Now we're gonna talk about some common
clinical presentations involving the elbow.
We're gonna discuss some of the presentations
and how you could evaluate it.
Sometimes you could apply a special
test to determine the source
and how we could also help manage it with
the osteopathic manipulative medicine.
So epicondylitis is a common
problem with the elbow.
It's usually a form of localized pain on either side,
either the lateral, medial epicondyle of the elbow
and usually it's associated with some sort of
inflammation or degeneration of the tendons
that attach in that area due
to repetitive microtrauma.
So if I have pain on the medial aspect of the
elbow, a lot of times you would consider this
inflammation of the
tendons that attach there.
So the muscles that attach here include the pronator
teres and the common flexor tendons of the wrist.
So any sort of repetitive motion that requires
wrist flexion will sometimes irritate
and cause some pain in the medial aspect of the
elbow and so this is also called Golfer's elbow.
Golfer's elbow because when you're
golfing, a lot of times you finish
and you put a lot of strain in the
wrist with the follow through.
If I'm having pain in the lateral aspect of the
epicondyle, this might be a lateral epicondylitis.
This is the origin of the supinator
and the common extensor tendons.
So anything where you have repetitive motion where your
wrist is constantly extending could cause problems.
So this is also referred to as Tennis elbow
because tennis players when they do the back hand
frequently has to hyperextend their wrist when
they're hitting the ball against resistance.
So if you have pain on the lateral aspect that
could be considered a lateral epicondylitis.
So there are a couple of special test that we could
perform to confirm the diagnosis of epicodylitis.
If I have lateral elbow pain, what we want to do is
to try to test the muscles attached to that region.
So remember that it is the wrist
extensors that attach to that area.
So in order to motion test the wrist
extensors, we could do two different things.
We could either actively test
it or passively test it.
So in order to test the wrist extensors
actively, what we're going to do
is we're going to flex the wrist and ask them to
actively extend your wrist against resistance
and as the extend your wrist against resistance,
if they have pain in the lateral elbow,
that is a positive test.
The other way to motion test and see if there's
pain there is to stretch those muscles.
So in order to stretch the wrist extensors, what
we're going to do is gonna passively flex the wrist.
So if there is pain there with passive wrist flexion,
that's gonna stretch the tendon and cause pain there
and that'll be a positive test.
Usually in clinical practice, I do the passive first
and if they complain of pain then that's positive.
If I do that and they don't have pain, then I tell them
to resist and try to push their wrist into extension
and sometimes that will elicit
pain when the passive did not.
For the medial epicondyle, here
we're testing the wrist flexors.
So here, if we wanted to test the wrist flexors
actively, we're going to extend the wrist
and ask the patient to
try to flex their wrist.
If there's pain in the medial epicondyle
when they try to flex their wrist
then that is a positive test.
You can also passively extend the wrist
thus stressing the wrist flexors
and if there's pain with passive wrist extension that
is also a positive test for medial epicondylitis.
So osteopathic manipulative medicine can
be utilized to treat epicondylitis.
Secondary to inflammation and pain,
there could be muscle spasms
that could cause problems at the
radial head, the wrist and the elbow.
There could be lack of range of motion and so
what we could do, we could use the treatments
directed to help decrease some
of that muscle spasm and pain.
There are certain techniques that we use
to try to decrease the muscle spasm.
Counterstrain is a good technique to localize over the
tender point and try to decrease the pain in the region.
We wanna assess the joints above
and below the elbow joint.
Also sometimes we could have elbow problems
but the source of the problem
could really be at the wrist and hand
or in the shoulder.
Ulnar nerve compressions syndrome is usually
due to a direct trauama of the ulnar nerve
or sometimes it could be from
repetitive or prolonged elbow flexion.
Sometimes you could sleep wrong or if you kinda rest
your elbow on a hard surface like a desk for too long,
it could irritate the region where the ulnar
nerve passes through the ulnar groove.
Sometimes there might be
hypermobility of the ulnar nerve.
If you are just having excessive valgus carrying
angle that could also compress the ulnar groove.
Patients simetimes may have
osteophytes that develop there.
Another name for ulnar neuropathy
is also cubital tunnel syndrome.
So usually patients who present with
some posterior medial elbow pain
sometimes they coud say that they have numbness
and tingling into the ring and the forefinger
because that is the innervation
of the ulnar nerve.
Sometimes patients may present with motor deficits
but usually that is a more advanced presentation.
Pain will be forced.
Pain usually is worse
with forced elbow flexion
and in the long term if you
have compression of that nerve,
the muscles in the hand may start to waste
away and become a little bit more hypotonic.
Ulnar nerve compression syndrome could be confirmed by
performing provocative test such as the Tinel's test.
So the Tinel's test is just really
tapping over the nerve.
So you find the ulnar groove and you're
gonna gently tap over the groove
and you see if it recreates symptoms of numbness
and tingling going down into the fingers.
Management usually involves rest, taking anti-inflammatories
to help decrease inflammation or edema.
You could protect the elbow
by wearing a brace or sleeve
and also remind the patient not to
rest the elbow on any hard surfaces.
Sometimes you may need to confirm the
diagnosis using your diagnostic studies.
Osteopathic manipulation could help
ulnar nerve compression syndrome
by treating some of the inflammation
and swelling in the area.
What we could do is to try to use techniques
that helps improve lymphatic drainage.
We wanna open up the thoracic outlet,
do some myofascial techniques
to free up any muscle spasm and tissue texture restrictions
that might be preventing proper lymphatic flow
and then you could perform some gentle
upper extremity lymphatic pumps
that help with lymphatic flow return
from the arm back to the body.
You wanna definitely assess the joints
above and below the elbow joint
and also take a look at the neck and upper
thoracic cage to improve lymphatic drainage.
So the ulnar nerve compression test could be
confirmed using the Tinel's test for the ulnar nerve.
What you're going to do is you're going to gently tap on
that ulnar groove on the posterior aspect of the elbow.
Positive test is if you have shooting
pain going down into the hand
Medial and lateral collateral
tendonitis or tears could occur.
Usually you're gonna have pain in the
medial or lateral aspect of the elbow
You have to differentiate
this from epicondylitis.
Usually there might be some sort
of trauma to cause the disruption.
Anything that causes too much
valgus strain or varus strain could
potentially tear the medial and
lateral collateral ligaments.
There are provocative tests to perform to see
if you recreate pain or have increased joint play.
The valgus stress test will test
the medial aspect of the elbow
and the varus stress test will test
the lateral aspect of the elbow.
If you do have a medial or collateral tendonitis,
usually you advise rest.
Sometimes you could
You could use anti-inflammatories
to decrease the inflammation.
Again you wanna protect the
elbow or maybe brace the area.
If it is a full tear or really a severe
tear, you may need to have surgical repair.
Overall, you wanna try to
decrease the muscle spasms
and osteopathic manipulative medicine will be similar
to the where you're trying to decrease spasms
and improve lymphatic
drainage and circulation.
So we could perform special test to assess for
medial or lateral collateral tendonitis or tears.
So at the elbow, if we perform a valgus test, we're
gonna be testing the medial collateral ligament.
And so to perform a valgus test,we're going to
stabilize the forearm and also above the elbow
and we're gonna try to gently bring the forearm more
laterally, that's gonna create a valgus stress.
So when you perform a valgus test that's going
to test the medial aspect of the elbow.
If there is increase laxity
or pain as you do that,
then that might point towards a
medial collateral ligament tear.
To test the lateral aspect, we're
going to perform a varus stress test.
So for varus stress test, what we're going to do
is we're gonna bring the forearm more medially
and you could see how that would gap
the lateral aspect of the elbow.
Increased laxity or pain as you
perform the varus stress test
would confirm a lateral
collateral tendonitis or tear.
So that concludes our
review of the elbow joint
and how the anatomy and physiology of the elbow
relates to osteopathic diagnosis and treatment.