1. DIAGNOSIS AND MANAGEMENT OF ELBOW PAIN

2. ELBOW PAIN Lateral elbow pain Medial elbow pain Posterior elbow pain

3. Lateral elbow pain - Causes Common –Extensor tendinopathy –Referred pain (cervical/ upper thoracic/ neural) Less common –Sinovitis of radiohumeral joint –Posterior interosseous nerve entrapment Rare –Osteocondritis dissecans (capitulum/ radius)

4. Lateral elbow pain - History History of pain –Onset, duration, character, severity, radiation, aggravating movements. –Recent change of activity –Treatment obtained –RA, DM

5. Lateral elbow pain- Examination 1.Observation 2.Active movements 3.Passive movements 4.Resisted movements 5. Palpation 6. Special tests

6. Wrist flexion with forearm fully pronated Examination of the patient with lateral elbow pain Active movement

7. Examination of the patient with lateral elbow pain Resisted muscle testing Wrist extension

8. Examination of the patient with lateral elbow pain Resisted muscle testing Extension at third metacarpophlangeal joint

9. Examination of the patient with lateral elbow pain Restricted muscle testing Grip strength, attempt to reproduce pain

10. Examination of the patient with lateral elbow pain Palpation Lateral epicondyle Try to locate painful site distal to the lateral epicondyle

11. Neural tension test Upper limb tension test with forearm pronation to isolate the radial nerve Examination of the patient with lateral elbow pain

12. Lateral elbow pain - Causes Common –Extensor tendinopathy –Referred pain (cervical/ upper thoracic/ neural) Less common –Sinovitis of radiohumeral joint –Posterior interosseous nerve entrapment Rare –Osteocondritis dissecans (capitulum/ radius)

13. Extensor tendinopathy Pathology –Degeneration of ECRB tendon in proximal 1-2 cm –Angiofibroblstic hyperplasia which contain large number of nociceptive nerve endings. –Microscopic tears in degenerative tissue leading to scarring

14. Process leading to development of ERCB tendinoathy

15. Clinical features 40 to 50 years Associated with repeated wrist extension activity Maximal tendernes is 1 to 2 cm distal to lateral epicondyle Rest of the muscle is tight and hypersensitive Tests – Mills’ test, Extension of middle finger *perform neural tension tests *Examine cervical spine

16. Treatment A combination of different treatments necessary 1.Control of inflammation with rest, ice, NSAIDS 2.Electrotheraputic modalities ultrasound, laser, galvanic stimulation 3. Local heat therapy (heat retaining brace) 4. Massage therapy sustained myofascial tension transverse friction digital ischemic pressure 5. Dry needling of trigger points

17. Treatment cont. 6. Muscle stretching 7. Muscle strengthening 8. Treat other components of pain 9. Correct predisposing factors 10. Corticosteroid injection 11. Surgery 12.Graduated return of activity

18. Sustained myofascial tension Applied to the injured area from proximal to remove fibrous irregularities Massage techniques

19. Transverse friction with extensor tissue under tension (wrist and hand flexion)

20. Stretching of ERCB tendon Muscle stretching

21. Strengthening exercises for elbow Concentric and eccentric

22. Treat other components of pain Cervical mobilization

23. Back hand technique Correct Incorrect Correct predisposing factors

24. Steroid Injection

25. Posterior interosseous nerve entrapment Possible entapments @ fibrous bands in front of the radial head Recurrent radial vessels Arcade of Frhose Tendinous margin of the ECRB muscle Lateral elbow pain

26. Neural stretch Posterior interosseous nerve entrapment

27. Medial elbow pain Common Flexor tendinopathy medial collateral ligament sprain acute chronic Less common Ulna nerve compression avulsion of medial epicondyle traction apophysitis of medial epicondyle Referred pain

28. Medial elbow pain- Flexor tendinopathy Clinical features Repeated strain Localized tenderness just below medial epicondyle Pain on resisted wrist flexion and pronation Test – reverse Mills’ test Treatment – Same liens as lateral tendinopathy

29. Medial elbow Pain – Flexor tendinopathy Pain is reproduced with resisted wrist flexion and forearm pronation

30. Stretching exercises for forearm flexors and pronators

31. Medial elbow pain Medial collateral ligament pain Acute injury Chronic injury Clinical features localized tenderness instability in valgus strain Treatment activity modification local electrotheraputic modalities ulrtasound muscle strengthening strapping

32. Assessment of the integrity of the medial collateral ligament

33. Medial elbow pain- Ulna nerve compression Ulna nerve entrapment Traction injuries Inflammatory adhesions Recurrent subluxation of nerve Irregularities in the bony grove Clinical features posteromedial elbow pain neurological symptoms tender nerve TREATMENT Local massage therapy Neural streching Nerve transposition

34. Nural streching – ulna nerve The strech can be increased by further shoulder abduction, Forearm supination and wrist extension

35. Posterior elbow pain 1.Olecranon bursitis 2.Triceps tendinopathy 3.Posterior impingement

36. Olecranon bursitis