Differential Diagnosis of Lateral Elbow Pain · Lateral Elbow Pain. Not for reproduction or redistribution Course objectives – Verbalize the key anatomic structures that could be

Not for reproduction or redistribution

Live 2019 Update

Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT

Differential Diagnosis of Lateral Elbow Pain


Course objectives– Verbalize the key anatomic structures that could be

involved with lateral elbow pain: humeroradial joint, extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), lateral ulnar collateral ligament, and radial nerve

– Recognize when special tests are needed to rule out posterolateral rotatory instability

– Perform a systematic clinical examination to determine the pain-generator

Differential Diagnosis of Lateral Elbow


Chapter OneAnatomy of the Lateral Elbow


The Elbow

Pain reference– More reliable than

shoulder– Localized to the area – Moderately trustworthy


The Elbow Complex

• Humeroulnar• Humeroradial

• Proximal radioulnar• (Distal radioulnar)


Elbow Anatomy


Elbow Anatomy (cont.)

Humeroradial joint(HRJ)

– Can be a source of pain at the lateral elbow


Humeral Capitulum


Radial Head

L


Schenk RC et al. Biomechanical analysis of articular cartilage of the human elbow and potential relationship to osteochondritis dissecans. Clin Orthop Rel Res 1994; 299:305-12.

Radial Head Asymmetries


Radial Head Asymmetries (cont.)


Radial Head Asymmetries (cont.)

• Neutral between pronation and supination

• Full pronation and/or supination

van Riet RP, VanGlabbeek F, Neale PG, et al. The noncircular shape of the radial head. J Hand Surg 2003; 28A:972-978.; Roidis N et al. A radiographic study of proximal radius with implications in radial head placement. J Shoulder Elbow Surg 2003; 12:380-4.


Stability Through Force Closure

Loading (such as grip), provides stability to the HRJ


Proximal Radioulnar Joint (PRUJ)

Maximal loose-packed position (MLPP)

– 70 degree flexion– 35 degree supination


PRUJ: Radial Notch


Elbow AnatomyCapsule and Ligamentous Support


Elbow Complex Capsule: Anterior1

• Not as important biomechanically2

• More important clinically: very thick

1. Sakai K, et al. Extension restriction of the elbow caused by a synovial fold - a report on 2 athletes. Acta Orthopaedica Scandinavica, 1999;70 (1): 85-86.

2. Nielsen KK, Osen BS. No stabilizing effect of the elbow joint capsule - A kinematic study.Acta Orthopaedica Scandinavica: 1999, Vol 70, (1): 6-8.;


Elbow Complex Capsule: Posterior

• Not very extensive vs. anterior capsule

• The posterior portion of the capsule can become entrapped between the radial head and capitulum

Sakai K, et al. Extension restriction of the elbow caused by a synovial fold - a report on 2 athletes. Acta Orthopaedica Scandinavica, 1999;70 (1): 85-86.


Elbow Complex: Capsular Plica

• Plica: redundancy of the capsule (develops embryonically)

• Can become painful• Posterior plica: can

become irritated with elbow extension (especially hyperextension)


Lateral Ligaments

These ligaments do not provide strong stabilization to the lateral aspect of the elbow

Lateral Collateral Ligament (LCL)

Radial annular ligament


Lateral ulnar collateral ligament (LUCL)

Lateral Ligaments (cont.)

• This is the most important lateral stabilizer

• Limits valgus stability from 0 to 140 degrees



• The lateral ulnar collateral ligament (LUCL) arises from the lateral epicondyle and inserts onto the proximal ulna

• Taut in both elbow flexion and extension

Imatani J, Ogura T, Morito Y, et al. Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg 1999; 8:625-627.



• Lateral ulnar-collateral ligament (LUCL): most important stabilizer to prevent posterior lateral rotatory instability (PLRI)

• PLRI: PRUJ is intact– Forearm moves as a

unit

Dunning CE, Zarzour ZDS, Patterson SD, Johnson JA, King GJW. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop Rel Res 2001; 118-124.; O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. JBJS 1991; 73 A: 440-446.; Smith JP, Savoie FH, Field LD. Posterolateral rotatory instability of the elbow. Clin Sports Med 2001; 20:47-58.


Annular Ring

• The proximal portion is cartilage (Type I collagen), the distal portion synovial tissue

• The radial head translates during pronation and supination; but the primary function of annular ring is to protect radius from inferior dislocation

Galik K, Baratz ME, Butler AL, Dougherty J, Cohen MS, Miller MC. The effect of the annular ligament on kinematics of the radial head. J Hand Surg [Am]. 2007;32(8):1218-24.

3DAnnular ring


Annular Ring (cont.)

• Attaches from coronoid process to coronoid process

• Synovial fold can become thickened, which can become a pain generator


Medial Ligaments

Bundles: anterior, posterior, intermediate (or transverse)

Timmerman LA, Andrews JR. Histology and arthroscopic anatomy of the ulnar collateral ligament of the elbow. Am J Sports Med 1994; 22:667-673.


Medial Ligaments (cont.)

• Anterior bundle• Restrains pronation of

the ulna on the humerus

Pomianowski S, O’Driscoll SW, Neale PG, Park MJ, Morrey BF, An KN. The effect of forearm rotation on laxity and stability of the elbow. Clin Biomech. 2001;16:401-407.; Armstrong AD, Dunning CE, Faber KJ, Duck TR, Johnson JA, King GJW. Rehabilitation of the medial collateral ligament-deficient elbow: An in vitro biomechanical study. J Hand Surg. 2000;25A:1051-1057.


Medial Ligaments (cont.)

• Anterior bundle• “The maximum valgus and

internal rotatory instability after transection of the anterior band, 11.7 degrees and 11.2 degrees respectively, were found at elbow flexions of 30 degrees and 40 degrees"

Ahmad CS, et al. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med 2003; 31:332-337.; Wavreille G, Seraphin J, Chantelot C, et al. Ligament fibre recruitment of the elbow joint during gravity-loaded passive motion: an experimental study. Clin Biomech. 2008;23(2):193-202.


Elbow AnatomyMuscles


Lateral Group: Brachioradialis


Lateral Group: Extensor Carpi Radialis Longus (ECRL)


Lateral Group: Extensor Carpi Radialis Brevis (ECRB)


Lateral Group: Extensor Digitorum Communis (EDC)


Lateral Group: Extensor Carpi Ulnaris (ECU)


Lateral Group: Anconeus


Supinator


Elbow AnatomyRadial Nerve


The Pathway of the Radial Nerve


Irritation Sites

• Fibrous bands: thickened fascia superficial to the HRJ

• ECRB• Leash of Henry: vascular

network/branches of the radial artery

• Arcade of Frohse: tendinous portion of the supinator– Most common site

• Supinator

Moradi A, et al. Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Joint Surg. 2015;3(3); 156-162.


Chapter TwoPathomechanics of Lateral Elbow Pain


• Musculotendinous• Articular

• Ligamentous• Neural

Etiologies


• Common condition for which people seek therapy• Numerous etiologies present similarly

• A systematic examination helps a therapist identify the pain generator to formulate a structure-specific plan of care

Lateral Epicondylosis


Extensor carpi radialis brevis– “In patients with lateral tennis elbow, the origin of the

extensor carpi radialis brevis is always more or less involved”

Organ, SW, Nirschl, RP, Kraushaar, BS, Guidi, EJ. Salvage surgery for lateral tennis elbow. Am J Sports Medicine. 1997; 25, 746-750.; Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010; 30(1), 167-184.

Lateral Epicondylosis (cont.)


Patient history: age– Most prevalent in the forth decade of life (19% of

population 30 to 60 years of age)– Women more severe than men – Duration: six months to two years– Commonly recurs

Stasinopoulos, D. & Johnson, MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. British Journal of Sports Medicine. 2004; 38, 675-677.

Lateral Epicondylosis (cont.)


1. Cyriax 1936, Baily 1957, Hohl 1961, Goldie 1964, Smidt 20022. Binder 1983, Chard 1989, Hertling 1990, Verhaar 1995

Lateral Elbow Pain: Musculotendinous

Tendinopathy extensors

“Self limiting disorder” “Non self limiting disorder”

Spontaneous healing within 8 to 12 months1 No spontaneous healing2


Etiologies– Too much load, or too little load-ability– Overuse – Degeneration: tendinosis– Hypomobility HRJ synovitis: capsule hypertrophy– Hypermobility HRJ – Limits in the chain– Technique– Increased sympathetic activity and decreased vascular

supply

Lateral Elbow Pain: Musculotendinous (cont.)


Decreased loadability– Age: highest incidence in 40 to 49 year olds– Decreased collagen integrity and vascular supply

Sanders TL, Kremers HL, Bryan AJ, et al. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015; 43(5): 1066-1071.



Overuse – The ECRL and ECRB remain the only active synergistic

muscles during grasping – Increased grip à decreased blood supply à ischemia

and anaerobic crisis– Result: fatigue and overload, especially eccentric– Fatigue effects are generally larger in extensors vs.

flexors

Hagg GM & Milerad E. Forearm Extensor and Flexor Muscle Exertion During Simulated Gripping Work - An Electromyographic Study. Clinical Biomechanics, 1997, Vol 12, Iss 1, pp 39-43.



Tendinosis – Consequence of a degenerative and avascular processes – Associated with degenerative tendon microtears in

response to cumulative loading

Nakama LH, King KB, Abrahamsson S, Rempel DM. Evidence of tendon microtears due to cyclical loading in an in vivo tendinopathy model. J Orthop Res 2005;23:1199-1205.



Tendinosis – Non-inflammatory response in the tendon– Has been named angiofibrioblastic tendinosis – Consequence of a degenerative and avascular processes – Characterized by disorganized immature collagen

formation in association with immature fibroblastic and vascular elements

Nirschl RP. Tennis elbow tendinosis: Pathoanatomy, Nonsurgical and surgical Management. In: Gordon SL, Blair SJ, Fine LJ. Repetitive motion disorders of the upper extremity, eds. Rosemont,IL: American Academy of Orthopaedic Surgeons;1995:467-478; Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with Tennis elbow. Knee Surg Sports Traumatol Arthrosc. 2006 Jul;14(7):659-63.



Tendinosis – Gross pathologic presentation: grayish edematous friable

material– The location is in 100% in ECRB, and additionally in EDC

in 35%– 20% of patients have associated bony exostosis at the

lateral epicondyle

Nirschl RP. Tennis elbow tendinosis: Pathoanatomy, Nonsurgical and surgical Management. In: Gordon SL, Blair SJ, Fine LJ. Repetitive motion disorders of the upper extremity, eds. Rosemont,IL: American Academy of Orthopaedic Surgeons;1995:467-478



• Sympathetic nervous system– Increased duration leads to increased activity of the

autonomic nervous system– Increased tissue susceptibility– Increased sensitization and pain

• Incidence of median, radial and ulnar nerve sensitivity greater in patients with chronic lateral epicondylitis

Fernández-de-Las-Peñas C, Ortega-Santiago R, et al. Specific mechanical pain hypersensitivity over peripheral nerve trunks in women with either unilateral epicondylalgia or carpal tunnel syndrome. JOSPT. 2010 ;40(11):751-60.



Vascular compromise– Undersurface of the tendon is essentially

hypovascularized – May contribute to vulnerability of the tissue– Noted reduction of healing response and possible

contribution to tendinosis

Schneeberger AG, Masquelet AC. Arterial vascularization of the proximal extensor carpi radialis brevis tendon. Clin Orthop Rel Res, 2002, 398:239-44.



“Some painful syndromes of the lateral side of the elbow are not related to tendinitis or to posterior interosseous nerve compression, but have an intra-articular origin”

Duparc F, Putz R, Michot C, et al. The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat. 2002 Dec;24(5):302-7.

Lateral Elbow Pain: Articular


Etiologies– Osteocartilagenous– Capsular– Ligamentous

Knisesel B, Huth J, Bauer G, Mauch F. Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability. Arch Orthop Trauma Surg. 2014; 134:1641-1647.

Lateral Elbow Pain: Articular (cont.)



• Capsular– Plica– Traumatic synovitis– Non-traumatic synovitis

• Ligamentous– Annular ring – Lateral ulnar collateral

ligament (LUCL)

Duparc F, Putz R, Michot C, Muller JM, Freger P. The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat. 2002 Dec;24(5):302-7.



• Capsular• Plica

– Consequence of an insertion redundancy

Akagi M, Nakamura T. Snapping elbow caused by the synovial fold in the radio-humeral joint. J Shoulder Elbow Surg. 1998;7:427-429.; Clarke RP. Symptomatic, lateral synovial fringe (plica) of the elbow joint. Arthroscopy. 1988; 4:112-116.


• Capsular• Synovitis

– Traumatic vs. non-traumatic– Synovial fold– Can result in capsular hypertrophy

Duparc F, Putz R, Michot C, Muller JM, Freger P: The synovial fold of the humeroradial joint: Anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat. 2002:24:302–307.



Ligamentous– Annular ring – Lateral ulnar collateral ligament (LUCL)

• Posterior lateral rotatory instability (PLRI)• Most common form of elbow instability

Deutch SR et al. Elbow joint stability in relation to forced external rotation: An experimental study of the osseus constraint. J Elbow Joint Surg 2003; 12:287-92.; McAdams TR, Masters GW, Srivastava S. The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability. J Shoulder Elbow Surg 2005;14:298-301.

Lateral Elbow Pain: Ligamentous


• Patient history: LUCL injury = PLRI• Most common form of instability

• Acute traumatic event: fall on an outstretched hand with the forearm in supination, causing an axial load in the valgus direction– Results in disruption of the stabilizing structures starting

laterally and progressing medially

O’Driscoll SW. Elbow instability. Hand Clin. 1994; 10(3): 405-415.; Szekeres M, Chinchalkar SJ, King GJW. Optimizing elbow rehabilitation after instability. Hand Clin. 2008; 24: 27-38.

Posterolateral Rotatory Instability


Complaints – Nonspecific lateral elbow pain– Painful snap or click– Occasional locking with possible giving way– Symptoms while pushing up from prone with the forearm

in supination– Apprehension in extension and supination

Smith JP, Savoie FH. Posterolateral rotatory instability of the elbow. Clin Sports Med. 2001; 20:47-58.

Patient History


Lateral Elbow Pain: Ligamentous

• Case of three middle-aged women who presented with atraumatic lateral epicondylitis with clinical findings consistent with PLRI

• Underwent debridement and reconstruction of LUCL

Kalainov DM, Cohen MS. Posterolateral rotatory instability of the elbow in association with lateral epicondylitis - A report of three cases. J Bone Joint Surg 2005;87A:1120-1125.


Posterior Lateral Rotatory Instability (PLRI)

Mechanism of dislocation

– Combination of valgus and supination with axial compression during flexion

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.


O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation: a spectrum of instability. Clin Orthop Relat Res 1992; 280: 186-197.; Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.

Spectrum of Instability


• Most common• Ulna “supinates” away from the trochlea

• Involves combination of axial forearm rotation and valgus

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.

Posterolateral Rotatory Instability (PLRI)


Valgus Instability

Corresponding overload on the lateral side

– HRJ chondromalacia, osteophytes, loose bodies

O’Holleran JD, Altchek DW. The Thrower’s Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome. HSSJ. 2006 (2):83-93.; Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.


Sign and symptoms– Localized tenderness over the radial nerve,

approximately five cm distal to the lateral epicondyle– Patients typically report aggravated pain at night that may

interfere with sleeping– Arm fatigue is a common clinical presentation

Moradi A, et al. Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Joint Surg.2015;3(3):156-162.

Radial Tunnel Syndrome


Relationship to tennis elbow– It is estimated that radial tunnel syndrome is present in

5% of patients diagnosed with lateral epicondylitis– Radial tunnel symptoms increase with use of the tennis

elbow strap

Lee JT, Azari K, Jones NF. Long term results of radial tunnel release--the effect of co-existing tennis elbow, multiple compression syndromes and worker’s compensation. J Plast Reconstr Aesthet Surg. 2008;61(9):1095-1099.; Gelbermann R, Eaton R, Urbaniak J. Peripheral nerve compression. J Bone Joint Surg. 1993; 75-A:1854-1878.

Radial Tunnel Syndrome (cont.)


Lateral Elbow Pain: Nerve“The tendinous arcades of the ECRB and supinator will compress the radial nerve when the elbow is in extension, pronation with wrist flexion”

Erak, S, Day, R, Wang, A. The role of supinator in the pathogenesis of chronic lateral elbow pain: A biomechanical study. J Hand Surg. 2004; 29B, 461-464.; Guse, TR & Ostrum, RF. The Surgical Anatomy of the Radial Nerve Around the Humerus. Clinical Orthopaedics & Related Research. 1995; 320:149-153.


Irritation Sites

• Fibrous bands: thickened fascia superficial to the HRJ

• ECRB• Leash of Henry: vascular

network/branches of the radial artery

• Arcade of Frohse: tendinous portion of the supinator– Most common site

• Supinator

Moradi A, et al. Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Joint Surg. 2015;3(3); 156-162.


Classification

• PIN inflammation in radial tunnel– No motor weakness:

radial tunnel syndrome

• PIN compression– Compression in the

tunnel– Increased motor

weakness: PIN syndrome

Dang AC, Rodner CM. Unusual compression neuropathies of the forearm, part I: radial nerve. J Hand Surg. 2009;34(10):1906-1914.; Gelbermann R, Eaton R, Urbaniak J. Peripheral nerve compression. J Bone Joint Surg. 1993; 75-A:1854-1878.


• Radial tunnel syndrome: predominant complaint is pain

• PIN syndrome: predominant complaint is weakness (with ECRL preserved)

Naan NH, Nemani S. Radial tunnel syndrome. Ortho Clin North Am. 2012; 43(14):529-536.; Dang AC, Rodner CM. Unusual compression neuropathies of the forearm, part I: radial nerve. J Hand Surg. 2009;34(10):1906-1914.

Classification (cont.)


Chapter ThreeClinical Examination


• Tendon• Joint

• Nerve

So How Do We Know What’s Causing the Problem?


Lateral Epicondylosis: Proximal Screen

• Rule out external rotator cuff impingement

• Referred pain to the deltoid, but can occur distally to the lateral elbow

Flatow, E.L., Soslowsky, L.J., Ticker, J.B., Pawluk, R.J., Helper, M., Ark, J., Mow, V.C., Bigliani, L.U. (1994) Excursion of the rotator cuff under the acromion. Patterns of subacromial contact. Am J Sports Med, 22, 779-788.

Painfularc


Lateral Epicondylosis: Proximal Screen (cont.)

Scapular dyskinesis External rotator cuff impingement

– C5 referral pattern


• 123 patients with unilateral symptoms, 75 men and 48 women with a mean age of 43 years (19 to 63) and a mean symptom duration of eleven months (0.5 to 72)

• In patients with unilateral radial epicondylalgia, almost all measured ROMs of the elbow and wrist were found to be limited in the affected arm

Solveborn SA, Olerud C. Radial epicondylalgia (tennis elbow) - measurement of range of motion of the wrist and the elbow. JOSPT.1996; 23(4): 251-257.

Limits in the Chain


• 23 patients with unilateral symptoms, 18 men and 5 women with a mean age of 43 years (19 to 63) and a mean symptom duration of 16 months

• In patients with unilateral radial epicondylalgia, shoulder ER was significantly reduced on the affected side (P = 0.038)

Abbot JH. Mobilization with movement applied to the elbow affects shoulder range of movement ion subjects with lateral epicondylalgia. Man Ther. 2001; 6: 170-177.

Limits in the Chain (cont.)


Lateral Epicondylosis: Testing


Active and Passive Elbow Flexion• Look for

– Quantity– Quality: end feel

• Test in– Full supination– Forearm neutral– Full pronation


Active and Passive Elbow Extension• Look for

– Quantity– Quality: end feel

• Test in– Full pronation– Full supination


Wrist Extension with RD and UD

• Positive extension with RD > extension with UD– ECRB and/or EDC

tendinopathy

• Positive extension with RD = extension with UD– Suspect HRJ

chondropathy– Perform special tests

Extension with RD

Extension with UD


• Most will have positive wrist extension• We need extra tests

• First, add wrist extension with RD and UD• Positive RD and negative UD à lateral epicondylosis• Positive RD and positive UD à HRJ

Lateral Epicondylosis: Testing


Metacarpophalangeal Extension

• Positive pain IF and MF– Suspect ECRB

tendinopathy• Positive pain IF through SF

– Suspect EDC tendinopathy• Positive pain middle finger

only– Suspect radial nerve– Confirm with resisted

supination, tinel sign, scratch collapse test, and upper limb neurodynamic testing


ECRB: Proximal Attachment

Exam findings– Most pain with wrist

extension with RD– Mild pain with passive

wrist flex– Most pain with MP

extension of IF and MF– Tenderness over five mm

by five mm cube on the top of the

– Lateral epicondyle– Very common


EDC: Proximal AttachmentExam findings

– Most pain with wrist extension with RD

– Mild pain with passive wrist flex

– Most pain with MP extension of IF, MF, RF, SF

– Tenderness over anterior lateral epicondyle

– Relatively common in concert with the ECRB

Fairbank SAM, Corlett RJ. Role of the extensor digitorum communis muscle in lateral epicondylitis. J Hand Surg 2002; 27B:405-9.


Likelihood ratio (LR): allows the clinician to determine the probability that a target pathology is present by relating the result of the test with the pre-test probability

– LR more than one indicates that the test result is associated with the pathology

– LR close to one has little clinical significance– Diagnostic accuracy of any test is considered useful if

• Positive (+) LR is 2.0 or greater• Negative (-) LR is 0.50 or less

Valdes K & LaStayo P. The value of provocative tests for the wrist and hand: a literature review. J Hand Ther. 2013; 26: 32-43.; Halleman D, et al. Quantitative assessments from the clinical examination. How should clinicians integrate the numerous results? J Gen Intern Med. 1997;12:165-171.

Special Tests


How are likelihood ratios calculated?– The LR of a positive test result (+LR) is sensitivity divided

by one minus the specificity– The LR of a negative test result (-LR) is one minus the

sensitivity divided by specificity

Valdes K & LaStayo P. The value of provocative tests for the wrist and hand: a literature review. J Hand Ther. 2013; 26: 32-43.

Special Tests (cont.)


• Pull (Wolff) test: HRJ chondropathy• Humeroradial joint position test: malalignment, plica• O’Driscoll or pivot shift test: posteriolateral rotatory

instability (PLRI)• Push up sign: posteriolateral rotatory instability (PLRI)• Chair sign: posteriolateral rotatory instability (PLRI)• Valgus stress test: MCL/HRJ chondropathy, PLRI• Resisted forearm supination: radial tunnel• Upper limb neurodynamic test number two: radial tunnel• Grip test: lateral tendinopathy

Special Tests (cont.)


HRJ Chrondropathy: Pull (Wolff) Test

• Indications: pain with both wrist extension with RD and wrist extension with UD

• Patient performs resisted wrist extension against examiner’s forearm

• Repeat test with distal pull at radius Step one


HRJ Chrondropathy: Pull (Wolff) Test (cont.)

• Positive test: decreased pain with distal pull

• If pain increases: more likely a tendinopathy

Step two


HRJ Chondropathy• Evaluated via arthroscopy the

articular cartilage in 31 elbows undergoing surgery for lateral epicondylosis

• Results: cartilage injuries of the capitulum were found in 65% of cases and cartilage injuries of the radial head found in 81% of cases

– The absence of ECRB tears was independently associated with a higher risk of cartilage injuries of the capitulum

• Conclusion: cartilage injury was frequently found in the lateral edge of the capitulum and radial head

Sasaki K, Onda K, Ohki G, et al. Radiocapitellar cartilage injuries associated with tennis elbow syndrome. J Hand Surg. 2012;37A:748-754.


Special Tests: Malalignment, Plica

Humeroradial joint position test

– Monitor radial head position as you transition from passive elbow flexion to extension

– Feel HR joint line to appreciate thickness and texture of a plica, which may be irritated

Step one


Special Tests: Malalignment, Plica (cont.)

Humeroradial joint position test

– Positive (+) test: increased motion of radial head in a posterolateral direction

– Next, perform joint specific testing to localize the problem Step two


Special Tests: PLRI

O’Driscoll or pivot shift test

– Patient supine and the arm overhead

– Supination and valgus moments with axial compression applied during flexion causing the radius and ulna to subluxate maximally at approximately 40 degrees to 70 degree flexion

Dunning CE, Zarzour ZDS, Patterson SD, Johnson JA, King GJW. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop Rel Res 2001; 118-124.; O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. JBJS 1991; 73 A: 440-446.; Smith JP, Savoie FH, Field LD. Posterolateral rotatory instability of the elbow. Clin Sports Med 2001; 20:47-58


Special Tests: PLRI (cont.)

• Place the patients elbow in an extended position to begin the test

• While palpating the HRJ, provide a supination force at the forearm and valgus moment at the elbow with axial compression as you flex the patient’s elbow

• If positive, the radius and ulna will sublux at approximately 40 degrees to 70 degree flexion

Step 1

Step 2


“A limitation of the pivot shift test for posterolateral instability of elbow test is that it requires general anesthesia to optimize accuracy”

– Not recommended provocative test

Valdes K, LaStayo P. The value of provocative tests for the wrist and elbow: A literature review. J Hand Ther. 2013;26:32-43.



Push up sign

ê

Axial Load

Supination

ê

ê

Valgus Load


• Positive LR: 0.87• Negative LR: unable to

calculate• Active apprehension test

– Patient is required to perform an active floor push up

– Positive push up sign: apprehension or dislocation with terminal extension

Regan W & Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability. J Shoulder Elbow Surg. 2006;15: 344-346.; Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.



Chair sign • Positive LR: 0.87• Negative LR: unable to

calculate• Active apprehension

test– Patient is required to

stand from the sitting position by pushing on the seat with the hand at the side and the elbow fully supinated

Regan W & Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability. J Shoulder Elbow Surg. 2006;15: 344-346.; Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery 6th ed. Elsevier Inc. Philadelphia. 2011.



• Positive chair sign: apprehension or dislocation with terminal extension

• Reluctance to fully extend elbow

Regan W & Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability. J Shoulder Elbow Surg. 2006;15: 344-346.

Axial load, valgus, supination of

forearm

ê


• Push up sign• Chair sign

• If positive: refer to MD



Valgus Stress Test

• Valgus stress with forearm pronation: instability present in this position indicates the MCL is deficient

• If instability is present with both supination and pronation: posteriolateral rotatory instability (PLRI)

Smith JP, Savoie FH, Field LD. Posteriolateral rotatory instability of the elbow. Clin Sports Med 2001; 20(1): 47-58.; Pomianowski S, O’Driscoll SW, Neale PG, Park MJ, Morrey BF, An KN. The effect of forearm rotation on laxity and stability of the elbow. Clin Biomech 2001;16:401-407.


Valgus Stress Test (cont.)

Pomianowski S, O’Driscoll SW, Neale PG, Park MJ, Morrey BF, An KN. The effect of forearm rotation on laxity and stability of the elbow. Clin Biomech 2001;16:401-407.

Forearm supinationForearm pronation


“Valgus stress is applied to a pronated forearm, only the medial structures of the elbow are tested… Instability that is present in this pronated position actually indicates that the medial collateral ligament is deficient; If increased in pronation and supination: PLRI”

Smith JP, Savoie FH, Field LD. Posteriolateral rotatory instability of the elbow. Clin Sports Med 2001; 20(1): 47-58.; Pomianowski S, O’Driscoll SW, Neale PG, Park MJ, Morrey BF, An KN. The effect of forearm rotation on laxity and stability of the elbow. Clin Biomech 2001;16:401-407.

Valgus Testing


Moving Valgus Stress Test• Patient is upright with shoulder

abducted to 90 degrees• Therapist support the upper

arm with the elbow in maximum flexion

• Moderate valgus torque is provided until the shoulder reaches its limit of external rotation

• The elbow is then rapidly extended to 30 degrees while maintaining the valgus torque

• LR: infinity• LR: 0.05

• MCL insufficiency

• Sensitivity = 1.0• Specificity = 0.75

O’Driscoll SW, Lawton RL, Smith AM. The moving valgus stress test for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;(33)2:231-239.


Moving Valgus Stress Test (cont.)

• MCL insufficiency• Positive test

– Must reproduce patient’s medial elbow pain at the MCL

– Pain should be maximal between 120 degrees and 70 degrees of flexion (shear angle) as opposed to total arc of movement (shear range)

O’Driscoll SW, Lawton RL, Smith AM. The moving valgus stress test for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;(33)2:231-239.


Resisted Forearm Supination

Positive (+) test elicits pain at the radial tunnel

Lister G et al. The radial tunnel syndrome. J Hand Surg 1979; 4:52-59.; Moradi A, et al. Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Joint Surg. 2015;3(3):156-162.


Tinel Sign

• Tap four to five cm distal to the lateral condyle at the radial tunnel

• Positive (+) test: reproduction of nerve symptoms


Scratch Collapse Test

Technique– The therapist provides

resistance with shoulder ER

– The area of the radial tunnel is lightly stroked

– The resistance is reapplied to determine if a change in strength is detected

Cheng CJ, Mackinnon-Patterson B, Beck JL, et al. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J of Hand Surg.2008;33A:1518-1524.


Scratch Collapse Test (cont.)

Technique– The therapist provides

resistance with shoulder ER

– The area of the radial tunnel is lightly stroked

– The resistance is reapplied to determine if a change in strength is detected



Scratch Collapse Test (cont.)

• Positive test: sudden loss in strength

• Proposed mechanism: when the nervi-nervorum at the site of the neuritis is stimulated, an ipsilateral central inhibition is transiently activated



• Upper limb neurodynamic test (ULNT) vs. upper limb tension test (ULTT)– “Neurodynamic” encompasses the neurophysiological

aspects of mechanosensitivity• Test the active movement first: if negative, then you do

not need to test passively• Looking for a hyperalgesic response

– Hyperalgesia: increased response to a stimulus that is normally painful

– ULNT may be more sensitive on the involved side– This is why we need to test the uninvolved side first

Butler, D. (2000). The sensitive nervous system. Australia: Noigroup publications.

Special Tests: Radial Nerve


Upper Limb Neurodynamic Test Number Two: Radial

• Active test • Passive test– Thumb flexion– Wrist flexion and UD– Forearm pronation– Elbow extension– Shoulder abduction



Upper Limb Neurodynamic Test Number Two: Radial (cont.)

Passive test– Thumb flexion– Wrist flexion and UD– Forearm pronation– Elbow extension– Shoulder abduction



Grip Test

• Using a handheld dynamometer, patient performs three consecutive trials for the involved and uninvolved UE– At 90 degrees of elbow

flexion– At full elbow extension

• Patient is asked to rate their pain from mild to severe

Wixom SM, LaStayo P. A potential classification model for individuals with tennis elbow. J Hand Ther. 2012;25(4):418-420.


Chapter FourLive 2019 Update


Lateral Elbow PainUpdates regarding our understanding of pain

with more chronic conditions


• Purpose: to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching and use of a counterforce brace

• N=131 patients with LE symptoms for under six months– Measured pain sensitization by assessing pressure pain

thresholds (PPTs) in the uninvolved middorsal forearm and administering a pain sensitization questionnaire (PSQ)

Roh, YH, Gong YS, Baek GH. The prognostic value of pain sensitization in patients with lateral epicondylitis. J Hand Surg Am. 2019 Mar;44(3):250

Lateral Elbow Pain: Presentation of Pain


Pain sensitivity questionnaire (PSQ)– 17 items grading how painful a situation would be (0 to 10

pain scale)• Bumping shin badly on a hard edge• Imagine burning tongue on a very hot drink• Imagine muscles are slightly sore as a result of physical

activity• Imagine you trap your finger in a drawer• Imagine you take a shower with lukewarm water• Imagine you have a mild sunburn on your shoulders, etc.


Lateral Elbow Pain: Presentation of Pain (cont.)


• Used the self-administered questionnaire: disabilities of the arm, shoulder and hand (DASH) score to determine functional status

• Results– Higher pain sensitization measured by PPTs and PSQ scores

correlated with increased DASH score and longer symptom duration

– Pain sensitization measured by PPTs and PSQ scores correlated with initial symptom severity and duration and was associated with poor prognosis in terms of improved DASH scores for nonsurgical treatment for lateral epicondylitis




• Lim et al., evaluated the conditioned pain modulation (CPM) in lateral epicondylalgia patients compared with controls, and to better understand the relationship between CPM and clinical pain measures in lateral epicondylalgia

• What is the conditioned pain modulation?

Lim ECW, Sterling M, Vicenzino B. Chronic lateral epicondylalgia does not exhibit mechanic pain modulation in response to noxious conditioning heat stimulus. Clin J Pain. 2017 Oct;33(10):932-938.



Conditioned pain modulation (CPM)– Definition: conditioned pain modulation is a

psychophysical experimental measure of endogenous pain inhibitory pathway in humans; the “pain inhibits pain” phenomena

– CPM paradigms consist of the evaluation of a painful test stimulus followed by a second stimulus after the painful conditioning stimulus has been withdrawn

• In most subjects the pain intensity experienced with the test stimulus will be reduced during or immediately after exposure to the conditioning stimulus

Kennedy DL, Kemp HI, Ridout D, et al. Reliability of conditioned pain modulation: a systematic review. Pain. 2016.Nov;157(11):2410-2419.



Conditioned pain modulation (CPM)– “There is great interest in the science and conduct of

CPM testing as there is a growing body of evidence suggesting that CPM may be an important biomarker of chronic pain and a predictor of treatment response”

Kennedy DL, Kemp HI, Ridout D, et al. Reliability of conditioned pain modulation: a systematic review. Pain. 2016.Nov;157(11):2410-2419.



• N=20 with lateral elbow pain for on average for 10.2 months• Diagnostic criteria: pain over the lateral epicondyle with

gripping, resisted wrist or middle finger extension or palpation of the lateral epicondyle in conjunction with reduced pain-free grip

• Tested the pressure pain threshold (PPT) at the lateral epicondyle before and during the heat pain-conditioning stimulus (applied over the left calf)– After three minutes of the heat stimulus retested grip strength

and reassessed PPT




• Results– Unlike the pain-free control group, individuals with lateral

epicondylalgia did not exhibit the conditioned pain modulation

• Discussion– Those with lateral epicondylalgia might contribute to ongoing

nociceptive afferent input and increase the excitability of spinal cord neurons

– Further studies are required to better understand the relationship between heightened spinal cord excitability and less efficacious conditioned pain modulation in chronic pain




• Primary aim of study: to examine the association between tendon structural and sensory characteristics in people with chronic lateral epicondylalgia

• N=66– Diagnostic criteria: lateral elbow pain present for a minimum of

six weeks aggravated by palpation, gripping, and resisted wrist/finger extension

• Evaluated the tendon structural changes with static ultrasound images and sensory changes using quantitative sensory testing: PPT, cold pain threshold, heat pain threshold, and vibration detection threshold

Palaniswamy V, Ng SK, Manickaraj N, et al. Relationship between ultrasound detected tendon abnormalities, and sensory and clinical characteristics in people with chronic lateral epicondyalygia. PLoS One. 2018 Oct 24;13(10): e0205171. doi: 10.1371/journal.pone.0205171. eCollection 2018.



• Results– Few structural characteristics are related to sensory

system changes, and in many cases the relationship is conflicting

– The more severe clinical symptoms were associated with less severe structural and sensory characteristics

• Discussion– Pain in tendinopathy may be derived from the increased

expression of nociceptive substances near or in the peritendon




Discussion– The nociceptive stimulation from the peritendon may occur due

to increased tendon thickness or a reactive process in the healthy load-bearing portion of the tendon in response to the inability of the degenerative tendon to transmit tensile load

– This reactive-on-degenerative model may explain the lack of association between structural tendon changes and sensory and clinical characteristics in lateral epicondylalgia, as the size and severity of the degenerative tendon are not responsible for the magnitude of nociception in this model




Lateral Elbow PainUpdates with Articular Issues


Synovial plica– The presence of a pathologic radiocapitellar synovial

plica is a potential source of lateral elbow pain– Normally, existing plicae have no known function and do

not cause any symptoms– Humeroradial synovial plica is quite common in throwing

athletes and golfers

Rajeev A & Pooley J. Arthroscopic resection of humeroradial synovial plica for persistent lateral elbow pain. J Orthop Surg (Hong Kong). 2015; Apr. 23(1):11-14.Lee HI, Koh KH, Kim J-P, et al. Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinic-radiologic correlation. J Shoulder Elbow Surg. 2018;27:1349-1356.

Lateral Elbow Pain: Intra-articular Issues


Synovial plica– Rajeev and Pooley reviewed the outcome of 121 patients who

underwent arthroscopic resection of the humeroradial synovial plica for persistent lateral elbow pain

– Clinical presentation (in addition to lateral elbow pain): catching or snapping sensation and locking in extension

– Pain in the humeroradial synovial plica may be due to pain fibers in the folds, as well as a release of cytokines and other inflammatory mediators

• Entrapment of abrasion of the synovial fringe also leads to the development of chondromalacia and pain

Rajeev A & Pooley J. Arthroscopic resection of humeroradial synovial plica for persistent lateral elbow pain. J Orthop Surg (Hong Kong). 2015; Apr. 23(1):11-14.

Lateral Elbow Pain: Intra-articular Issues (cont.)


Osteochrondritis Dissecans (OCD)– History: OCD of the capitellum occurs due to repetitive compression at

the radiocapitellar joint from either excessive valgus or axial loading (i.e., overhead throwing)

• Highest incidence: youth baseball players from 1 to 7% – Clinical presentation: progressively worsening pain over the lateral

aspect of elbow, decreased ROM and mechanical symptoms that may interfere with athletic performance

• Almost exclusive to the dominant arm– On physical exam, the most common finding is tenderness over the

radiocapitellar joint or capitellum with the elbow maximally flexed

Logli AL, Bernard CD, O’Driscoll SW, et al. Osteochrondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm. Curr Rev Musculoskelet Med. 2019 Mar;12(1):1-12

Lateral Elbow Pain and OCD


Lateral Elbow Pain and Intra-articular Issues• Retrospective review describing a

novel arthroscopic treatment involving resection of the capsulosynovial fringe for symptoms mimicking lateral epicondylitis

• N=35, follow up: 9.2 years• Pain scores decreased from 8/10 to

0/10• Author’s opinion: the degenerative

capsular fold that impinges on the radial head becomes interposed in the anterior or posterior portion of the radiocapitellar joint which causes typical lateral epicondylitis symptoms that are exacerbated by contraction of the strong wrist extensors

Sochol KM, London DA, Rothenberg ES, et al. Arthroscopic treatment of lateral elbow pain mimicking lateral epicondylitis: long-term follow-up of a unique surgical protocol. Tech Hand Surg. 2019:23;27-30.


• New diagnostic tool for lateral elbow pain, as no tests have been designed to investigate the anterior and posterior compartments of the elbow

• Two new clinical tests– SALT: supination and anterolateral pain test– PEPPER: posterior elbow pain by palpation-extension of the

radiocapitellar joint• N=10 atraumatic lateral elbow pain unresponsive to

conservative treatment• In 90% of patients, at least one test was positive

– All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive (+) response to at least one of the two tests

Arrigoni P, Cucchi D, Menon A, et al. It’s time to change perspective! New diagnosis tools for lateral elbow pain. Musculoskelet Surg. 2017 Dec;101(Suppl 2):175-179.

Lateral Elbow Pain and Intra-articular Issues (cont.)


Potential pain generators

Lateral Elbow Pain and Intra-articular Issues (cont.)

Lateral epicondyle Posterior aspect of

humeroradial joint (aka: radiocapitellar joint)

Anterior capsule and synovial tissue


• SALT (supination and anterolateral pain test): high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis

• PEPPER (posterior elbow pain by palpation-extension of the radiocapitellar joint): was sensitive, specific and accurate in the detection of radial head chrondropathy

Arrigoni P, Cucchi D, Menon A, et al. It’s time to change perspective! New diagnosis tools for lateral elbow pain. Musculoskelet Surg. 2017 Dec;101(Suppl 2):175-179.

Special Tests: Intra-articular Issues and Synovitis


Special Tests:

Step 1

SALT: Supination and Antero-Lateral Pain Test

• Slide your finger from the lateral aspect of the radial head to the anterior aspect while simultaneously supinating the forearm

• Indications– Localized pain anterior

to the radial head

Arrigoni et al, 2017


Step 1

SALT: Supination and Antero-Lateral Pain Test (cont.)

• Slide your finger from the lateral aspect of the radial head to the anterior aspect while simultaneously supinating the forearm

• Indications– Localized pain anterior

to the radial head




Positive (+) test: reproduction of anterior elbow pain, indicating the presence of at least one intra-articular finding, especially synovitis


Step 2

Special Tests:


Step 2Arrigoni et al, 2017


Positive (+) test: reproduction of anterior elbow pain, indicating the presence of at least one intra-articular finding, especially synovitis


Special Tests:

SALT Test Video


Step 1


PEPPER: Posterior Elbow Pain by Palpation-extension of the Radiocapitellar Joint

• Using your thumb, place pressure at the level of the joint while extending the elbow

• Indications– Localized pain on the

posterior aspect of the radiocapitellar joint


Step 1

PEPPER: Posterior Elbow Pain by Palpation-extension of the Radiocapitellar Joint (cont.)

• Using your thumb, place pressure at the level of the joint while extending the elbow

• Indications– Localized pain on the

posterior aspect of the radiocapitellar joint



Step 2

Positive (+) test: reproduction of posterior elbow pain, indicating radial head chondropathy




Step 2

Positive (+) test: reproduction of posterior elbow pain, indicating radial head chondropathy




PEPPER Test Video


• Systematic review to determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with lateral elbow tendinopathy

• Evaluated 20 studies• Conclusion: there is compelling evidence that joint

mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of lateral elbow tendinopathy

Lucado AM, Dale RB, Vicent J, et al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J Hand Ther. 2018 Apr 25.

Lateral Elbow Pain: Intra-articular Issues


Lateral Elbow Pain: Updates with Ligamentous Issues


• Objectives– To evaluate the inter- and intra-observer reliabilities of

MRI for the diagnosis of lateral epicondylitis– To examine whether the degree of tendon injury was

related to other elbow abnormalities on MRI– To investigate the correlation between elbow

abnormalities on MRI and patient symptoms

• Methods– 51 subjects with chronic lateral elbow pain; average

duration of symptoms: 2.3 yearsCha YK, Kim SL, Park NH, et al. Magnetic resonance imaging of patients with lateral epicondylitis: relationship between pain and severity of imaging features in elbow joints. Acta Orthop Traumatol Turc. 2019 Apr 28.

Lateral Elbow Pain and PLRI


• Results– Other than extensor injuries, radial collateral ligament (RCL)

and lateral ulnar collateral ligament (LUCL) injury was the most common accompanying elbow abnormality

– Significant correlation between the degree of extensor tendon injury and RCL/LUCL injuries

– Also significant correlation between the degree of RCL/LUCL injuries and Visual Analogue Score (VAS)

• Conclusion– In addition to extensor tendinopathy, RCL/LUCL abnormality

was the most common accompanying finding– The degree of RCL/LUCL injuries positively correlates with

severity of painCha YK, Kim SL, Park NH, et al. Magnetic resonance imaging of patients with lateral epicondylitis: relationship between pain and severity of imaging features in elbow joints. Acta Orthop Traumatol Turc. 2019 Apr 28.

Lateral Elbow Pain and PLRI (cont.)


Posterolateral rotatory instability (PLRI)– “Lateral elbow pain may have several etiologies,

including lateral plica, radial tunnel syndrome, radiocapitellar cartilage lesions and posterolateral rotatory instability (PLRI) which may coexist with other etiologies. In PLRI-induced lateral elbow pain, the characteristic of pain is usually provoked by leaning on the hand in a slight flexion and forearm in supination”

– Described a surgical reconstruction for 36 patients with chronic lateral elbow pain with a nontraumatic PLRI

Chanlalit CC & Dilokhuttakarn T. Lateral collateral ligament reconstruction in atraumatic posterolateral rotatory instability. J Shoulder Elbow Surg. 2018;121-125.



Additional test for PLRI– Previously discussed the Push Up Sign and Chair Sign

for assessment of a PLRI– The table-top relocation test helps to differentiate

between a PLRI and intra-articular injury – Performed in three steps

Smith MV, Lamplot JD, Wright RW, et al. Comprehensive review of the elbow physical examination. J Am Acad Orthop Surg. 2018 Oct 1;26(19):678-687.Arvind CH, Hargreaves DG: Tabletop relocation test: A new clinical test for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2006;15: 707-708.




Table-top relocation test– Set up position: patient

grasps the outer edge of a table and performs a press up maneuver with the olecranon pointing laterally




Table-top relocation test– Step one

• Patient is then asked to push down through the hand on the edge of the table, allowing the elbow to flex

• Positive (+) test: pain and apprehension occurs at about 40 degrees of flexion




Table-top relocation test– Step two

• This is repeated with placing your thumb over the radial head

• Symptoms of pain and instability should be relieved as the thumb prevents posterior subluxation of the radial head

• Positive (+): alleviation of pain




Table-top relocation test– Step three

• The therapists’ thumb is removed during mid-elbow flexion

• Positive (+) test: pain and apprehension return



Table-top relocation test– If pain and apprehension occur during steps one and

three and are relieved during step two, this reinforces the diagnosis of posterolateral instability and helps to exclude intra-articular injury




• The push up sign, chair sign, and table-top relocation test all use the patient’s body weight to create an axial load and valgus torque on the elbow, resulting in posterolateral subluxation– However, they do not determine the severity of the

instability

• The authors presented that dynamic fluoroscopy and ultrasound can readily show PLRI in many cases, further research and validation in the clinical setting is needed

Camp CL, Smith J, O’Driscoll SW. Posterolateral rotatory instability of the elbow: part II. Supplementary examination and dynamic imaging techniques. Arthrosc Tech. 2017 Apr 3;6(2):e407-e411.



• Retrospective review of 14 patients with chronic lateral elbow pain and insufficiency of the lateral ulnar collateral ligament

• They found the number of steroid injections and number of cases receiving steroid injections more than three times were significantly higher in patients with ligament insufficiency

• Conclusion: assessment of stability is important in patients with chronic lateral elbow pain and risk factors such as multiple steroid injections

Shim JW, Yoo SH, Park MJ. Surgical management of lateral epicondylitis combined with ligament insufficiency. J Shoulder Elbow Surg. 2018:27;1907-1912.



122 elbows diagnosed with intractable lateral epicondylitis underwent arthroscopy

– None of the elbows demonstrated instability on physical exam

– Under anesthesia, the elbows were examined for subtle instability via fluoroscopy and divided into two groups: stable and unstable

Kwak SH, Lee S-J, Jeong HS, et al. Subtle elbow instability associated with lateral epicondylitis. BMC Musculoskeletal Disorders. 2018:19;136.



• Results– 17 elbows (13.9%) had subtle instability

• The preop VAS was higher in this group as well as a history of multiple corticosteroid injections

– 15 elbows showed subtle instability among 28 elbows with abnormal MRI findings

• Conclusion– Recommended to consider checking for subtle instability,

especially when patients have a history of multiple corticosteroid injections (at least three) or severe pain and positive MRI

Kwak SH, Lee S-J, Jeong HS, et al. Subtle elbow instability associated with lateral epicondylitis. BMC Musculoskeletal Disorders. 2018:19;136.



SUMMARY• Plica: history of catching or snapping sensation and locking in extension

• PLRI: history of multiple corticosteroid injections– In addition to push up sign and chair sign, can perform

the table-top relocation test

• Chondropathy: PEPPER test (posterior elbow pain by palpation-extension of the radiocapitellar joint test)

• Intra-articular issue with synovitis: SALT test (supination and antero-lateral pain test)

Special Tests


Lateral Elbow Pain: Assessing the Kinetic Chain


Looking proximally at the shoulder– Case-control study: assessed scapular alignment and

shoulder strength– N=51 with unilateral LE with 51 age-matched controls– Diagnostic criteria

• Pain with palpation over the lateral epicondyle or ECRB muscle

• Pain with resisted wrist extension• Pain with passive stretch to the wrist extensors

Ucurum SG, Karabay D, Osturk BB, et al. Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study. J Shoulder Elbow Surg. 2019 Mar 26

Assessing the Kinetic Chain


• Assessed scapular position with the lateral scapular slide test (LSST)

• Measured the distance between the inferior angle of each scapula and the closest spinous process using a tape measure in three positions:– Arms at side in neutral– Hands on hips (lateral iliac crests) with thumbs pointed

posteriorly– Shoulders in 90 degree abduction with full internal rotation


Assessing the Kinetic Chain (cont.)


• Subtracted the uninvolved measurement from the involved– If greater than or equal to 1.5 cm difference, this was

considered a positive result, indicating scapular asymmetry

• Then measured strength in the following order: (using hand-held dynamometer: maximum of three reps) patient seated– Shoulder internal rotation (IR)– Shoulder external rotation (ER)– Shoulder abduction




• Assessed scapular stabilizers: upper trap, middle trap, and lower trap

• Results– Scapular asymmetry was greater in patients with lateral

epicondylalgia vs. controls– Shoulder ER strength was significantly weaker than

controls– The involved side with the lateral epicondylalgia subjects

was significantly weaker than the uninvolved side with shoulder abduction, ER, and IR




Scapular Position at Rest

Step one– Find the spinous

process of C7 (typically the most prominent at the lower cervical spine)


Scapular Position at Rest (cont.)

Step two– To confirm C7, move up

to the C6 spinous process and extend the patient’s cervical spine

– You should feel it disappear, due to the anterior translation of the vertebra



Step three– Once you find T2,

compare the height with the superior angle of the scapula

– This will help you to determine if the scapula is elevated (above T2) or depressed (below T2)

– Normal scapular alignment is T2 to T6



Step four– Assess the distance

from the medial scapular border to the thoracic spine

– This can determine if the scapula is abducted



Step five – Assess the position of

the inferior angle in relation to the rib cage

– If it is more prominent, the scapula may be anteriorly-tilted


Assessing the Kinetic Chain Video 1


• Case study of a 54-year-old women with a five month h/o lateral elbow pain– Her scapula presented in an abducted position on the

involved side• With manual correction into adduction, patient’s grip

strength improved by five kg and pain decreased from 7/10 to 0

• Intervention: middle and lower trap strengthening– Three sets of ten, two times per day (no specific

strengthening for wrist extensors) over ten weeks

Bhatt JB, Glaser R, Chavez A, et al. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: a case report. JOSPT. 2013;43(11):841-847.

Looking Proximally at the Shoulder


• Treatment progression

• Outcome: complete resolution of lateral elbow pain with return to all activities and grip strength improved by 38%

• Conclusion: assessment and treatment of scapular musculature warrant consideration in the management of lateral elbow pain

Bhatt JB, Glaser R, Chavez A, et al. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: a case report. JOSPT. 2013;43(11):841-847.

Looking Proximally at the Shoulder (cont.)


LOOKING PROXIMALLY AT THE SHOULDER…• Cross-sectional study compared 28 patients with symptomatic

lateral epicondylalgia and 28 age-matched controls• Results: the involved side with lateral epicondylalgia had

significantly lower values for middle trap, lower trap, and serratus anterior strength compared to the uninvolved side

• Conclusion: when compared to age-matched controls, impairments of scapular musculature strength and endurance were present in patients with lateral epicondylalgia

• Weakness of the scapular musculature could be a result of lateral epicondylalgia

Day, JM, Bush H, Nitz AJ, et al. Scapular muscle performance in individuals with lateral epicondylalgia. JOSPT. 2015;45(5):414-424.



• Aim: compared the normalized eccentric peak torque of the shoulder abductors and ERs using a Biodex isokinetic dynamometer– Compared healthy athletes, athletes with tennis elbow,

and athletes with golfer’s elbow to help establish proper treatment programs for those with elbow pathologies

• Experimental non-randomized controlled study• N=30 male elite athletes (weight lifters, volleyball

players, and swimmers)

Nabil BA, Ameer MA, Abdelmohsen AM, et al. The impact of tennis and golfer’s elbow on shoulder external rotators and abductors peak torque. J Sport Rehabil. 2019;Apr 29:1-24.



• Results: a significant increase in the mean values of shoulder abductors and ERs normalized eccentric peak torque in the healthy control group compared with both the tennis elbow and golfer’s elbow groups, which may attribute to the imbalance between the elbow and shoulder joint function in the kinetic chain

• Conclusion: this imbalance tends to decrease the stability of the shoulder and place high stress on the distal joints of the upper kinetic chain– Rehab of the affected joint (elbow) and other joints in the

same kinetic chain (shoulder) should be includedNabil BA, Ameer MA, Abdelmohsen AM, et al. The impact of tennis and golfer’s elbow on shoulder external rotators and abductors peak torque. J Sport Rehabil. 2019;Apr 29:1-24.



Rotator Cuff Strength

Assessing external rotator (ER) strength

– With patient’s arm at side, perform resisted ER, just proximal to patient’s dorsal wrist with verbal cue, “don’t let me move you”


Rotator Cuff Strength (cont.)

Assessing internal rotator (IR) strength

– With patient’s arm at side, perform resisted IR, just proximal to patient’s volar wrist with verbal cue, “don’t let me move you”


Rotator Cuff Strength (cont.)

Assessing shoulder abductor strength

– With patient’s arm at side, perform resisted abduction with verbal cue, “don’t let me move you”


Assessing the Kinetic Chain Video 2


• In Ann’s clinical experience, what helps lateral elbow pain patients get better and stay better?

• Answer: scapular stabilization of the serratus anterior, middle trap and lower trap, the muscles that tends to be weakest with lateral elbow pain (in Ann’s clinical experience) is the middle and lower traps

Scapular Stabilization


Middle trapezius

Assessing Scapular Stabilizer Strength


Assessing Scapular Stabilizer Strength (cont.)

Lower trapezius


• Resting scapular alignment• Rotator cuff strength: strength of the shoulder

abductors, internal rotators, and external rotators• Scapular stabilizer strength: especially middle

trapezius and lower trapezius

Summary


• Purpose: to investigate whether patients with tennis elbow have a different psychological profile compared with healthy controls

• Case-control design: 69 subjects and 100 controls– Self-reported questionnaire about big five personality

traits: perfectionism, anxiety, depression, work satisfaction, and working conditions

Aben A, De Wilde L, Hollevoet N,et al. Tennis elbow: associated psychological factors. J Shoulder Elbow Surg. 2018;27:387-392.

Psychological Factors


• Results: tennis elbow patients are less agreeable and have more depressive feelings; men: are more perfectionists compared with healthy controls

• Conclusion: doctors (and therapists) should take more time during the consultation to adapt their explanations about the condition, as not to increase anxiety or depressive feelings and to strengthen the doctor/therapist-patient relationship

Aben A, De Wilde L, Hollevoet N,et al. Tennis elbow: associated psychological factors. J Shoulder Elbow Surg. 2018;27:387-392.

Psychological Factors (cont.)


Question and Answer Session

Differential Diagnosis of Lateral Elbow Pain – Live 2019 Update

1

Bibliography

MedBridge Differential Diagnosis of Lateral Elbow Pain – Live 2019 Update

Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT Psychological Factors:

1. Aben A, De Wild L, Hollevot N, et al. Tennis elbow: associated psychological factors. J Shoulder Elbow Surg. 2018 Mar;27(3):387-392.

Pain:

2. Cha YK, Kim SL, Park NH, et al. Magnetic resonance imaging of patients with lateral epicondylitis: relationship between pain and severity of imaging features in elbow joints. Acta Orthop Traumatol Turc. 2019 Apr 28. pii: S1017-995X(18)30499-1. doi: 10.1016/j.aott.2019.04.006. [Epub ahead of print]

3. Roh, YH, Gong YS, Baek GH. The prognostic value of pain sensitization in patients with lateral epicondylitis. J Hand Surg Am. 2019 Mar;44(3):250.e1-250.e7. doi: 10.1016/j.jhsa.2018.06.013. Epub 2018 Jul 20.

4. Lim ECW, Sterling M, Vicenzino B. Chronic lateral epicondylalgia does not exhibit mechanic pain modulation in response to noxious conditioning heat stimulus. Clin J Pain. 2017 Oct;33(10):932-938.

Clinical Testing:

5. Smith MV, Lamplot JD, Wright RW, et al. Comprehensive review of the elbow physical examination. J Am Acad Orthop Surg. 2018 Oct 1;26(19):678-687.

6. Arrigoni P, Cucchi D, Menon A, et al. It’s time to change perspective! New diagnosis tools for lateral elbow pain. Musculoskelet Surg. 2017 Dec;101(Suppl 2):175-179.

Tendon Involvement:

7. Palaniswamy V, Ng SK, Manickaraj N, et al. Relationship between ultrasound detected tendon abnormalities, and sensory and clinical characteristics in people with chronic lateral epicondyalygia. PLoS One. 2018 Oct 24;13(10): e0205171. doi: 10.1371/journal.pone.0205171. eCollection 2018.

Joint Issues:

8. Camp CL, Smith J, O’Driscoll SW. Posterolateral rotatory instability of the elbow: part II. Supplementary examination and dynamic imaging techniques. Arthrosc Tech. 2017 Apr 3;6(2):e407-e411.

9. Lee HI, Koh KH, Kim JP, et al. Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinico-radiologic correction. J Shoulder Elbow Surg. 2018 Aug;27(8):1329-1356.

10. Logli AL, Bernard CD, O’Driscoll SW, et al. Osteochrondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm. Curr Rev Musculoskelet Med. 2019 Mar;12(1):1-12.


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11. Lucado AM, Dale RB, Vicent J, et al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J Hand Ther. 2018 Apr 25. pii: S0894-1130(17)30289-2. doi: 10.1016/j.jht.2018.01.010. [Epub ahead of print]

12. Kwak SH, Lee SJ, Jeong HS, et al. Subtle elbow instability associated with lateral epicondylitis. BMC Musculoskeletal Disorders. 2018; 19:136-143.

13. Rajeev A & Pooley J. Arthroscopic resection of humeroradial synovial plica for persistent lateral elbow pain. J Orthop Surg (Hong Kong). 2015 Apr;23(1):11-14.

14. Shim JW, Yoo SH, Park MJ. Surgical management of lateral epicondylitis combined with ligament insufficiency. J Shoulder Elbow Surg. 2018 Oct;27(10):1907-1912.

15. Sochol KM, London DA, Rothenberg ES, et al. Arthroscopic treatment of lateral elbow pain mimicking lateral epicondylitis: long-term follow-up of a unique surgical protocol. Tech Hand Up Extrem Surg. 2019 Mar;23(1):27-30.

Proximal issues (scapular alignment and shoulder strength):

16. Ucurum SG, Karabay D, Osturk BB, et al. Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study. J Shoulder Elbow Surg. 2019 Mar 26. pii: S1058-2746(18)30951-0. doi: 10.1016/j.jse.2018.12.010. [Epub ahead of print]

17. Nabil BA, Ameer MA, Abdelmohsen AM, et al. The impact of tennis and golfer’s elbow on shoulder external rotators and abductors peak torque. J Sport Rehabil. 2019 Apr 29:1-24. doi: 10.1123/jsr.2018-0159. [Epub ahead of print]

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Differential Diagnosis of Lateral Elbow Pain · Lateral Elbow Pain. Not for reproduction or redistribution Course objectives – Verbalize the key anatomic structures that could be