
Differential Diagnoses |
Joint |
Local arthritis |
℗ at Rest |
Joint |
Intra-articular pathology |
Clicking with motion, Locking in Extension & Catching |
Joint |
Radiocapitellar Chondromalacia |
- ℗ from throwing or racquet sports; valgus stress
- Clicking & Snapping
Compression Test:
Patient holds palm down & supinates & pronates fully extended arm |
Nerve |
Radial Tunnel Syndrome (RTS) & Posterior Interosseus Nerve (PIN) Entrapment |
RTS:
- anatomy: from the level of the radiocapitellar joint, extending distally past the proximal edge of the supinator
- Night ℗
- Localized tenderness over radial nerve 5cm distal to lateral epicondyle
PIN:
- anatomy: branch of the radial nerve that provides motor innervation to the extensor compartment
- Strength deficits of extensor musculature
- Weakness in finger, wrist & thumb movements
- Impaired ability to extend thumb (DeQuervain’s tendinopathy)
- Impaired ability to extend wrist in neutral or ulnar deviation
Tests:
- Resisted Hyperextension of Wrist (Cozen’s Sign) → ℗ in proximal radial forearm & over radial tunnel
- Resisted Supination (with wrist flexed) → ℗ in proximal radial forearm & over radial tunnel
- Passive Pronation, applying pressure on the posterior interosseous nerve → ℗ in proximal radial forearm & over radial tunnel + S1 supinator
- Resisted Extension of Middle Finger, Extended Elbow (Maudsley’s Test) → ℗
- Neurodynamic Tension Test
|
Nerve |
Cervical Referred ℗ or C5 Radiculopathy |
- Nerve Root; Disc Hernia
- Type of ℗ can vary
Tests:
- Axial Loading (Spurling manoeuvre)
- Shoulder abduction relief (Bakody’s Sign) → ↓℗
- Neck Distraction
- Valsalva manoeuvre
- Neurodynamic Tension Test
|
Ligament |
Posterolateral Rotatory Instability (PLRI) |
- persistent insufficiency of LCL complex, particularly the lateral ulnar collateral ligament
- ℗ from trauma causing elbow subluxation or dislocation
Tests:
- Posterolateral Pivot Shift (O’Driscoll’s Sign) (supine, arm overhead; supination & valgus with axial compression) → radial head subluxes at 40⁰ elbow flexion
- Posterolateral Rotary Drawer Test (supine, arm overhead, elbow flexed 40-90⁰)
|
Tendon |
Extensor Tendinopathy Lateral Epicondylalgia |
Tests:
- Tenderness on palpation over the lateral epicondyle
- Resisted Hyperextension of Wrist (Cozen’s Sign) → ℗
- Resisted Supination (with wrist flexed) → PB
- Passive Wrist Flexion with Radial Deviation (Mill’s Test) → ℗
- Passive Elbow Extension → ℗
- Resisted Extension of Middle Finger, Extended Elbow (Maudsley’s Test) → ℗
- Grip Strength Weakness
|
Stages of Tendinopathy |
Tenosynovitis
- inflammation of tendon & tendon sheath
- ℗ worse with activity
|
Tendinosis
- response to an overuse injury resulting in a pathologic cascade of changes in normal tendon reparative process described as a cycle of degeneration & attempted failed regeneration
- ℗ worse @ night
|
Reactive Tendinopathy |
- Non-inflammatory proliferative response, which is a short-term adaptive thickening in an attempt to reduce stresses
- Generally follows a period of acute overload or direct blow
- Fusiform swelling
|
Tendon Dysrepair |
- Loss of parallel & longitudinal alignment of collagen bundles
- Neurovascular ingrowth/proliferation from failed healing response
- Increase matrix disorganization & evident swelling
- Increased Tendon Thickening → ℗
|
Degenerative Tendinopathy |
- Degenerative Changes
- Extensive compromise of the tendon
|
Management of Tendinopathy |
Risk Level |
Prognosis |
Treatment Modalities |
High Risk |
- Co-existing neck or shoulder ℗
- Central Sensitization
|
- Prescribed meds
- Ergonomic/sport-specific advice
- Ice, heat, taping, brace, orthoses
- Electrophysical agents*
- Cervical and/or elbow manual therapy
- Exercise therapy (isometric contractions†)
|
Moderate Risk |
- Repetitive manual loads
- Co-existing elbow pathology
- Neuromuscular impairments
|
- Self-administered meds
- Ergonomic/sport-specific advice
- Ice, heat, taping, brace, orthoses
- Electrophysical agents*
- Elbow manual therapy
- Exercise therapy (progressive resistance‡, motor control, general upper limb)
|
Low Risk |
|
- General advice to reduce loads
- Self-administered meds
- Ice, heat
|
* EPAs include: cold (cryotherapy), heat (superficial thermal agents), electrical stimulation (TENS, NMES, HVPC), low-level laser therapy, short-wave diathermy, and therapeutic ultrasound |
† Isometric contractions: wrist 20-30⁰ ext, elbow 90⁰ flex, 30-60 sec in duration |
‡ Concentric/Eccentric loading: 2-3 sets of 10 reps, 4 sec for each direction
Emphasis is placed on maintaining neutral radial-ulnar deviation of the wrist
Progressions: (1) Increase load; (2) Greater elbow extension |
References
Coombes, B.K., Bisset, L. and Vicenzino, B. (2015) ‘Management of Lateral Elbow Tendinopathy: One size does not fit all’, Journal of Orthopaedic & Sports Physical Therapy, 45(11), pp. 938–949. doi: 10.2519/jospt.2015.5841.
Like this:
Like Loading...
Related
You must be logged in to post a comment.