unaffected sides, is there a deficit?
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Re: How do you treat lat. epicondylitis - January 18, 2006 7:49:00 PM
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Rwantz
Posts: 84
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From: Middletown, PA
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clydes, why wouldn't you try the cortisone? Decrease the inflammation...Decrease pain...Enable you to work on the problem better...Possibly better and faster healing.
I get amused sometimes when PTs throw out obscure reasons for elbow pain. I was reading in another forum about a PT that was treating shin splints with sacral glides. Where is the evidence behind some of this???
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Re: How do you treat lat. epicondylitis - January 19, 2006 1:28:00 AM
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JLS_PT_OCS
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Rwantz-
There is a growing body of evidence that supports the contention that much elbow pain can be referred. While it's interesting that you are "amused" by it, it implies you are dismissing it, which is curious.
We have addressed the concept of the supposed "inflammation" you speak of - given the current state of evidence in the treatment of lateral epicondylitis and clydes' description of his pain, do you feel there is an inflammatory process present? If so, could you say why?
Or do you contend that you fully understand the problem of lat epicondylitis and that alternate explanations based on emerging evidence and scientific theory are useless?
I'm "amused" to hear your response.
J
_____________________________
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 19, 2006 4:45:00 AM
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Rwantz
Posts: 84
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From: Middletown, PA
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Jason,
Based on the mechanism, which I suppose could involve nerve tension (possibly), wouldn't it most likely be an elbow injury. I do agree with clydes that you would not treat the neck for lateral epi. For elbow pain that may be warranted. I do respect each person's view, however do we have to go to the neck? Can't an elbow injury be an elbow injury perhaps?
Also, wouldn't a tear produce inflammation? It was on the MRI.
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Re: How do you treat lat. epicondylitis - January 19, 2006 12:33:00 PM
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JLS_PT_OCS
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oh, Rwantz....
What does "a tear" have to do with the inflammatory process? Do such tears always cause inflammation? If a tear is inflamed, is it always so? If not, does the pain behave differently when the inflammation subsides? Would we expect the pain to be different?
Why does the tear seen on the MRI have to be the one and only cause of his pain? Why has his pain persisted beyond the usual timeframe for tissue healing? Does the inflammatory process explain this?
It's unfortunate that some people don't want to consider treating the neck in patients with persistent lateral elbow pain of any cause. Smart people seem to think that it might be helpful:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15609491&query_hl=2&itool=pubmed_docsum
When dealing with chronic pain, putting on blinders is rarely helpful. Of course, as you said, an elbow injury is just an elbow injury. We're not really talking about an injury here, we're talking about chronic pain that is not explained well by assuming it's all "a tear, and inflammation". Certainly the cortisone may help. Maybe it won't.
But your refusal to consider certain aspects of treatment for this condition and your weak grasp of pain theory is "amusing" to say the least.
Sorry, I don't mean to be harsh. But your position is not supported by what we currently know about the clinical course of lateral elbow pain (with or without 'trauma'), pain physiology, or even the inflammatory process.
J
_____________________________
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 19, 2006 3:23:00 PM
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PTupdate.com
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Jason's line "Why does the tear seen on the MRI have to be the one and only cause of his pain?" is the failure of so many in medicine. Just because something is found on a scan does not mean that is the source of their problem
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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www.PTupdate.com
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Re: How do you treat lat. epicondylitis - January 19, 2006 4:50:00 PM
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ginger
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From: Melbourne Victoria
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Jason , you certainly find ways to express the sentiments and reasoning that go with evidence based medicine, as well as allowing for the free thinking /rational attitudes that go with pragmatism. I support you.
I read an article in the current edition of Australasian Musculoskeletal Medicine journal ( vol 10 no 2 ) by the Chairman of the FIMM academy. I'm not sure it can be accessed online, so I've lifted the following from his article ,
"In support of pragmatism"
Evidence based maedicine (EBM ) is a late twentieth and early twenty first century phenomenon. It is recognisably importanat, but in practical terms it has to incorporate intuition and experimenting . Evidence informed practice ( EIP ) is more digestable to many people than EBM. It infers that a little wisdom and patients involvement in values and context are essential components.
Exponenets increasingly emphasise the limitations of using evidence alone to make decisions, and the importance of the values and preference judgements that are implicit in every clinical management decision.In other words good science is not the sole determinant of the right thing to do."
We are fully rational only if we take advantage of every means, within and outside of ourselves in finding solutions.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: How do you treat lat. epicondylitis - January 19, 2006 9:48:00 PM
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Randy Dixon
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Is "EIP" your term Ginger or someone elses? I ask because I think you bring up a good point, the what many practitioners call EBM doesn't seem to be EBM. I would consider Jason one of those, a sort of EBM with more flexibility and open to more possibilties. I've used the term BEM (Best Evidence Medicine) but I think yours is better.
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Re: How do you treat lat. epicondylitis - January 22, 2006 11:43:00 AM
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ginger
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From: Melbourne Victoria
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Randy the chairman of the FIMM is Dr Michael Hudson. It was he who I quoted with the EIP thoughts. I ought to have added his name in my quote, sorry bout that.
Science and the strict methods that go with "proving" a concept or method, almost always follow periods of observation, allowing for understanding to be derived from what has gone before. Common sense guides us in ways thay science alone cannot. By this I mean a general field of allowing for what is , for what is consistant with our education and values to form the basis of most interactions with the world of phenomomena.
Not so long ago Stanford and the team of diligent behavioural scientists there published a study showing an expectant world that yes , babies do have emotions. Ta daaaah. oh really. Nooooo.
Researchers in Townsville came up with evidence that, yup, fish feel pain. Amazing.
Lets not forget to feel the freedom to explore, to be mindfull of alternatives that fit the common sense bill.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: How do you treat lat. epicondylitis - January 22, 2006 4:21:00 PM
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bp2317
Posts: 55
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From: Columbus, GA
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liz -
that first link looks like a good read. thanks!
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Brian Phillips, PT
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Re: How do you treat lat. epicondylitis - January 22, 2006 4:32:00 PM
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ginger
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"phenomomena",= anything your mother does.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: How do you treat lat. epicondylitis - January 23, 2006 3:45:00 AM
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JLS_PT_OCS
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WEll, EBM was always about integrating evidence with that flexibility and openness that we all think is important.
No need for a separate term, as no one in the EBP/EBM world is interested in shutting off valuable areas of pursuit.
It is my impression that only those who oppose the basic principles of EBM/EBP tend to characterize it as narrow and limited in scope.
J
_____________________________
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 23, 2006 12:40:00 PM
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clydesdale6
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well, let me fill you guys in. For starters, i have not gotten the cortisone injection. I have read the autologous blood article and I agree with much of the reasoning. One thing i dont like with the study is that they also immobilize the people. I think this throws another variable into the mix. But, I have tried strenghthening it. My pain has reduced by at least 50% over the last few weeks. My grip has improved from 80lbs to 100lbs, and my usual is 125lbs. What i have been doing is basic wrist extension with a 5lb weight at 90 elbow flexion, then 45, then full ext. I have progressed to 10lb and do 3 sets in the fully extended position. At first this was quite painful. My theory was that I would be "breaking up the tendonosis", possibly as if doing tfm. The tear on the mri was not of surgical stature so I felt "what the hell do i have to lose and pushed on. Within the first week i felt a major improvement. I have given my ortho the article and I will see if he would like to give me an injection. But i will stay away from the steroid for now.
So, I believe this confirms that we are dealing with an elbow problem. In my case I knew the neck was not an issue. I imagine I am dealing with tendonosis. So i will progress with strengthening and put this behind me.
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Re: How do you treat lat. epicondylitis - January 23, 2006 12:43:00 PM
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dosrinc
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From: Bonita Springs
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Confirms it is an elbow problem?
Not until you clear the neck.
Rick
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Re: How do you treat lat. epicondylitis - January 23, 2006 2:44:00 PM
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JLS_PT_OCS
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From: USA
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I agree with rick.
But you good luck thus far with the eccentrics indicate that likely Duff was spot on when he suggested tendonosis as the most likely problem, hence the extensor tendon the most likely tissue of origin.
J
_____________________________
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 23, 2006 3:33:00 PM
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clydesdale6
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Rick, this is how i cleared the spine:
No cervical ROM loss
No upper limb tension
No peripheral symptoms except localized palpatory extensor tendon pain.
No strength loss except wrist extension, supination and grip.
And most importantly, the subjective doesnt fit with a neck problem.
Please correct me if I am wrong in my thinking.
If Duff is the guy that suggested tendonosis, then i say thank you Duff!! I knew it was elbow, i just wasnt quite sure how to attack this. I was sitting on the fence with the injection.
I still don't seem why some thought and may still think it is an elbow problem. I am not insulting you, I just want to further understand your reasoning. Thanks
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Re: How do you treat lat. epicondylitis - January 23, 2006 4:03:00 PM
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dosrinc
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From: Bonita Springs
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clydes, my thinking is that if it was just an elbow problem it would have resolved by now, I would still check C45 and C56 for segmental mobiity and nerve root/ facet irritability before I would declare the cspine cleared, glad things seem to be improving, if they linger or come back next time with lesser trauma, i would be sure to check the neck. good luck
Rick
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