Physio Charlie - elbow

Upper limb disorders Occupational aspects of management

noreply@blogspirit.com (PhysioCharlie) — Mon, 26 Oct 2009 16:29:10 +0100

Upper limb disorders Occupational aspects of management

This is a very up to date look at the evidence for the management of ULD's in the workplace. As with a lot of research, the only good evidence they have found is that multidisiplinary treatment with a biopsychosocial approach for non specific arm pain and changing a keyboard for carpal tunnel are better than usual care.

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Treatment of Tennis Elbow

noreply@blogspirit.com (PhysioCharlie) — Wed, 17 Sep 2008 12:25:36 +0200

I found this discussion on Tennis Elbow on iCSP:

Hi
I am looking at the evidence for using Orthopaedic Medicine approach (DTFM & Mills manip) for treating Tennis Elbow and it is sparse!
Alot of the papers say that the evidence base has developed througnthe personal experience of Physio's who utilise this treatment in a rehab setting.

I am hoping for a few responses from Physio's who use "Cyriax treatment" for Tennis Elbow in their clinical practice and what evidence or hospital protocol they are following in doing so. I would be equally as interesed in hearing from those who use alternative approaches and why they don't use Cyriax treatment.

Thank You
Ellie
Newly Graduated Physio

Showing 1 to 10 of 11

Title:	injections
Added by:	manter_physio
Posted:	12 December 2007 16:48

Try looking up the latest thinking on sclerosing injections rather than steroids

Title:	tennis elbow
Added by:	vicclarke
Posted:	30 November 2007 10:23

Hi Ellie

Nothing to do with side effects or cost (it is actually cheaper than multiple physio sessions). I personally prefer to use non invasive procedures, as I am sure do most physios. I have however used injections for acute and sub acute presentations that are very painful to massage. I have had good results from injection therapy as well as the other modalities, my choices depend on clinical presentation and reasoning but also a little intuition.

Vic

Title:	Thank You
Added by:	elliejohnson02
Posted:	16 November 2007 14:55

Thank You all for your responses

A question for vicclarke: Why do you only resort to injection for the resistence ones? Is it a cost thing or are you wary of side effects?

Thank You again it is very interesting,

I am thinking of doing a study to find out what the reasoning is behind PT's treatment of tennis elbow. I think some guidelines would be helpful as it is such a common condition and as alot of you said results can be variable, and the research (I have been looking) is very conflicting.

Thanks again

Title:	tennis elbow and cyriax
Added by:	007G
Posted:	16 November 2007 13:33

I have done various courses in the past including some Cyrix and Maitland.
I am very much in agreement with the comments from Wendy Emberson regarding connection with cervical and neural origins of both golfers and tennis elbow.

Title:	tennis elbow
Added by:	vicclarke
Posted:	16 November 2007 05:29

I have had good results with Mills' manip, I always "prepare" the tissues with TFM first. The resistant ones I inject. Whatever treatment I use to reduce the symptoms I always progress to eccentric loading rehab. Diagnosis is of course important and I rely on palpation and resisted extension testing, resisted middle finger extension testing is usually positive in genuine lateral epicondylitis

Vic

Title:	tennis elbow and Cyriax
Added by:	Wendy Emberson
Posted:	15 November 2007 18:12

I used DTF, Mills manips, US and IFT for tennis elbows for many years following the Orthopaedic Medicne course I did with Jimmy C back in 1974! The results were very vaiable and it was the one condition that I would not try and predict an outcome. Patients would come in with years of problem elbows and they would get better very quickly or they would take for ever! Since the first neural tension course I did with Louis Gifford back in the 80's, I would think I have seen maybe 2 or 3 genuine tennis elbows/ golfers elbows/ carpal tunnel cases. All the others have proved to be from the cervical spine ie target tissue to the limb. They all have ULTT signs and limited ROM in the c/spine etc.They respond very quickly to manipulation, IFT, acupuncture and rehab programme and management ie within 2 or 3 sessions max. Mobs take abit longer if manips are not appropriate. I strongly believe that neuropathodynamics is the name of the game especially having seen just how the nerves move/slide/glide etc in a neck/upper limb dissection as well as all the research to back it up - see David Butler etc etc

Title:	eccentric training + cyriax
Added by:	araval
Posted:	01 November 2007 16:15

hi
i find combining cyriax style of treating TE i.e. using frictions +/- mills manipulation along with eccentric training of common extensors and some work place adjustment i.e. using light equipments, thinner grips works well

Title:	CEO pathologies
Added by:	johanna
Posted:	30 October 2007 21:08

Hi
Yes to all of the above. There was a Dutch study in 'Physiotherapy' some years ago and there is a cochrane database overview on this condition. Also the pathologic state tendinitis versus tendinosis will identify a pathway for treatment.

Title:	Current evidence in management of tendinopathy
Added by:	manter_physio
Posted:	29 October 2007 22:23

The best evidence out there for tennis elbow management is around eccentric exercises. You need to look up Alfredson and Ohberg! Their studies are excellent and the conclusions make sense.
Past experience has taught me DTFs have no effect, neither does ultrasound and seem to just make the therapists hands ache!

Title:	tennis elbow
Added by:	molly
Posted:	29 October 2007 17:16

Just for information - I had bilateral tennis elbow 4 years ago and it opened my eyes to how much patients can suffer - it really was very disabling.
I tried ultra-sound, frictions, acupuncture, 3 x steroid injections in each elbow and still ended up with, (very successful), surgery on the most painful one.
Once that had healed the other elbow also recovered on its own.

Olecranon Bursitis

noreply@blogspirit.com (PhysioCharlie) — Tue, 05 Aug 2008 13:17:15 +0200

I found this on Emergency Medicine website:

http://www.emedmag.com/html/pre/wou/0402.asp

"A 60-year-old man sought medical attention in the emergency department for painless elbow swelling that had developed gradually over the previous week. He could not remember falling or any other precipitating trauma. Examination revealed a painless, fluctuant, mobile, homogeneous mass about the size of a golf ball over the olecranon. The skin was intact; no warmth or tenderness was noted, and the joint had full range of motion. The patient was afebrile. Radiographs revealed no evidence of fracture, foreign body, or joint effusion. Though his medical history documented only well-controlled hypertension and no current anticoagulant use, the patient thought he remembered having the same problem 15 years ago and "getting a shot for it." Most of his afternoons, he did admit, were spent with his elbows on a bar as he chatted with friends over a "few beers." That revelation led one examiner to assume that the elbow mass was probably a bruise or other trauma sustained while the patient was intoxicated and that it should be treated with an elastic bandage and some ibuprofen. A logical conclusion, it would seem, but the examiner was overlooking another possibility."...

What is the diagnosis?

"The actual diagnosis was an accumulation of sterile fluid in the olecranon bursa, of which this was a classic example. Though neither painful nor acutely inflammatory, the disorder is nevertheless referred to as olecranon bursitis. The exact etiology remains unknown in many cases, but generally the condition has been ascribed to minor or repeated trauma to the elbow. Radiographs are usually obtained because patients often conjure up some type of trauma in the history to explain the swelling. A calcific spur on the olecranon is a common finding but has no diagnostic or etiologic significance.
A more serious variant of olecranon bursal fluid accumulation is septic olecranon bursitis, which is usually caused by gram-positive bacteria such as Staphylococcus aureus. This is easily distinguished from benign sterile fluid accumulation by significant pain and tenderness, more diffuse swelling, and redness and warmth of the skin over the area. It is often accompanied by fever and leukocytosis. (Acute gouty bursitis, however, may mimic a bursal infection.) Septic bursitis usually occurs in patients with a predisposing factor such as diabetes or a break in the skin. Drainage and antibiotics, occasionally by parenteral administration, are required. A final consideration in the differential diagnosis of this case was hematoma, which would have been likely if the patient had been taking coumadin.
The patient would likely have returned soon if misdiagnosed, since spontaneous resolution of benign olecranon bursitis is unusual. The fluid needs to be aspirated, followed by injection of a long-acting corticosteroid. Without the steroid injection, the fluid typically reaccumulates. After the procedure, an elastic compression bandage can be applied; usually there is no need for analgesic or anti-inflammatory medication. Culture and additional analysis of the aspirated fluid rarely provide any useful information and is not standard if infection can be ruled out on clinical grounds."

Emerg Med 34(4):55, 2002

Tennis elbow

noreply@blogspirit.com (PhysioCharlie) — Wed, 22 Aug 2007 15:40:00 +0200

Found this on Tennis elbow:

http://www.nismat.org/ptcor/tennis_elbow

Olecranon bursitis

noreply@blogspirit.com (PhysioCharlie) — Tue, 23 Jan 2007 10:35:00 +0100

I had a patient come to see me with bilateral tennis elbow and L olecranon bursitis. I advised the patient to: RICE and have the bursa aspirated and injected with corticosteriod, was this correct? I researched the web and the advice was similar:

http://orthopedics.about.com/cs/elbow/a/olecranonbursa_2.htm

http://www.prodigy.nhs.uk/patient_information/pils/olecranon_bursitis.htm

I could also advise the patient to wear an elbow pad. He sleeps on his elbow which may be a cause of the problem.

Tennis Elbow and the effects of a Cx Lateral Glide Rx

noreply@blogspirit.com (PhysioCharlie) — Fri, 11 Aug 2006 11:24:52 +0200

cervicobrachial_pain.pdf

This study states that; "A cervical lateral glide mobilization has positive immediate effects in patients with subacute peripheral neurogenic cervicobrachial pain if a cervical segmental motion restriction is present which can be regarded as a plausible cause of the neurogenic disorder or as a contributing factor that impedes natural recovery."

Elbow control

noreply@blogspirit.com (PhysioCharlie) — Fri, 04 Aug 2006 12:30:00 +0200

My colleague emailed me an article on elbow control:

elbowforearm_20stability.pdf

"Neural compression of the thoracic outlet is characterised by referred pain and paraesthesia primarily in the ulnar nerve distribution with some median nerve involvement and motor changes to the finger flexors and the intrinsic muscles of the hand (Halle 1996). This referred pain or paraesthesia is commonly reported as elbow or forearm symptoms.

Several specific muscle dysfunctions can be related to thoracic outlet compression (McClune et al. 1998):

1.‘Short’ or overactive anterior or middle scalene muscles directly compressing the neural plexus at the interscalene triangle.

2. Elevated 1st rib compressing the costo-clavicular space (secondary to short scalenae).

3. Scapular depression or downward rotation compressing the costo-clavicular space (secondary to a loss of

scapular control associated with inefficient serratus anterior and trapezius muscles).

4. Short or overactive pectoralis minor directly compressing the costo-clavicular space.

The cervical spine, scapulo-thoracic and gleno-humeral joints and related neural and myofascial structures may influence movement dysfunction and symptoms at the elbow and forearm. Proximal movement dysfunction needs to be assessed and rehabilitated if a relationship link to elbow and forearm problems can be identified (Comerford & Mottram 2001b, Mottram 1997). Cervical articular dysfunction and related neural irritation or compression commonly can contribute to radicular symptoms in the elbow and forearm (Petty & Moore 2001, Maitland 1986, Cyriax 1996). The dermatomes of C5 to T1 can affect elbow and forearm symptoms. The muscles that control elbow and forearm motion are innervated by the musculo-cutaneous, radial, median and ulnar nerves and have spinal level segmental innervation from C6 to T1. Consequently, spinal or other related tissues, which may irritate these structures, can affect both motor function and symptoms at the elbow and forearm. This spinal irritation may be secondary to dysfunction of the cervical muscle control systems. For example, dominant or overactive scalene muscles contribute to excessive flexion loading of the low cervical spine.

The relationship between Deep Neck Flexor muscle (DNF) stability function and a modified ULNT can also link cervical dysfunction and neural irritation with secondary elbow and forearm dysfunction.

The DNF stability function is assessed with the client’s arm in 90 abduction with the elbow and wrist relaxed. The elbow and wrist are then slowly extended to increase tension in neural structures, and the DNF stability function is reassessed. If the DNF stability function is decreased with the ULNT, it links cervical or neural dysfunction with the forearm dysfunction. Shoulder dysfunction can directly affect neck stability mechanisms. It is possible to combine existing tests to help in assessing treatment priorities or tissue involvement.

The Kinetic Medial Rotation Test (KMRT) was described by Sahrmann (1992) and developed further by Comerford (1994). Morrissey (1998) has since validated this test using 3-dimensional movement analysis. The client lies supine with the shoulder abducted to 90 degrees in the plane of the scapula and the hand pointing to the ceiling. The therapist palpates the coracoid and the humeral head to monitor for inferior or anterior movement. The client actively medially rotates the glenohumeral joint and should ideally be able to achieve 70 degrees of medial rotation without loss of scapular or glenohumeral stability. Humeral head movement before 70 implicates a primary stability dysfunction of the glenohumeral joint, while early coracoid movement implicates a primary stability dysfunction of the scapula (impingement).

DNF stability function is assessed with the arm in the starting position for the KMRT. The subject performs the KMRT and stops at the point of either coracoid or humeral head inferior-anterior movement. The DNF stability function is then reassessed in this position. A decrease in DNF stability function implicates scapulo-thoracic or gleno-humeral dysfunction coupled with cervical dysfunction. Concurrent cervical and shoulder girdle stability retraining is recommended."