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Treating elbow pain sounds simple and with the correct information, it is! Evidence-based chiropractors DO NOT (and cannot) memorize every evaluation, treatment, patient education tip, ADL modification, and exercise for every condition; however, the most effective providers DO understand how to use clinical tools, prediction rules, and practice resources to remind them of everything necessary to make the most of each visit for both the patient and provider. 

This week’s blog covers the top four tips (Including downloadable resources) to effectively assess and treat lateral elbow pain.

Here’s a proven four-step process for successfully managing lateral elbow pain.

1. Arrive at The Correct Diagnosis

Making the correct diagnosis begins with listening. But don’t just listen; ask leading questions. A well-guided conversation provides invaluable insight into the origin of symptoms. Then, employing a validated cluster of tests will (hopefully) illuminate the correct diagnosis.

A combination of history and physical exam will differentiate between the three top culprits: lateral epicondylitis, epicondylosis, and radial tunnel syndrome.

Each of the following tests will provide clues as to which tissues are injured based on symptom responses. However, be sure to read the clinical pearls at the end for some valuable nuances.

Ulnar nerve floss

Cozen's Test

The seated patient partially extends their arm, with their wrist pronated and slightly radially deviated, fingers closed into a fist. The clinician stabilizes the elbow with one hand while the patient extends their wrist against resistance. Reproduction of symptoms suggests lateral epicondyle involvement.

Ulnar nerve floss

Mill's Test

The patient is seated with their arm fully extended. The clinician passively flexes the wrist and applies radial deviation to stretch the wrist extensors fully. Reproduction of pain suggests wrist extensor or lateral epicondyle involvement.

Ulnar nerve floss

Resisted Long Finger Extension Test

With the patient’s forearm and fingers extended, the examiner resists middle finger extension. During this test, the reproduction of radial nerve pain suggests compression of the radial nerve by the extensor carpi radialis brevis. This test may also be positive in lateral epicondylitis. Still, radial tunnel irritation is the likely diagnosis when this test is more painful than passively flexing the fingers and wrist of an extended elbow. Aka Middle Finger Sign.

Differential Pearls

Pain that localizes to the lateral epicondyle upon Mill’s or Cozen’s tests suggests contractile tissue involvement, i.e., muscle or tendon.

Pain, tingling, or burning radiating into the forearm suggests radial nerve involvement. These symptoms often are a result of Radial Tunnel Syndrome (RTS). RTS presents with peak tenderness to pain in the forearm, 3-5 cm distal to the lateral epicondyle.

If weakness is present upon extension of the finger, Posterior Interosseous Nerve (PIN) syndrome is a more likely diagnosis. PIN syndrome is often due to long-lasting radial nerve compression at the elbow. This neurologic loss will extend the prognosis and warrant possible referral. (1)

Remember, always note the test performed and the symptoms reproduced, as these will point to a more specific diagnosis.

2. Stop Offending Activities

  • When tissue load exceeds its capacity—injuries happen. Muscle and tendon strains are often the result of the patient’s movements and postures. These routine activities generate overuse tissue failure. So, the essential components of a correct MSK diagnosis include determining the cause of tissue overload and removing it. 
  • The primary risk factors for lateral epicondlyopathy (LE) include repeated wrist extension and forearm supination/pronation. Certain occupations and activities are predisposed, including carpenters, bricklayers, tailors, pianists, drummers, those who shake hands excessively (politicians), and those who perform prolonged keyboard or mouse work. 
  • Only 5% of LE patients participate in racquet sports, but among tennis players, 50-60% will be affected at some point in their career. Predisposing factors include the one-handed backhand, a heavy racquet, and too small grip size. (2)
  • Compression = ischemia. Speed up the healing process by preventing compression. Sleeping with the affected elbow under the pillow results in slower healing times. (Check out this recent BLOG reviewing how six different orthopedic conditions are affected by sleep position.)

3. Consider Alternate Pathology for Recalcitrant Cases

  • Proper classification of orthopedic diagnoses is necessary before treatment can begin. However, MSK diagnoses often masquerade as similar conditions. 
  • Increased symptoms with a counterforce brace should also raise concern for radial tunnel syndrome (RTS). Treatment of RTS is vastly different than LE. For quick tips on effectively treating RTS, check out the ChiroUp Radial Tunnel Syndrome protocol, including video demonstrations of the most appropriate tests, treatments, and exercises.
  • Always include clinical prediction rules to help identify the correct diagnosis the first time; however, don’t be afraid to change your target after an unsuccessful trial of care. Non-responsive patients may require additional testing to help elucidate primary and contributory diagnoses. X-ray evaluation may be necessary after a failed trial of care. 

4. Conservative Care Is the Best Option

Don’t just wait and see

A multi-arm trial comparing conservative care, wait-and-see, and steroid injection demonstrated significantly better outcomes at six weeks for those undergoing conservative care. Patients who received conservative care sought significantly less other treatment compared with both corticosteroid injection and wait-and-see approaches. (3) 

Make sure you are treating the proper diagnosis

Corticosteroids may offer benefits for tendinitis (inflammation); however, true tendinitis is rare compared to tendinopathy (degeneration). (4)

Beginning with an injection often result in surgery

Even worse, when a patient does not receive pain relief from an injection, they often funnel into surgery. And a recent prospective, randomized, double-blinded, placebo-controlled clinical trial found that the surgical excision of the degenerative portion of the ECRB offers no additional benefit over and above placebo surgery. (5).

There is a growing need for competent providers who recognize the actual cause of dysfunction and treat it effectively with the tips outlined above. Keep in mind that “joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process before formal exercise loading rehabilitation or other proven effective treatment approaches.” (6) 

Restoring normal joint range of motion is an often overlooked but crucial component of therapy, allowing chiropractors to achieve superior results!

So, hopefully, this information will help you:

  1. Assess lateral elbow pain using the most sensitive and specific tests
  2. Identify and eliminate the aggravating factors
  3. Consider alternate pathology when a patient is not responding to care.

And the final piece of the puzzle: Automating your clinical excellence with ChiroUp’s online platform.

  • Access to 104 up-to-date best practice condition protocols with straightforward video tutorials of every associated test, treatment, exercise, and ADL – to help you nail down clinical excellence.
  • Instantly relay this information to patients via condition reports that answer your patient’s essential questions plus video demonstrations of exercises and ADL’s -meaning better compliance with fewer questions. 
  • Automate patient satisfaction and clinical outcome collection so you can see real-time feedback and know where and how to improve continually.
  • Automate Google and Healthgrades reviews from your most satisfied patients so you can market your most credible endorsements – high patient satisfaction and outcomes.
  • Join a network of evidence-based providers working together to continually refine best practices to become the undeniable best choice for patients and payors.

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