The elbow joint is a joint that provides mechanical connection between the shoulder joint and wrist joint and has important functions. Loss of function of the elbow joint can seriously affect activities of daily living. The elbow joint regulates the position of the wrist in space and allows strong grip.
Lateral epicondylitis; It was first described as printer's cramp or tennis elbow by the German doctor Runge in 1873. Although the exact cause is not known, Cyriax in 1936 identified 26 possible mechanisms and grouped them into 3 groups: neuroirritative process, recurrent pain, and tendon damage. The incidence rate in the general population is 1-3%; This rate increases to 19% in the 30-60 age range and is often seen in women and on the dominant side. Tennis is the factor in 5-10% of cases of lateral epicondylitis. 50% of active tennis players do not have symptoms and complaints of lateral epicondylitis. Wadsworth et al. They found that half of the tennis players over the age of 30 complained of lateral epicondylitis and stated that in half of them, the problem was minor and the symptoms disappeared in less than 6 months.
It is seen in 59 out of every 1000 people in industrial workers. There are 4 factors in the development of work-related diseases; physical characteristics of the work, shape, size and weight of the tools used; mechanical, physiological and psychological state of the work; physiological ability of the individual; It is the function and health status of the individual. In 1980, the World Health Organization (WHO) classified lateral epicondylitis as a disability because it frequently limits work capacity. It is often the reason for early retirement.
Lateral epicondylitis or tennis elbow is a common disease of the arm and is characterized by increasing pain in the lateral (outer part) of the elbow during activities such as grasping and squeezing with the hand. It is a disease that is difficult to treat and recurs. It is 10-20 times more common than medial epicondylitis (Golfer's elbow).
Lateral elbow pain; It may be caused by elbow joint pathologies or C5-6, C6-7 cervical vertebra (neck) problems. Lateral elbow pain may also occur due to the cervical vertebra (cervical disc) segment with reduced movement. Especially in the chronic phase, cervical vertebra problems develop secondarily and the cervical vertebra It is stated that it is observed in 20-50% of bra abnormalities. It usually occurs with repetitive contractions and excessive use related to work or sports. Smoking affects the circulation of tendons and poses a risk for lateral epicondylitis, and also delays the healing of tissues during the recovery period. Obesity can lead to type 2 diabetes by causing insulin resistance and increases the risk of lateral epicondylitis.
Lateral epicondylitis; It can cause serious difficulties in daily life, quality of life and business life, as it can cause pain at rest, movement and sleep, as well as limitation of movement.
Repetitive loads on the muscle-tendon unit cause fatigue-type tears, and if the load continues, healing problems occur.
ELBOW JOINT ASSESSMENT
The evaluation includes the three joints that make up the joint complex and the soft tissues surrounding them. Elbow pain affects elbow functions and daily living activities, causing the patient to consult a physician. Pain may be caused by a cause localized to the elbow, or it may originate from the neck, shoulder, wrist or hand.
History:
History is very important in the diagnosis of elbow pain. Since pain is often the complaint that brings the patient to the doctor, the nature of the pain should be revealed. Pain may occur in the joint, in extra-articular tissues, or in the form of radiating pain (40). Sharp and localized pain may indicate extra-articular pathologies. Deep and non-localized pain may result from neuropathies or nerve compression. Referred pains are generally widespread and often originate from the neck and shoulders.
Questions to ask in the history are as follows:
- When and how the pain started,
- Initiator whether there is trauma,
- The intensity, duration, quality of the pain, whether it increases or not,
- The place of onset of the pain
- The localization of the pain, whether it is radiating,
- Whether it has occurred before,
- Reasons that increase the pain,
- Relationship with work and profession, sports habits,
- Times when the pain increases (during the day, week, month, year)
- Whether it is in other joints,
- Symmetrical tu overalls,
- Morning stiffness and its duration,
- Effect of climate and environment,
- Reasons that alleviate joint pain,
- Whether there is locking in the joint,
- Presence of systemic complaints (muscle weakness, etc.)
- Presence of a similar disease in the family,
- Psychosocial status of the patient,
- Important diseases in his/her past history,
- Medications used,
- Diet habits
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After these are questioned, the physiotherapist or doctor observes the elbow area by opening it completely and looks for edema, redness and other abnormal conditions. Then, he evaluates the pain area and other adjacent areas manually (palpation) and determines the exact problem. Its location and severity are determined. After this, the joint range of motion is examined and it is determined whether there is a limitation.
Finally, special orthopedic tests are performed by the Physiotherapist or Doctor and information about lateral epicondylitis is collected.
After detailed evaluation, radiological imaging methods can be used to help the definitive diagnosis (Conventional Radiography, Ultrasonography, Magnetic Resonance Imaging). (MRI).
Treatment:
In the treatment of lateral epicondylitis; Conservative, medical or surgical approaches are used to reduce pain and increase function. Researchers have stated that non-surgical treatments are effective in acute stages, and surgery is effective in advanced calcified (ossified) stages.
Conservative Treatment
The purpose of conservative treatment is; to reduce pain, control the loads on the tendon, restore flexibility and strength, and prevent the recurrence of symptoms. In the acute period, rest, cold application, orthosis, compression, elevation, physical agents, active joint range of motion of the elbow, wrist and hand. exercises and isometric exercises are given, and it is recommended to prevent activities that increase symptoms.
In the chronic period, orthosis, physical agents, deep friction massage, manual therapy, stretching and progressive strengthening exercises are given. Carrying and grasping activities for patients Arranging the limbs and controlling the loads on the forearm are taught, and ergonomic arrangements are recommended. In the protection phase, home programs that improve strength, endurance and flexibility, and active warm-up and stretching exercises that need to be done before the activity can be taught. Necessary analyzes are made to ensure ergonomic analysis of the work area, suitability of sports equipment, and to ensure appropriate posture and position during work and sports activities.
In Preventive Treatments: Patients should be evaluated in their daily life activities and workplace activities, and athletes in their sports activities, the positions they should follow and the pain relief. They should be informed to avoid aggravating positions. Activity modifications, patient education, ergonomic recommendations and vitamin B supplementation are recommended. Activities such as shaking hands, grasping, using knives, writing, lifting, driving, hammer and screwdriver should be prohibited. Patients should gradually return to activity and overload should be avoided for at least 3 months. It is especially aimed to teach correct technique to athletes. Sports equipment and technique need to be evaluated for athletes. Racket handle size, string tension, material and suitability of the playing surface reduce the load transfer to the extensor muscles in tennis players. Starting with submaximal ball strokes, changing stroke mechanics and two-handed backhand strokes help in returning to the game. Compliance with general rules that can be applied to all sports branches and prevent the occurrence of injuries reduces injuries.
Among the general approaches in the treatment of lateral epicondylitis; Patient education, rest, activity modifications, splint use, corticosteroid drugs and physiotherapy applications are included. Physiotherapy applications generally include ice massage, laser applications, ultrasound therapy, manipulative treatments, deep friction massage and exercise therapy. Although autologous blood injection, Cyriax, acupuncture, extracorporeal shock wave therapy (ESWT), corticosteroid injection and botulinium toxin applications have come to the fore in the treatment of lateral epicondylitis in recent years, their effectiveness is controversial.
Orthoses: The most commonly used orthoses in lateral epicondylitis are the lateral epicondylitis band. and wrist rest splint.
Orthosis approaches for rest in the acute period are quite simple and useful. are approaches. The injured area should be restored by increasing upper extremity muscle strength, endurance and flexibility as much as possible and ensuring optimum function in the person's elbow.
The main goal of the treatments is; The aim is to relieve the person's pain, resolve inflammation, minimize the overload that causes the problem, and thus provide full pain-free function as soon as possible. These are achieved by increasing upper extremity muscle strength, endurance and flexibility.
Exercise Treatment in Lateral Epicondylitis:
No specific exercise program has been described in the treatment of lateral epicondylitis, but extensor (wrist) Emphasis is placed on exercise training that will increase the loading tolerance of the tendons (muscles that lift up). The basis of the exercise program is stretching and strengthening exercises. Because the tendon should not only be strengthened, it should also be flexible. Once pain and inflammation are under control, exercise programs can be started and the level of activities should be increased slowly. Then, stretching exercises should be started. Following the stretching exercises, strengthening exercises (with weights) should be gradually started. Home exercises should generally be done once or twice a day for at least three months. To strengthen soft tissues such as tendons; There are 3 different muscle contractions: isometric, concentric and eccentric. It is reported that the most effective method in the treatment of lateral epicondylitis is eccentric contractions (the contraction of the muscle as it lengthens). Eccentric training should be planned for the tendons most affected in Lateral Epicondylitis. It is important that the arm is supported during the strengthening exercises and that it is done in 3 sets of 10 repetitions. The main purpose of stretching exercises planned in the treatment of lateral epicondylitis is to increase flexibility. Flexibility is defined as the possible range of motion in any joint. The best stretching position is reported to be the position in which the person is pain-free and/or comfortable. Static stretching exercises should be planned in the treatment of Lateral Epicondylitis. It is recommended that the most effective stretching be done for 30-45 seconds and rest for 15-45 seconds between each repetition. In a study investigating eccentric and static stretching exercises, post-treatment and scar
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