2. Background - Medial Epicondylalgia
• Overall prevalence of <1% (3.8%-8.2% of patients in occupational setting)1
• 10-20% of epicondylalgia cases affect medial side 1
• 4th-6th decades of life 1
• Equally affects males and females 1
• Etiology thought to be repetitive microtrauma to CFT, but can also occur with
a single traumatic event 2
3. Examination
Patient History
• Demographics: 50-yr old female
• Chief complaint: R forearm pain
• Onset: October 2015, pulled a generator cord that recoiled
• Medical history: back fusion 2008, elbow debridement 20 years ago
for tennis elbow
• Medications: Prozac, Aciphex
• Review of systems: no red flags
4. Examination
Symptom Behavior
• Primary complaints:
– P1: R forearm, constant throbbing (70%
of the time), aching, best: 2/10, current
8/10, worst 10/10
– P2: R anterolateral shoulder
• Relationship between symptom areas:
P2 started to become bothersome about 5
months after P1
6. Examination
Systems Review
• Integumentary: intact
• Cardiopulmonary: no known cardiac issues
• Musculoskeletal:
• Postural observation - forward head and increased thoracic kyphosis
• Cervical screen (active movements and overpressures) - no symptom reproduction
• Neuromuscular: Normal myotomes, dermatomes, and reflexes
7. Examination
Tests and measures
• Mobility
o Shoulder ROM WNL
- painful arc with abduction
- P2 with reaching behind back and
behind head
o Elbow ROM WNL, no reproduction
of symptoms
o Wrist ROM:
Wrist Extension Wrist Flexion
R 60 (reproduced P1) 60 (reproduced P1)
L 70 85
8. Examination
Tests and measures
• Functional testing
o Pain-free grip strength3:
• Structure
o Elbow varus/valgus testing (-)
R 40 lbs
L 60 lbs
9. Examination
Tests and measures
• Manual Muscle Testing
• Palpation
‒ Tenderness in anterior forearm, lateral epicondyle, thenar musculature, point
tenderness in palm (P1)
‒ Joint hypomobility in distal radioulnar and radiocarpal joints
Wrist Extension Wrist Flexion
R 5/5 5/5 (reproduced P1)
L 5/5 5/5
10. Examination
Tests and measures
• Special Tests
‒ Hawkins-Kennedy (+ for reproduction of P2)
‒ Tinel’s sign over cubital tunnel (-) and carpal tunnel (-)
‒ ULTT median I (+ for reproduction of P1)
‒ Pronator teres test4 (+ for reproduction of P2)
11. Examination
Decision Making – Applying Evidence-Based Practice
• PECO question: For a female in her 50s, is grip strength a valid diagnostic
indicator of chronic medial epicondylalgia?
• Search terms on PubMed: medial (epicondylitis OR epicondylalgia) AND grip
12. Examination
Applying Evidence-Based Practice – Methods5
• 25 patients with chronic medial epicondylitis were each matched with a
control subject of the same gender and age with lateral epicondylitis
• Inclusion criteria
• Subjects completed a pain questionnaire, whole body pain diagram,
underwent testing for pain pressure threshold, isometric grip strength, and
isokinetic arm function
15. Examination
Applying Evidence-Based Practice – Applying to patient care
• Decreased grip strength may be associated with medial epicondylitis
• Maximal vs painfree grip strength
16. Examination
Collaborative Process
• Information from other sources
‒ EMG study showed slowing of median nerve, no abnormal findings from X-ray or
MRI
‒ CT scan showed some cervical spine degeneration
17. Evaluation
Impairments
Decreased wrist flexion
and extension range of
motion
Pain with resisted wrist
flexion
Decreased shoulder
range of motion
Decreased grip strength
Activity Limitations
Lifting/carrying/pulling
heavy weights
Overhead activities
Participation
Restrictions
Performing duties
associated with her
snow cone stand
Yard work/household
tasks
19. Diagnosis
The patient’s primary impairment of medial forearm pain with resisted
wrist flexion is related to their primary activity limitation of lifting,
carrying, and pulling heavy weights.
20. Diagnosis
Autonomous Practice
The patient had received several different diagnoses from healthcare providers
• Wrist/thumb dysfunction
‒ Thumb casting, 3 different splints, cortisone injections in her thumb and wrist
• Cervical radiculopathy
‒ Was told “we’re not sure but we may have to do a cervical fusion”
22. Prognosis
The patient should have 90% recovery of function
• Self-limiting condition (81% of patients fully recovered within 3 years)6
23. Prognosis
Patient
Goals
Have full pain-free wrist range of
motion within 2 weeks.
Be able to pull generator for
snow cone stand without pain
within 4 weeks.
Be able to perform household
tasks without pain within 4
weeks.
24. Prognosis
Intended Outcomes
• Pain-free maximal grip strength
• Full pain-free wrist range of motion
• Able to raise arm overhead without pain
• Able to push/pull/lift heavy weights
26. Interventions
Wrist and elbow joint mobilizations
• Parameters: 3-5 min bouts of graded oscillations depending on impairments
found and patient response
• Distal radioulnar, radiocarpal AP glides, elbow lateral mobilization with movement, passive
flexion/extension
• Progression: higher grades as tolerated
• Goal: improve wrist range of motion and painfree grip strength
28. Interventions
Instrument-assisted soft tissue mobilization
• Parameters: 5-10 min around areas of complaint
• Medial and lateral forearm down to the wrist
• Goal: decrease pain and improve range of motion
30. Interventions
Applying Evidence-Based Practice
• PICO question: For a female in her 50s with medial epicondylalgia, are
eccentric exercises more effective at improving grip strength than stretching?
• Search terms on PEDro: medial epicondylitis eccentric
31. Interventions
Applying Evidence-Based Practice – Methods7
• 30 subjects (19 females and 11 males; mean age of 38) were randomized to
either group A (static stretching and ultrasound) or group B (eccentric
exercises plus static stretching and ultrasound)
• Inclusion criteria
• Pain ratings and grip strength were measured initially and after 12 treatment
sessions (4 weeks)
32. Interventions
Applying Evidence-Based Practice - Are the results valid?
• Subjects similar with respect to prognostic factors
• Random allocation
• No blinding of subjects, therapists, or assessors
• No intention to treat analysis
33. Interventions
Applying Evidence-Based Practice - What are the results?
Group A difference: 11.2 lbs
(95% CI -6.35, 28.75)
Group B difference: 20.74 lbs
(95% CI 2.55, 38.93)
Between-group difference:
17.14 lbs (95% CI -2.62, 36.90)
34. Interventions
Applying Evidence-Based Practice – Applying to patient care
• Similarity between patient and subjects in study
• Consideration of all patient-important outcomes
• Treatment benefits compared to the costs
35. Interventions
Functional strengthening
• Parameters: Resisted
pronation/supination, putty gripping, UE
D2 flexion, wrist roll-ups, body blade, # of
sets/reps dependent on patient response
• Progression: increased resistance and
sets/reps
• Goal: improve forearm and shoulder
endurance with functional tasks
36. Outcomes
• 11-item questionnaire to assess upper extremity function9
• 0-5 scale for each question9
• Scores range from 0 (no disability) to 100 (most severe disability)9
• MCID: 19 points10
41. Summary
Outcomes
Maximal painfree grip strength
Painfree wrist and shoulder
range of motion
Able to perform all household
and work duties without pain
Interventions
Joint/soft tissue mobilization Eccentric exercises Functional strengthening
Patient with medial forearm pain
Pain with gripping, wrist flex/ext, raising arm overhead
42. References
1. Amin N, Kumar N, Schickendantz M. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015;23(6):348-355.
doi:10.5435/jaaos-d-14-00145.
2. Ciccotti M, Schwartz M, Ciccotti M. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004;23(4):693-705.
doi:10.1016/j.csm.2004.04.011.
3. Kim J, Park M, Shin S. What is the minimum clinically important difference in grip strength?. Clin Orthop Relat Res. 2014;472(8):2536-2541.
doi:10.1007/s11999-014-3666-y.
4. Bair M, Gross M, Cooke J, Hill C. Differential diagnosis and intervention of proximal median nerve entrapment: a resident's case problem. J Orthop
Sports Phys Ther. 2016;46(9):800-808. doi:10.2519/jospt.2016.6723.
5. Pienimäki T, Siira P, Vanharanta H. Chronic medial and lateral epicondylitis: a comparison of pain, disability, and function. Arch Phys Med Rehabil.
2002;83(3):317-321. doi:10.1053/apmr.2002.29620.
6. Descatha A, Leclerc A, Chastang J, Roquelaure Y. Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. J
Occup Environ Med. 2003;45(9):993-1001. doi:10.1097/01.jom.0000085888.37273.d9.
7. Akhilesh M, Babu V, Kumar S, Ayyappan V. Effect of eccentric exercise programme on pain and grip strength for subjects with medial
epicondylitis. Int J Physiother. 2014;1(1):17-27.
8. Bialosky J, Bishop M, Price D, Robinson M, George S. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a
comprehensive model. Man Ther. 2009;14(5):531-538. doi:10.1016/j.math.2008.09.001.
9. Rehab Measures - Quick Disabilities of Arm, Shoulder & Hand... The Rehabilitation Measures Database. 2016. Available at:
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1267. Accessed December 1, 2016.
43. References
10. Polson K, Reid D, McNair P, Larmer P. Responsiveness, minimal importance difference and minimal detectable change scores of the shortened
disability arm shoulder hand (QuickDASH) questionnaire. Man Ther. 2010;15(4):404-407. doi:10.1016/j.math.2010.03.008.
11. Rosenberg N, Soudry M, Stahl S. Comparison of two methods for the evaluation of treatment in medial epicondylitis: pain estimation vs grip strength
measurements. Arch Orthop Trauma Surg. 2004;124(6). doi:10.1007/s00402-004-0658-5.
12. Abbott J, Patla C, Jensen R. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral
epicondylalgia. Man Ther. 2001;6(3):163-169. doi:10.1054/math.2001.0408.
13. Blanchette M, Normand M. Impairment assessment of lateral epicondylitis through electromyography and dynamometry. J Can Chiropr Assoc.
2016;55(2):96-106.
14. Hoogvliet P, Randsdorp M, Dingemanse R, Koes B, Huisstede B. Does effectiveness of exercise therapy and mobilisation techniques offer guidance
for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013;47(17):1112-1119. doi:10.1136/bjsports-2012-
091990.
