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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 assess and treat lateral elbow pain effectively.

Watch Dr. Steele explain why the management of lateral elbow pain should be straightforward. The limiting factors are how well YOU and your PATIENT understand the condition.

What you can expect to learn:

✔ The value of spending time to make the right diagnosis
✔ Activity modifications that speed healing
✔ When it’s time to consider alternative diagnoses
✔ Why conservative care is your patient’s best option

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.

In the case of lateral elbow pain, 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.

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.

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.

Resisted Long Finger Extension Test

With the patient’s forearm and fingers extended, the examiner resists middle finger extension. The reproduction of radial nerve pain during this test 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., a 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)

Speed up the healing process by preventing compression. Compression = ischemia. 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. For example, lateral elbow pain may include a differential of radiocapitellar osteoarthritis.

Similarly, 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 how to effectively treat 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. While x-ray evaluation is not generally indicated at the onset of an uncomplicated presentation, it may be necessary after a failed trial of care. 

4. Conservative Care Is the Best Option

Why? A multi-arm trial comparing conservative care, “wait and see,” and steroid injection demonstrated significantly better outcomes at six weeks for those in the conservative care arm. Patients who received conservative care sought significantly less other treatment compared with both corticosteroid injection and wait-and-see approaches. (3) Corticosteroids may offer benefits for tendinitis (inflammation); however, true tendinitis is rare compared to tendinopathy (degeneration). (4)

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.

Remember: repetitive microtrauma does not cause inflammation, but rather a failure of the natural healing process, resulting in a disorganized pathological degeneration of the tendon.

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 finally, rest easy knowing that with ChiroUp at your side, you are providing the best care possible. Thanks for being in our worldwide community of like-minded providers.

References
  1. Wheeler R, DeCastro A. Posterior Interosseous Nerve Syndrome. InStatPearls [Internet] 2019 Apr 19. StatPearls Publishing. Link
  2. Brukner P, Khan K. Brukner & Khan’s clinical sports medicine. 4th edn. Sydney: McGraw-Hill, 2012.
  3. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. BMJ 2006; 333(7575): 939–941. Link
  4. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis: part 1: a new paradigm for a difficult clinical problem. The Physician and sportsmedicine. 2000 May 1;28(5):38-48Link
  5. Kroslak M, Murrell GAC. Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2018; 46(5): 1106–1113. Link

About the Author

Dr. Brandon Steele

Dr. Brandon Steele

DC, DACO

Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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