Medial vs. Lateral Epicondylitis
Medial vs. Lateral Epicondylitis by Jon Tobey
The most common cause of Epicondylitis is excessive repetitive use or eccentric strain of the wrist or forearm muscles. The result is micro-damage and partial tears, usually near the musculotendinous junction when strain exceeds the strength of the tissues and the demand exceeds the repair process. Activities such as a backhand stroke in tennis, pulling weeds in a garden or any other activities that require firm wrist stability can cause lateral Epicondylitis. Activities that require repetitive movements into wrist flexion such as swinging a golf club, pitching a ball or work related grasping and lifting heavy objects can cause medial Epicondylitis.
The highest incidence in lateral Epicondylitis is in the musculotendinous junction of the extensor carpi radialis brevis, symptoms also occur when the annular ligament which is a strong band of fibers surrounding the head of the radius and retaining it in the radial notch of the ulna is stretched. Medial Epicondylitis involves the common flexor/pronator tendon at the tenoperiosteal junction near the medial epicondyle. With Epicondylitis inflammation of the periosteum may develop with formation of granulation tissue and adhesions.
One of the major symptoms is when the area becomes irritated and chronic inflammation develops. If the situation becomes worse pain will limit the movement of the elbow, wrist and hand. Also noticeable decreases in muscle strength and endurance will be seen along with a decrease in grip strength. If palpation of the area also causes pain this could be a sign of medial or lateral Epicondylitis.
There two general ways that epicondylitis is treated and that is through corticosteroid injections and physiotherapy. Corticosteroid injections have seen success rates as high as 95% in patients with symptoms of epicondylitis. (Smidt et al., 2002) There are also non-operative ways to treat epicondylitis that involve phases. The first non-operative phase used is the protection phase. During this phase the patient will rest the muscles in a splint to immobilize the joint. The patient should stay away from repetitive activities that aggravate the area. Also cryotherapy which is a therapeutic use of cold can be utilized to help the swelling. (http://www.nlm.nih.gov/medlineplus/mplusdictionary.html) Non-stressful mobility exercises should be performed including wrist flexion and wrist extension. Also active range of motion (ROM) should be performed to maintain full ROM of the joint. Other non-operative phases include controlled motion and return to function phase. During this first part of treatment the goal is to increase the flexibility of the muscle and create a mobil scar, to do this the patient must include passive and self stretching exercises. Also a Cross fiber massage will help heal the injury and increase range of motion with out pain. Next the patient must restore normal joint tracking of the radiohumeral joint. This is done by mobilization with movement techniques which have been shown to decrease pain in the elbow and increase grip strength. Step three is to strengthen the muscle and improve muscular endurance. This is done by using isometric exercises to mainly strengthen the forearm and wrist muscles. The last step is to progress to functional training and conditioning. During this step the patient should include strength, cardiovascular, muscle endurance, power and flexibility exercises throughout this portion of treatment. Most important they should be informed of overload symptoms that may reinjure the area in order to prevent a reoccurrence.
Mechanical, manual and self stretching techniques should be used to increase elbow extension. These techniques include mild flexion contracture, dynamic splinting and a manual, mechanical and self stretch of the bicep brachii. Elbow flexion also needs to be increased, this can be done with either mild extension contracture or a self stretch of the longhead of the triceps. Other muscles that need to be included in the stretching program are forearm pronators, supinators, wrist flexors and extensors.
The exercises used during controlled motion and return to function phases are isometric exercises, dynamic strengthening and endurance exercises and functional patterns of open and closed chain strengthening exercises. The isometric exercises used for this injury are multiple angle isometric exercises, angle specific training, endurance and also alternating isometrics and rhythmic stabilization open and closed chain.
The dynamic strengthening and endurance exercises include strengthening muscles that are multijoint including the bicep, long head of the tricep and wrist flexors and extensors. These exercises include bicep curls working elbow flexion using a pulley system, elastic tubing or free-weight’s. Elbow extension exercises are also used including the overhead tricep extensions working the long head of the triceps’. Pronation and supination exercises are also used. These exercises can be done using free-weight’s and also elastic tubing. These exercises will work the pronator teres and quadratus along with the supinator and biceps. The last dynamic exercises used are for wrist flexion and extension. Free-weight’s can be used for these types of exercises. For example wrist extensors can be worked by taking a dumbbell with the palm down and extending the wrist up against the resistance. A wrist roller can also be used, wrist flexion exercises tend to work the medial epicondyle, and wrist extension exercises work the lateral epicondyle.
Functional patterns including open and closed chain strengthening exercises can also be used during this type of program. Diagonal patterns, combined pulling motions, combined pushing motions, stretch shortening drills, and simulated tasks and activities should be used to increase performance. ( Colby, Kisner 414)
Medial vs. Lateral Epicondylitis Exercises
1) To increase cardiovascular endurance but while still in the phase of recovery the patient would want to stay away from repetitive elbow, wrist and hand movements. This would eliminate the hand ergometer and rowing machine. The two machines that the patient should be using are a treadmill and recumbent bike. While on these machines the patient should hold dumbbells in their hands to increase the muscular endurance in their hands and wrists.
A) Treadmill. 30 minutes for duration holding 3 lb dumbbells to start for 15 minutes total. 2x a week.
B) Recumbent bike. 30 minutes for duration holding 3 lb dumbbells for 15 minutes total. 1x a week.
2) In order to increase flexibility and range of motion the patient must understand and be sure that the joint capsule is not restricting motion in order to participate in the stretching exercises. (Colby, Kisner, 407) The muscles that need to be stretched are the elbow extensors, elbow flexors, forearm supinators and pronators along with wrist flexors and extensors.
A) Stretching the biceps brachii is necessary to increase elbow extension. The self stretch will allow the patient to do the stretch on their own. The technique is as follows: The patient should stand on the side of a table, grasp the end of the table and walk forward causing shoulder extension along with elbow extension. (Colby, Kisner, 408) Hold stretch for 20 seconds with a 10 second rest.
B) The patient must also stretch the triceps brachii in order to increase elbow flexion. This self stretch of the long head of the triceps can be done alone. The patient can either be sitting or standing and the patient will flex the elbow and shoulder as far as possible. The other hand will either push the shoulder into further flexion. Hold stretch for 20 seconds with a 10 second rest.
C) The patient must also stretch the wrist extensor muscles (extensor carpi radialis and extensor carpi ulnaris) to increase wrist flexion. One technique used is when the patient is standing with the elbow extended, forearm pronated and the back of the hand against the wall with the fingers pointing down. Have the patient then slide the back of the hand up the wall. (Colby, Kisner, 409)
D) The wrist flexor muscles (flexor carpi radialis and flexor carpi ulnaris) must also be stretched in order to increase wrist extension. In order to stretch this area the patient should be standing with the elbow extended and the forearm supinated. Have the patient put the palm of their hand against the wall with the fingers pointing down, and then have them move their hand up the wall until a stretch sensation is felt in the wrist flexors. (Colby, Kisner, 409)
3) In order for the patient to increase strength and muscular endurance, one method that will be used is an eccentric only training phase. Research has shown that eccentric training vs. stretching over a twelve week period demonstrated that 71% of the eccentric group rated themselves as completely recovered, compared to the 39% in the stretch group. (Hume, P. Reid, D. Edwards, T, 163)
A) Eccentric barbell curls, three sets of five repetitions. This exercise will allow the subject to strengthen the bicep brachii, brachialis and brachioradials. The patient will stand against a wall and the instructor will help on the concentric phase of lift while the patient goes down slow on the eccentric phase of the lift.
B) Supine one hand dumbbell French press, three sets eight to twelve repetitions. This will help the patient to increase muscular strength in the triceps and anconeus. This exercise will be done both eccentrically and concentrically. The patient will lie supine with the shoulder flexed at 90 degrees holding a weight in hand, while stabilizing the shoulder of the working arm with the other arm to help maintain a stable position. The client will repeat movement and extend the elbow and then eccentrically bring the weight back down to the start position in elbow flexion.
C) Dumbbell pronation, three sets of fifteen to twenty repetitions. This exercise will be working the pronator teres and quadratus. The patient will hold a dumbbell unevenly to create an uneven resistive force. A bar with only a weight on one side would be best. The patient will then rest their forearm on a table while rotating the dumbbell from supination to pronation. Repeat with other arm. (Colby, Kisner, 412)
D) Dumbbell wrist flexion, three sets of fifteen to twenty repetitions. This exercise will be working the flexor carpi radialis and flexor carpi ulnaris, and would be applied to strengthen the medial epicondyle. This exercise is done seated using a light dumbbell with your arm on a table except for your wrist. With you palm up let the weight drop so that your wrist is in full extension and then curl your wrist up into wrist flexion. Repeat with other arm. (Colby, Kisner, 412)
E) Wrist roller, up and down two times. This exercise is used to strengthen the wrist extensors (extensor carpi radialis and extensor carpi ulnaris). It is also used to strengthen grip and muscles of the lateral epicondyle. Using a wrist roller and a weight tied to it. Have the patient stand with their arms pronated and elbows slightly flexed. The patient must then slowly lower the weight by alternating a wrist rolling extension/flexion action and then wind back up the weight using the same alternating wrist action. (Colby, Kisner, 412)
4) While working on balance, proprioception and function, the patient will be using a variety of machines. As the patient progresses in this type of routine they will increase their resistance, repetitions and if necessary speed. These exercises will work several muscle groups while focusing in on the elbow, wrist and hand.
A) The lawn mower pull is a functional exercise for strengthening the upper body. The patient will start by taking elastic tubing and attaching it to their foot. Then with the opposite hand the client will pull up through the elbow on the other end of the tubing. This is done while in a standing position. Three sets of twelve to fifteen repetitions. (Colby, Kisner, 414)
B) Modified push ups, three sets of eight to ten repetitions. This exercise will work the triceps, anterior deltoids, serratus anterior, pectoralis minor and lower trapezius. Using a wall, chair or bench the client will place their hands slightly outside shoulder width on the object while keeping their body angled with the hips up in a pushup position. The patient will then lower themselves close to the table and push out to starting position. This will help improve the function of all the muscles involved so the triceps do not have to do all the work when in a similar situation.
C) The last important activity for the patient to do is simulated tasks and activities. This patient is a racquetball player, so he will be doing tasks similar to that in racquetball. He will be using a pulley system to work on his backhand, forehand and serve. These exercises will help the patient recover and work on controlling the movement so that the elbow improves. The resistance, time and speed will be the challenging factors in this exercise. To start the patient will be on light weight for 20 seconds each movement each arm.
5) In order for this patient to prevent future complications and reoccurrences, they need to understand what activities made this injury occur. The reason in most cases is due to lack of control of the wrist and elbow, repeated wrist extension, heavy lifting and lack of strength training and flexibility of this area. The patient should not be involved in activities that seem to provoke the injury. They should also continue to participate and expand on the activities and exercises that have been learned. Also the patient should keep in mind that they need to rest the muscle used in the particular activity in order for the muscle to recover. If the muscle does not receive enough rest then musculotendinous unit will become inflamed and the same injury will occur. For more information on injury prevention contact Jon Tobey at http://www.jontobeyfitness.com
References
Colby, L.A. Kisner, C (2002) Therapeutic Exercise foundations and Techniques. F.A. Davis Co. Philadelphia.
Hume, P. Reid, D. Edwards, T. (2006) Epicondylar Injury in Sport. Sports Medicine Vol. 36, I.2, 151-170
Medline Dictionary (Cryotherapy) A service of the U.S. National Library of Medicine (2003, Feb 4) http://www.nlm.nih.gov/medlineplus/mplusdictionary.html)
Smidt, N. Van der Windt, D. Assendellft, W. Deville, W. Korthals-de Bos, I. Bouter, L. (2002) Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Vol. 359 Issue 9307, p657. From Ebsco Host.
About the Author
Jon Tobey is a Certified Personal Trainer and Nutrition Coach at the Salem Athletic Club in Salem, NH. He specializes in Weight Loss, Toning and group training including: Boxing Boot Camp and regular Boot Camp Training.
http://www.sac-nh.com/specialized_programs.php
http://www.sac-nh.com/contact_tobey.php
|
|
NONFS300 Medline 96 EA/CS,4 BX/CS SHIELD,FACE,FULL,FOAM TOP,ELASTIC Medline NONFS300 $130.00 Medline NONFS300 SHIELD,FACE,FULL,FOAM TOP,ELASTIC Safety Products Safety Eyewear… |
|
|
Dupont Tyvek Coveralls – Elastic Wrist, Hood and Boots – XX-Large, White – Qty of 25 $496.68 Medline’s lint-free Tyvek Coveralls offer enough protection for use in the O.R. or “clean” areas. In a variety of styles to meet all of your needs, coveralls are sturdy and feature a full-length zipper for ease of use…. |
|
|
Protection Plus Undergarments – Reusable Belts – 25 Pair / Bag $53.00 The thin design and super absorbent core of Medline Protection Plus undergarments keep patients dry and control moderate flow. Super absorbent polymer improves dryness, containment and skin care. Extra wide belts are comfortable yet secure. Cloth-like outer cover…. |
|
|
Curad Silver Solution Antimicrobial Gel, .5 oz, (Pack of 2) $8.98 Curad Brand Products Offer Protection For The Entire Family. From Our Unique And Colorful Character Bandages To Hospital Quality Gauze Items, Curad Is There Every Step Of The Way Covering All Of Your Family’S First-Aid Needs…. |
|
|
Medline Disposable Face Shields – Full Foam Top Elastic Shield – Model NONFS300H $3.99 Medline’s disposable face shields serve as a final layer of protection during surgery. Latex-free band and contoured foam material ensure that the shield rests comfortably on the forehead. Can be used in conjunction with Prohibit face masks…. |
|
|
Bandage, Elastic, Matrix, 4x5yd, Velcro $12.28 … |
|
|
Medline Disposable Scrub Wear – Elastic Waist Scrub Pants – Pants, Elastic, Large – Qty of 30 $53.51 These disposable scrubs offer complete coverage and are made from breathable, fluid resistant SMS material. Generously cut shirts have one chest pocket. Choose either round neck or V-neck. Pants have one rear pocket. Choose from drawstring waist or elastic waist. Both shirt and pants available in blue…. |
|
|
NON27213M Medline 30 EA/CS PANT,SCRUB,ELASTIC-WAIST,BLUE,MD,DISP Medline NON27213M $59.10 Medline NON27213M PANT,SCRUB,ELASTIC-WAIST,BLUE,MD,DISP WOVEN & NONWOVEN GOODS Scrub Suits, Disposable, Tops and Pants PANT,SCRUB,ELASTIC-WAIST,BLUE,MD,DISP Disposable Scrub Wear: These Disposable Scrub Pants Offer Complete Coverage; Made From Breathable, Fluid Resistant Multi-Ply Polypropylene Material, The Elastic Waist Style Waist Pants Are Generously Sized And Have One Side Leg Pocket. Blue, M… |
|
|
NON27213XL Medline 30 EA/CS PANT,SCRUB,ELASTIC-WAIST,BLUE,XLG,DISP Medline NON27213XL $55.28 Medline NON27213XL PANT,SCRUB,ELASTIC-WAIST,BLUE,XLG,DISP WOVEN & NONWOVEN GOODS Scrub Suits, Disposable, Tops and Pants PANT,SCRUB,ELASTIC-WAIST,BLUE,XLG,DISP Disposable Scrub Wear: These Disposable Scrub Pants Offer Complete Coverage; Made From Breathable, Fluid Resistant Multi-Ply Polypropylene Material, The Elastic Waist Style Waist Pants Are Generously Sized And Have One Side Leg Pocket. Blue… |
|
|
Curad Open Heel Ankle Supports, Elastic,RETAIL,MD, 4/cs $26.51 0… |