Lateral Epicondylitis (Tennis Elbow) Inflammation, at the muscular origin of the extensor carpi radialis brevis (ECRB). the most common overuse injury of the elbow up to 10 times more frequently than medial epicondylitis most often occurs between the third and fifth decades of life.
Ergonomic Stressors Frequent lifting Repetitive wrist dorsiflexion with force Sustained power gripping. Repetitive forearm supination Sudden elbow extension Tool use, shaking hand, twisting movement
Clinical Presentations lateral elbow pain of gradual onset. pain generally increases with activity Picking up a cup of coffee or a gallon of milk Heavy lifting Gripping Pain may be present at night. Symptoms are typically unilateral.
Physical Examination localized tenderness to palpation just distal and anterior to the lateral epicondyle.
Presumptive Diagnosis Requires: Local tenderness directly over the lateral epicondyle Pain aggravated by resisted wrist extension and radial deviation Pain aggravated by strong gripping Normal elbow range of motion
Paraclinical Testing No specific test is required
Splints for Tennis Elbow
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a traumatic or pressure neuropathy of the median nerve in the wrist The most common entrapment neuropathy in the body Compression of the median nerve as it passes through the carpal tunnel Overall prevalence is 2.7% Is more common in women and between ages 40 to 60 years
Work Related Risk Factors Occupations that require Repetitive Flexion and extension of the fingers and wrist
Symptoms Paresthesias in the median nerve distribution, gradually and spontaneously With progression: pain, numbness, tingling and burning In more progressed cases: Reduced force, Skin sensory deficit and Thenar Atrophy
Diagnosis History: Night-time and morning symptoms, sometimes occurring with driving, and relief by shaking or movement ( Flick sign ) Intermittent Nocturnal Brachalgia Clumsiness Rule out of systemic causes
Physical Exam: Phalen’s Test and Tinnel’s sign Two-Point Discrimination Test thumb abduction thumb opposition pinch movements
Electrodiagnostic studies: EMG/NCV confirm diagnosis Thenar weakness should warrant full EMG studies
Treatment 1- Treatment of associated conditions 2- Splinting the wrist in a neutral position at night and during the day. For 2 to 4 weeks Job task modification is often critical in this phase 3- Corticosteroid injection into the carpal tunnel 4- Surgery. After 3 month of conservative treatment
Inflammation of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus Combination of Tendonitis and Tenosynovitis. In individuals between 30 and 50 years of age and is ten times more prevalent among women than men May be caused by OVER USE of thumb, like repetitive work and forceful gripping
Symptoms pain at the base of the thumb. swelling Differential diagnosis Old nonunion of navicular bone Osteoartritis of first carpometacarpal joint
Treatment Modifying hand activity Immubilization of thumb (3-6 weeks) NSAIDs Local Injection of Lidocain-triamcinolone into tendon sheat (Standard Treatment) Surgical decompression
Stenosing tenosinovitis of the flexor tendon of the finger Painful snap or jerking movements in PIP Collapse the joint suddenly like a trigger Usually associated with using tools that have handles with hard or sharp edges.
Occur in younger people Pain at the base of the thumb or wrist pain Tenderness of the tuberosity of scaphoid PA, Lateral and Scaphoid view Ragiographs MRI or Bone Scan
Treatment Nondisplaced 12 weaks immobilization Displased Open reduction and Internal Fixation
Disruption of extensor tendon at the distal interphalangial (DIP) joint
Some Useful Tests
Apley Scratch Test
Kyphosis is excessive curvature of the spine in the sagittal (A-P) plane. The normal back has 20° to 45° of curvature in the upper back, and anything in excess of 45° is called kyphosis. Scoliosis is abnormal curvature of the spine in the coronal (lateral) plane. Scoliosis of between 10° and 20° is called mild. Less than 10° is postural variation. Lordosis or hyperlordosis is excessive curving of the lower spine and is often associated with scoliosis or kyphosis.
Straight Leg Raise SLR Examiner raises straight leg (30 to 60 degrees) eliciting radicular pain on same side (Lasegue Sign). Then lowers leg until pain goes away, the foot is then dorsiflexed causing return of pain Sensitivity 91% Specificity 26 %
Crossed Straight Leg Raise (Crossed SLR) Examiner raises straight leg (30 to 60 degrees) eliciting radicular pain on opposite side. Sensitivity 25% Specificity 90-97%
Reverse Straight Leg Raise (Reverse SLR) Patient is prone, examiner raises straight leg (30 to 60 degrees) –pain radiating to anterior thigh indicative of L3-L4 root irritation Sensitivity ? Specificity ?