The Last Part of My Elbow Discussion
October 14th 2007 13:35
The nerve roots as we all know pass through the intervertebral foramen of the spine. The inferior articular process of the upper vertebra, when joined to the superior articular process of the lower vertebra forms the intervertebral foramen. This foramen can also be a site for spur formation happening among arthritic or degenerative patients. The premiere event that can compress and impinge the nerve roots is the narrowing of the intervertebral foramen due to accumulation of spurs. And with neck motions especially extension, we further add compression to the nerves eliciting more pain over the lateral epicondyle. Even sneezing and coughing can elicit pain over the lateral epicondyle in C5-C6 radiculopathy. Many studies reveal the presence of cystic cavities in the nerve roots and ganglia, accompanying fibrosis and inflammation. These cysts apparently contain cerebrospinal fluid which becomes elevated during sneezing and coughing. This condition further increases the symptoms of radiculopathy.
Hypermobility of the neck area is also a risk factor for acquiring not only radiculopathy but also lateral epicondylalgia. As stated above there are certain motions if done excessively (like hyperflexion or hyperextension) can aggravate the structural and biomechanical faults within the cervical region.
Contribution of the Periarticular Structures to Lateral Epicondylalgia
Periarticular structures also play roles in eliciting lateral elbow pain. Some of the structures that could contribute to the pain felt by patients are the lateral ligament, radiohumeral bursa, annular ligament, and the radial head (Cowdry, 2005). The lateral collateral ligament of the elbow is very essential in stabilizing the joint especially when external forces directed laterally contacts the medial part of the joint. With its proximity to the lateral epicondyle we can surely locate the pain over the bony prominence. Radiohumeral bursitis pain may also be localized over the lateral epicondyle. It is also true when we speak of degenerative changes on the radial head or annular ligament inflammation.
Abducted Ulna
Probably one of the most common examples of forearm bone misalignment that can elicit injury and pain over the wrist extensors as well as the lateral epicondyle is the abduction of the ulna resulting from ulnohumeral subluxation (Meadows, 2006). In this circumstance the proximal ulna separates from the proximal radius and the distal ulna approximates the distal radius. This condition is a positional fault of the elbow complex triggering contractile element pathology of the common extensor bundle (Miller, 2000).
What is the possible consequence of the ulnohumeral joint subluxation? Meadows clearly explains this in his discourse, “Abduction subluxation of the ulnohumeral joint results in the hand drifting into ulna deviation with subsequent loss of extension and radial deviation. The theory goes that the abnormal proprioception from the wrist due to the hypomobility leads to excessively forceful contractions of the radial extensors and deviators and subsequent overuse. Wrist hypomobility directly results in the same problem”. Again the concept goes back to fatiguing and overuse of the extensor muscles.
Functional Implication
Based from the biomechanical factors stated above what can we expect from patients functionally? If we are talking about lateral epicondylalgia brought about by cumulative stress over the extensors or peri-articular damages or ulnohumeral malalignment, we can expect that pain will be more pronounced during reaching and grasping heavy objects. Reaching, grasping, and manipulation of heavy objects require patients to exert more force from the muscles being discussed (especially during power grasp) thus we further elicit pain over the area. According to Castiello (2005) heavier objects need to be grasped more accurately and with a larger grip compared to lighter objects. Because of this, compensations can be observed during reaching and grasping.
The transport mechanism of reaching and grasping is composed of four phases. The preparation, acceleration, deceleration, and the stabilization phase. The “preparation” phase is the stage when the postural muscles are activated even before the reaching process has occurred. Here the trunk muscles as well as the leg muscles (during standing) contract to maintain balance in anticipation of its alteration during the arm motion. Also in this phase, the antigravity shoulder muscles contract to raise the upper extremity against gravity. The “acceleration” phase comes after the previous phase. In this stage the agonist muscles responsible for advancing the arms contract. Some of these muscles are the elbow extensors and shoulder flexors. These muscles are responsible in the sudden increase in the speed of the extremity as it approaches the target. However this does not last long. It only constitutes one-third of the whole reach. This will be immediately followed by the “deceleration” phase. During this phase the antagonist muscles slow down the reaching process for the purpose of ensuring accuracy. If the exact length of the reach has been achieved, the agonist and antagonist muscles coactivate to ensure stability of the extremity. This is what we call the “stabilization” phase.
Patients having pain over the lateral elbow usually would be apprehensive and slow (to become more accurate) in moving their affected upper limbs as a whole. They tend to guard the limbs and keep them closer to the body. This situation then results to more trunk motions in order to compensate and bring the limbs nearer to the objects which are to be manipulated. Aside from this we could also observe the forearm positioning among these patients once they grasp and manipulate heavy loads. Usually forearms are supinated among these patients. The reason for this is that forearm pronation can aggravate the pain being perceived by the patients.
In this scenario we can observe alterations in the normal reaching process. During the “preparation” phase the shoulder movement has been limited as the individuals try to keep the arm close to the trunk. We can also note that the “deceleration” phase has dominated if not completely been superimposed over the “acceleration” phase. And coactivation of the muscles can be observed to weaken due to the pain felt by the individuals as they perform grasping activities.
If lateral epicondylalgia is coupled with neurological affectation, not only sensory disturbances are to be expected. As what has been said earlier, if C5-C6 nerve roots are affected, we can expect weakness of the muscles they innervate (myotomes) especially the elbow flexors and the wrist extensors. In addition we can also expect limited neck motions direction of which depends on the laterality of the nerve root impingement. And thus when the neck moves the trunk also moves to provide greater range of motions for the body as a whole. Even overhead activities are affected and become more difficult. For example, a patient reaches overhead with shoulder (ipsilateral to the affected side) abducted, the nerve roots will be further irritated and still mimicking pain on the neck and on the lateral epicondyle.
Biomechanics -backed Assessment
In assessing patients’ conditions it is very important that we establish the nature of affectation. We have to identify whether the condition involves local peri-articular structures or the wrist extensors themselves. Ruling out or confirming collateral ligament, radial head, or bursa affectation is very important.
Also wrist extensors evaluation is a must. If we want to confirm extensor tendon problem, we have to subject the muscles and the tendons in an activity that provokes pain. As shown above the activities that provoke pain involve isometric and eccentric contraction. This is the reason why we do the Cozen’s Test. As we all know this test puts the extensors into isometric contraction while the elbow is extended and the forearm is pronated. This triggers pain not only over the bellies but especially over the tendon origin. This is also the case when we resist the extension of the middle finger while the elbow is extended and the forearm is pronated. Even grasping in itself will test the possibility of muscle-tendon affectation.
A very important element in lateral epicondylalgia rehabilitation is wrist extensor strengthening. But for some patients this just might not work. If this happens we need to shift our attention to other possible problems- like faulty forearm alignments and cervical neuropathy.
In a case study by Miller, he describes an interesting way of evaluating forearm configuration. In the subject that was studied he observed that the accessory movement of forearm adduction was restricted and painful at five degrees short of elbow extension. And so what he did is to use a mobilization belt to produce a lateral glide of the proximal forearm with respect to the humerus. Upon doing this and having instructed the subject to perform hand motions, the pain subsided. This confirms an abducted ulna.
To test for the integrity of the cervical nerve roots, we take note of the specific motions that are limited and that provokes pain over the area. Aside from this we try to elicit pain by narrowing the intervertebral foramen thus compressing the nerve roots. This is what actually Spurling’s Test does. Here the patient’s neck is laterally flexed as axial compression is applied. If the pain is duplicated over the neck and lateral epicondyle the nature of pain is neurological (Magee, 1997; Resari and Gilliam, 2005).
Muscle strength should also be assessed in situations when the nerve roots are affected. In this case, the wrist extensors and the elbow flexors are the muscles suspected to be affected more than any muscles of the upper extremity.
Upper limb tension testing can also examine the integrity of C5-C6 nerve roots. This is a tension test that puts stress on the neurological structures of the upper limb. Once done and the pain is duplicated we can rule out stress injury as cause of lateral epicondylalgia and address the problem accordingly and appropriately.
Correcting Biomechanical Faults
Strengthening of the wrist extensors is an essential element of rehabilitation in lateral epicondylalgia. However we have to consider the issues we have discussed earlier. According to Matthijs and colleagues, “The aerobic versus anaerobic activity level of the muscles can be kept in mind when performing strengthening exercises or when advising the patient regarding the pain provoking activities”. Strengthening should then be performed for a very short period of time, with minimal repetitions and lengthy rests between sets. During activities (either work, hobby or sport), the patient should try to keep demands on the wrist extensors at a level of 15% or less of maximal strength.
And since we have learned that the extensors are easily fatigued with activities, we can also perform endurance exercises later on. Initially we let patients perform concentric and isotonic contractions of their extensors, and afterwards we advance with isometric and eccentric contractions of the muscles. Why do we need to perform concentric exercises before isometric and eccentric? The reason for this kind of progression is because we have to consider the reeducation of our tendons through proprioceptive facilitation and we have to take note how tough it is for our muscles and tendons to cope with isometric and eccentric contractions.
A very interesting form of mobilization that maybe simultaneous with wrist and hand exercises is the Mulligan’s Technique. This is very important in correcting an abducted ulna as well as training the muscles to contract efficiently and appropriately. In this technique a lateral glide of the proximal ulna is produced through the mobilization belt as the forearm is pronated. The procedure is concurrent with strong resisted isometric wrist extension exercises.
Bracing and taping can also correct pathomechanical occurrence in the forearm. Aside from this, bracing reduces overload from muscles by reducing acceleration amplitude and acceleration integral within the extensors (Walther et al, 2002). Bracing and taping also presses the tendons against the attachment, increasing the surface area of the origin of the extensors, and guarding them against abrupt change in length and frequency of contraction.
If tendinosis is present in lateral epicondylalgia, deep friction massage is also applicable. If we can remember, in the first part of this discourse there are instances that fibroblasts and collagen become deposited on injured tendons. Therefore to promote healing and facilitate organized depositions of fibroblasts and collagen, friction massage is indicated (Matthijs et al., 1994).
If cervical neuropathy arises, we have to keep in mind that the answer is to bring about relief and decompress the nerve roots affected. Exercises can help a lot but it is essential that we create safe and correct exercises for the patient. So that if our patient complains of pain during neck extension, then we are not to provide neck extension exercises. If our patient complains of pain during flexion, then we are not to practice neck flexion exercises at the initial stage of our rehabilitation.
Conclusion
In this discourse we have illustrated numerous factors that can describe the nature of lateral epicondylalgia. We also tackled important issues on functional difficulties, assessment strategies, and how to deal with patients with different presentations of lateral epicondylalgia. Truly knowing these could give us vast amount of ideas on how to formulate strategies in managing this common but often times overlooked elbow pain. What we all have to realize is that proper distinction of the biomechanical faults among patients can bring the difference, and can establish the very foundation in the correctness of the management we provide for our patients.
Hypermobility of the neck area is also a risk factor for acquiring not only radiculopathy but also lateral epicondylalgia. As stated above there are certain motions if done excessively (like hyperflexion or hyperextension) can aggravate the structural and biomechanical faults within the cervical region.
Contribution of the Periarticular Structures to Lateral Epicondylalgia
Periarticular structures also play roles in eliciting lateral elbow pain. Some of the structures that could contribute to the pain felt by patients are the lateral ligament, radiohumeral bursa, annular ligament, and the radial head (Cowdry, 2005). The lateral collateral ligament of the elbow is very essential in stabilizing the joint especially when external forces directed laterally contacts the medial part of the joint. With its proximity to the lateral epicondyle we can surely locate the pain over the bony prominence. Radiohumeral bursitis pain may also be localized over the lateral epicondyle. It is also true when we speak of degenerative changes on the radial head or annular ligament inflammation.
Abducted Ulna
Probably one of the most common examples of forearm bone misalignment that can elicit injury and pain over the wrist extensors as well as the lateral epicondyle is the abduction of the ulna resulting from ulnohumeral subluxation (Meadows, 2006). In this circumstance the proximal ulna separates from the proximal radius and the distal ulna approximates the distal radius. This condition is a positional fault of the elbow complex triggering contractile element pathology of the common extensor bundle (Miller, 2000).
What is the possible consequence of the ulnohumeral joint subluxation? Meadows clearly explains this in his discourse, “Abduction subluxation of the ulnohumeral joint results in the hand drifting into ulna deviation with subsequent loss of extension and radial deviation. The theory goes that the abnormal proprioception from the wrist due to the hypomobility leads to excessively forceful contractions of the radial extensors and deviators and subsequent overuse. Wrist hypomobility directly results in the same problem”. Again the concept goes back to fatiguing and overuse of the extensor muscles.
Functional Implication
Based from the biomechanical factors stated above what can we expect from patients functionally? If we are talking about lateral epicondylalgia brought about by cumulative stress over the extensors or peri-articular damages or ulnohumeral malalignment, we can expect that pain will be more pronounced during reaching and grasping heavy objects. Reaching, grasping, and manipulation of heavy objects require patients to exert more force from the muscles being discussed (especially during power grasp) thus we further elicit pain over the area. According to Castiello (2005) heavier objects need to be grasped more accurately and with a larger grip compared to lighter objects. Because of this, compensations can be observed during reaching and grasping.
The transport mechanism of reaching and grasping is composed of four phases. The preparation, acceleration, deceleration, and the stabilization phase. The “preparation” phase is the stage when the postural muscles are activated even before the reaching process has occurred. Here the trunk muscles as well as the leg muscles (during standing) contract to maintain balance in anticipation of its alteration during the arm motion. Also in this phase, the antigravity shoulder muscles contract to raise the upper extremity against gravity. The “acceleration” phase comes after the previous phase. In this stage the agonist muscles responsible for advancing the arms contract. Some of these muscles are the elbow extensors and shoulder flexors. These muscles are responsible in the sudden increase in the speed of the extremity as it approaches the target. However this does not last long. It only constitutes one-third of the whole reach. This will be immediately followed by the “deceleration” phase. During this phase the antagonist muscles slow down the reaching process for the purpose of ensuring accuracy. If the exact length of the reach has been achieved, the agonist and antagonist muscles coactivate to ensure stability of the extremity. This is what we call the “stabilization” phase.
Patients having pain over the lateral elbow usually would be apprehensive and slow (to become more accurate) in moving their affected upper limbs as a whole. They tend to guard the limbs and keep them closer to the body. This situation then results to more trunk motions in order to compensate and bring the limbs nearer to the objects which are to be manipulated. Aside from this we could also observe the forearm positioning among these patients once they grasp and manipulate heavy loads. Usually forearms are supinated among these patients. The reason for this is that forearm pronation can aggravate the pain being perceived by the patients.
In this scenario we can observe alterations in the normal reaching process. During the “preparation” phase the shoulder movement has been limited as the individuals try to keep the arm close to the trunk. We can also note that the “deceleration” phase has dominated if not completely been superimposed over the “acceleration” phase. And coactivation of the muscles can be observed to weaken due to the pain felt by the individuals as they perform grasping activities.
If lateral epicondylalgia is coupled with neurological affectation, not only sensory disturbances are to be expected. As what has been said earlier, if C5-C6 nerve roots are affected, we can expect weakness of the muscles they innervate (myotomes) especially the elbow flexors and the wrist extensors. In addition we can also expect limited neck motions direction of which depends on the laterality of the nerve root impingement. And thus when the neck moves the trunk also moves to provide greater range of motions for the body as a whole. Even overhead activities are affected and become more difficult. For example, a patient reaches overhead with shoulder (ipsilateral to the affected side) abducted, the nerve roots will be further irritated and still mimicking pain on the neck and on the lateral epicondyle.
Biomechanics -backed Assessment
In assessing patients’ conditions it is very important that we establish the nature of affectation. We have to identify whether the condition involves local peri-articular structures or the wrist extensors themselves. Ruling out or confirming collateral ligament, radial head, or bursa affectation is very important.
Also wrist extensors evaluation is a must. If we want to confirm extensor tendon problem, we have to subject the muscles and the tendons in an activity that provokes pain. As shown above the activities that provoke pain involve isometric and eccentric contraction. This is the reason why we do the Cozen’s Test. As we all know this test puts the extensors into isometric contraction while the elbow is extended and the forearm is pronated. This triggers pain not only over the bellies but especially over the tendon origin. This is also the case when we resist the extension of the middle finger while the elbow is extended and the forearm is pronated. Even grasping in itself will test the possibility of muscle-tendon affectation.
A very important element in lateral epicondylalgia rehabilitation is wrist extensor strengthening. But for some patients this just might not work. If this happens we need to shift our attention to other possible problems- like faulty forearm alignments and cervical neuropathy.
In a case study by Miller, he describes an interesting way of evaluating forearm configuration. In the subject that was studied he observed that the accessory movement of forearm adduction was restricted and painful at five degrees short of elbow extension. And so what he did is to use a mobilization belt to produce a lateral glide of the proximal forearm with respect to the humerus. Upon doing this and having instructed the subject to perform hand motions, the pain subsided. This confirms an abducted ulna.
To test for the integrity of the cervical nerve roots, we take note of the specific motions that are limited and that provokes pain over the area. Aside from this we try to elicit pain by narrowing the intervertebral foramen thus compressing the nerve roots. This is what actually Spurling’s Test does. Here the patient’s neck is laterally flexed as axial compression is applied. If the pain is duplicated over the neck and lateral epicondyle the nature of pain is neurological (Magee, 1997; Resari and Gilliam, 2005).
Muscle strength should also be assessed in situations when the nerve roots are affected. In this case, the wrist extensors and the elbow flexors are the muscles suspected to be affected more than any muscles of the upper extremity.
Upper limb tension testing can also examine the integrity of C5-C6 nerve roots. This is a tension test that puts stress on the neurological structures of the upper limb. Once done and the pain is duplicated we can rule out stress injury as cause of lateral epicondylalgia and address the problem accordingly and appropriately.
Correcting Biomechanical Faults
Strengthening of the wrist extensors is an essential element of rehabilitation in lateral epicondylalgia. However we have to consider the issues we have discussed earlier. According to Matthijs and colleagues, “The aerobic versus anaerobic activity level of the muscles can be kept in mind when performing strengthening exercises or when advising the patient regarding the pain provoking activities”. Strengthening should then be performed for a very short period of time, with minimal repetitions and lengthy rests between sets. During activities (either work, hobby or sport), the patient should try to keep demands on the wrist extensors at a level of 15% or less of maximal strength.
And since we have learned that the extensors are easily fatigued with activities, we can also perform endurance exercises later on. Initially we let patients perform concentric and isotonic contractions of their extensors, and afterwards we advance with isometric and eccentric contractions of the muscles. Why do we need to perform concentric exercises before isometric and eccentric? The reason for this kind of progression is because we have to consider the reeducation of our tendons through proprioceptive facilitation and we have to take note how tough it is for our muscles and tendons to cope with isometric and eccentric contractions.
A very interesting form of mobilization that maybe simultaneous with wrist and hand exercises is the Mulligan’s Technique. This is very important in correcting an abducted ulna as well as training the muscles to contract efficiently and appropriately. In this technique a lateral glide of the proximal ulna is produced through the mobilization belt as the forearm is pronated. The procedure is concurrent with strong resisted isometric wrist extension exercises.
Bracing and taping can also correct pathomechanical occurrence in the forearm. Aside from this, bracing reduces overload from muscles by reducing acceleration amplitude and acceleration integral within the extensors (Walther et al, 2002). Bracing and taping also presses the tendons against the attachment, increasing the surface area of the origin of the extensors, and guarding them against abrupt change in length and frequency of contraction.
If tendinosis is present in lateral epicondylalgia, deep friction massage is also applicable. If we can remember, in the first part of this discourse there are instances that fibroblasts and collagen become deposited on injured tendons. Therefore to promote healing and facilitate organized depositions of fibroblasts and collagen, friction massage is indicated (Matthijs et al., 1994).
If cervical neuropathy arises, we have to keep in mind that the answer is to bring about relief and decompress the nerve roots affected. Exercises can help a lot but it is essential that we create safe and correct exercises for the patient. So that if our patient complains of pain during neck extension, then we are not to provide neck extension exercises. If our patient complains of pain during flexion, then we are not to practice neck flexion exercises at the initial stage of our rehabilitation.
Conclusion
In this discourse we have illustrated numerous factors that can describe the nature of lateral epicondylalgia. We also tackled important issues on functional difficulties, assessment strategies, and how to deal with patients with different presentations of lateral epicondylalgia. Truly knowing these could give us vast amount of ideas on how to formulate strategies in managing this common but often times overlooked elbow pain. What we all have to realize is that proper distinction of the biomechanical faults among patients can bring the difference, and can establish the very foundation in the correctness of the management we provide for our patients.
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