Epicondylitis, Ulnar Nerve Compression Syndrome and Collateral Tendonitis

by Sheldon C. Yao, DO

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    00:01 Now we're gonna talk about some common clinical presentations involving the elbow.

    00:05 We're gonna discuss some of the presentations and how you could evaluate it.

    00:08 Sometimes you could apply a special test to determine the source and how we could also help manage it with the osteopathic manipulative medicine.

    00:16 So epicondylitis is a common problem with the elbow.

    00:20 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.

    00:34 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.

    00:43 So the muscles that attach here include the pronator teres and the common flexor tendons of the wrist.

    00:48 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.

    01:00 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.

    01:09 If I'm having pain in the lateral aspect of the epicondyle, this might be a lateral epicondylitis.

    01:14 This is the origin of the supinator and the common extensor tendons.

    01:18 So anything where you have repetitive motion where your wrist is constantly extending could cause problems.

    01:24 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.

    01:35 So if you have pain on the lateral aspect that could be considered a lateral epicondylitis.

    01:41 So there are a couple of special test that we could perform to confirm the diagnosis of epicodylitis.

    01:46 If I have lateral elbow pain, what we want to do is to try to test the muscles attached to that region.

    01:52 So remember that it is the wrist extensors that attach to that area.

    01:56 So in order to motion test the wrist extensors, we could do two different things.

    02:00 We could either actively test it or passively test it.

    02:04 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.

    02:23 The other way to motion test and see if there's pain there is to stretch those muscles.

    02:29 So in order to stretch the wrist extensors, what we're going to do is gonna passively flex the wrist.

    02:35 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.

    02:42 Usually in clinical practice, I do the passive first and if they complain of pain then that's positive.

    02:48 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.

    02:59 For the medial epicondyle, here we're testing the wrist flexors.

    03:03 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.

    03:13 If there's pain in the medial epicondyle when they try to flex their wrist then that is a positive test.

    03:18 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.

    03:31 So osteopathic manipulative medicine can be utilized to treat epicondylitis.

    03:36 Secondary to inflammation and pain, there could be muscle spasms that could cause problems at the radial head, the wrist and the elbow.

    03:43 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.

    03:51 There are certain techniques that we use to try to decrease the muscle spasm.

    03:54 Counterstrain is a good technique to localize over the tender point and try to decrease the pain in the region.

    04:01 We wanna assess the joints above and below the elbow joint.

    04:04 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.

    04:11 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.

    04:19 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.

    04:30 Sometimes there might be hypermobility of the ulnar nerve.

    04:33 If you are just having excessive valgus carrying angle that could also compress the ulnar groove.

    04:40 Patients simetimes may have osteophytes that develop there.

    04:43 Another name for ulnar neuropathy is also cubital tunnel syndrome.

    04:49 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.

    05:02 Sometimes patients may present with motor deficits but usually that is a more advanced presentation.

    05:08 Pain will be forced.

    05:10 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.

    05:25 Ulnar nerve compression syndrome could be confirmed by performing provocative test such as the Tinel's test.

    05:31 So the Tinel's test is just really tapping over the nerve.

    05:34 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.

    05:43 Management usually involves rest, taking anti-inflammatories to help decrease inflammation or edema.

    05:50 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.

    05:57 Sometimes you may need to confirm the diagnosis using your diagnostic studies.

    06:04 Osteopathic manipulation could help ulnar nerve compression syndrome by treating some of the inflammation and swelling in the area.

    06:11 What we could do is to try to use techniques that helps improve lymphatic drainage.

    06:15 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.

    06:33 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.

    06:42 So the ulnar nerve compression test could be confirmed using the Tinel's test for the ulnar nerve.

    06:48 What you're going to do is you're going to gently tap on that ulnar groove on the posterior aspect of the elbow.

    06:53 Positive test is if you have shooting pain going down into the hand Medial and lateral collateral tendonitis or tears could occur.

    07:02 Usually you're gonna have pain in the medial or lateral aspect of the elbow You have to differentiate this from epicondylitis.

    07:09 Usually there might be some sort of trauma to cause the disruption.

    07:13 Anything that causes too much valgus strain or varus strain could potentially tear the medial and lateral collateral ligaments.

    07:21 There are provocative tests to perform to see if you recreate pain or have increased joint play.

    07:26 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.

    07:34 If you do have a medial or collateral tendonitis, usually you advise rest.

    07:39 Sometimes you could have bracing.

    07:41 You could use anti-inflammatories to decrease the inflammation.

    07:44 Again you wanna protect the elbow or maybe brace the area.

    07:47 If it is a full tear or really a severe tear, you may need to have surgical repair.

    07:52 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.

    08:03 So we could perform special test to assess for medial or lateral collateral tendonitis or tears.

    08:09 So at the elbow, if we perform a valgus test, we're gonna be testing the medial collateral ligament.

    08:15 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.

    08:26 So when you perform a valgus test that's going to test the medial aspect of the elbow.

    08:31 If there is increase laxity or pain as you do that, then that might point towards a medial collateral ligament tear.

    08:40 To test the lateral aspect, we're going to perform a varus stress test.

    08:44 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.

    08:52 Increased laxity or pain as you perform the varus stress test would confirm a lateral collateral tendonitis or tear.

    09:01 So that concludes our review of the elbow joint and how the anatomy and physiology of the elbow relates to osteopathic diagnosis and treatment.

    About the Lecture

    The lecture Epicondylitis, Ulnar Nerve Compression Syndrome and Collateral Tendonitis by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Elbow Region. It contains the following chapters:

    • Epicondylitis
    • Ulnar Nerve Compression Syndrome
    • Medial and Lateral Collateral Tendonitis

    Included Quiz Questions

    1. Repetitive extension
    2. Repetitive flexion
    3. Repetitive supination
    4. Restricted extension
    1. Repetitive flexion
    2. Repetitive supination
    3. Excessive extension
    4. Repetitive extension
    1. Wrist extensors
    2. Elbow extensors
    3. Wrist flexors
    4. Elbow flexors
    5. Shoulder flexors
    1. Little finger
    2. Index finger
    3. Thumb
    4. Medial forearm

    Author of lecture Epicondylitis, Ulnar Nerve Compression Syndrome and Collateral Tendonitis

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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