I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan Healthcare in Moses Lake, Washington. So in this case, we're talking about epicondylitis of the elbow, both medial and lateral. Lateral is typically referred to as tennis elbow. Medial is typically referred to as golfers. The funny thing is that I see more tennis players with golfer's elbow and more golfers with tennis elbow, so I'm not sure why the nomenclature was there. But what we're dealing with on the medial is the common flexor complex for the wrist and for the fingers. On the lateral, we're dealing with the common extensor complex for the wrist and for the fingers. What's going on, as you've read in the case, is that there's irritation, inflammation, and probably a little bit of scarring that's going through the tendons and the myotendinous junction at that region, causing a lot of pain and angst. It's usually from repetitive motion or a change in activity, such as switching jobs or switching different positions from one sport to another. Pain is pretty specific to the epicondyle, right along this little bump on the lateral side and a little bit more proximal, or excuse me, a little bit more distal towards the wrist. On the medial side, same thing. A bit tender on the bump, the bony bump, and a little bit more distal. This area, especially on the medial aspect, can be quite tender normally, but with medial epicondylitis, it is pretty exquisite. The other thing to keep in mind is that there is a lot of crossover of the different muscles, from the biceps and the brachialis, as well as the pronator teres and the supinator, and some of those muscles can be contributing as well. And that's what we need to focus on when we're thinking about manual treatment. It's easy to get caught up in just treating the common extensor or the common flexor, which is typically the main component, but there's also the brachialis that seems to contribute quite a bit as well. So when we're treating, what I choose to do is a counter-strain works best and is most simple. Finding that point or several points that are most painful, asking what the level of pain is before we start the treatment, monitoring at that spot, and in this case we're treating the common extensor and in this case we're treating the common extensor tendon complex, and then inducing extension at the wrist and even compressing through the wrist and radiocarpal joint directed right at that lateral epicondyle. If you want a little counter pressure from behind, I'll put my hand at the olecranon process as I'm trying to monitor, and that will shorten those muscle fibers. I can add in a little bit of twisting or torquing or supination pronation until I fine-tune to the point where the patient gives the feedback that the pain is less than 3 on a scale of 1 to 10 on the pain scale or hopefully all the way gone, and then I hold for about 90 seconds, maybe a little bit longer. Once I'm done, I relax. The patient relaxes to a more normal neutral position, and then I test that area again to make sure that I've given a good treatment. If there's still pain there, I can repeat the treatment three or four times to see if we get better success. Similarly, on the medial side when we're treating the common flexor complex, the mechanism of treatment is somewhat similar except we're doing flexion at the wrist instead of extension. Likewise, still adding compression through the olecranon through the posterior elbow and adding in any supination or pronation that helps to continue to relax those tissues where most of the pain and inflammation is at. So that's what we call a counter-strain treatment. The other treatments that are effective but not as comfortable as doing the counter-strain is to put the patient in a stretched position. So if we're treating the lateral epicondylitis, we induce flexion, hyperflexion at the wrist, hyper, well, as much flexion as you can get through the digits, straightening the elbow, and then turning the arm so that we get good internal rotation up at the shoulder and as much pronation at the palm. As we do this stretch, I'll have the patient then gently try to straighten their arm and their wrist back into a normal neutral position. I'll resist and hold for anywhere from three to five seconds. Once that's over, they relax, and then I take up any amount of slack to go to the next point of stretch, or what we call the barrier, and then repeat that until we feel like we've gotten good treatment. If we want to be a little bit more aggressive, then I'll come in with my fingertips once I get to the point of the stretch, and I'll induce either with my thumb or a finger and slide along the fibers of the tendon and the muscles to really try to deep tissue stretch the area that's receiving irritation. This is going to be quite uncomfortable, so you need to make sure and prepare your athlete or your patient of what you're going to do so that they and understand why that's so important to do, and that's to remove some of the inflammatory effect, the congested tissues, moving that extra fluid out of the interstitial tissues, and trying to settle this down. So in a way, we're making it a little bit worse at the forefront so that it gets better in the long run. Similarly, we can do that same type of treatment on the medial epicondyle. Just do everything in a little bit reversed order. Now keep in mind that you don't slip too far behind into that cubital space, that cubital tunnel, because you don't want to be compressing on that ulnar nerve, that's that funny bone, and inducing any sort of numbness or tingling or neural damage.

3rd Edition, CASE 13

3rd Edition

Elbow and Forearm

epicondylitis

counter-strain method

golfer's elbow

tennis elbow

ulnar nerve