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Lateral Epicondylalgia. What do we know about the pain mechanisms?

Elena Ozaes

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Lateral Epicondylalgia. What do we know about the pain mechanisms?

  2. 2. Pain over the lateral epicondyle Location: insertion of the extensor muscle mass of the wrist and fingers Pain can refer over the back forearm and the wrist LATERAL EPICONDYLALGIA (LE): CLINICAL SIGNS: - Pain to direct palpaction over the lateral epicondyle - Pain to resisted extension of the wrist and fingers - Pain and weakness during grip strength testing
  3. 3. MECHANISMS OF PAIN Multifactorial Character Coombes B, Bisset L, Vicenzino B 2009 Pathophysiological mechanisms of the local tendon Changes in the pain system Impairment in the motor system LE
  4. 4. Repetitive microtraumas or direct trauma in the proximal insertion of the extensors muscles of the wrist and fingers PATHOMECHANICS OF THE TENDON Repetitive contractions of the muscle - Degenerative process Tiny tears - Anomalous vascular repair - Angiofibroblastic tendinosis Bales CP 2007, Kraushaar BS 1999, Fedorczyk JM 2006 MECHANISMS OF PAIN Disorganized collagen fibers
  5. 5. Muscles involved in the LE: - ECRB (Extensor Carpi Radialis Brevis) - ECRL (Extensor Carpi Radialis Longus) - EDC (Extensor Digitorum Communis) - Brachioradialis The most frequent MECHANISMS OF PAIN
  6. 6. - Overuse of the tendon - Reparation of the tendon overwhelmed - Non-inflammation process absence of inflammatory cells - Degenerative process degenerative changes in the connective tissue Actual studies… Nirschl RP 2003, Vizencino B 2003 MECHANISMS OF PAIN
  7. 7. CHANGES IN THE PAIN SYSTEM Mechanical stress ECRB stimulate Peripheral liberation of neuropeptides: • Substance P • CGRP (Calcitonin Gene Related Peptide) Peripheral Sensitization R. Torres 2005, Slater 2005, Coombes 2012 NEUROGENIC INFLAMMATIONStimulation of more nociceptors Mechanical sensitization Nociception PRIMARY HYPERALGESIA MECHANISMS OF PAIN
  8. 8. Central Sensitization Changes primary nociceptors Neuronal excitability in the spinal cord CNS stimulate SECONDARY HYPERALGESIA - Pain outside injury area - Acute pain to Chronic pain Slater 2005, R. Torres 2005 MECHANISMS OF PAIN
  9. 9. MOTOR IMPAIRMENTS - Reduction grip capacity Grip strength test - Diminished muscle strength wrist and fingers extensors - Morphological changes of the muscles moth eaten fibres, fibre necrosis and signs of muscle fibre regeneration - Altered motor control TRIGGER POINTS AND MIOFASCIAL PAIN!!! Coombes B, Bisset L, Vicenzino B 2009 MECHANISMS OF PAIN
  10. 10. TRIGGER POINTS (TP) AND MIOFASCIAL PAIN Causes of formation Trigger Points: - Trauma - Forced posture - Mechanical overcharge - Psychological stress Simons et al. 1999 Implication of the TP of the forearm muscles in the sensory and motor impairments in LE patients MECHANISMS OF PAIN
  11. 11. Referred pain in Trigger Points…  Referred pain in active Trigger Points in the forearm muscles (ECRB, ECRL, EDC, brachioradialis) have similar patterns to the elbow and forearm pain in LE O. Mayoral 2001, Ferández-Carnero 2007 MECHANISMS OF PAIN CENTRAL PHENOMENA liberation Strain Hypoxia Distress tissue SENSITIZING SUBSTANCES Trigger Point
  12. 12. Strain TP in the skeletal muscle (Central TP) transmission - Myotendinous insertion - Tendon - Bony insertion of the muscle ENTHESOPATHY TENDINOPATHY (Insertional TP) Central TP are perpetual factors of the LE? First of all we have to treat the Central TP in LE? MECHANISMS OF PAIN Simons 2002, O. Mayoral 2001
  13. 13. Activation mechanisms of the Central TP:  DIRECTS: - Trauma - Overstretched muscle - Overstretched motor nerve - Overcharge muscle  UNDIRECTS: - TP in muscles that refer pain to the afected muscle - TP in antagonist muscles - Nerve entrapment MECHANISMS OF PAIN O. Mayoral 2001
  14. 14. Muscles to know: 1. Inserted muscles in the lateral epicondyle: ECRB, ECD, ECRL, brachioradialis, anconeus, supinator 2. TP that refer pain to the lateral epicondyle: Supinator, brachioradialis, ECRL, tríceps, supraspinous, EDC, anconeus 3. TP that active TP in muscles from section 1 and 2: Scalene, Infraspinous, Supraspinous, Subclavious and Triceps 4. TP from agonist/antagonist muscles from section 1: Biceps and Brachial / Wrist and fingers flexors MECHANISMS OF PAIN Continuous afferent nociceptive inputs from active TP Pain Perception Mechanical pain sensitivity Pain intensity elbow and forearm
  15. 15. QUESTION: What come first… …the pain over the lateral epicondyle? OR …motor impairment with the TP? MECHANISMS OF PAIN
  16. 16. BIBLIOGRAFIA: • Bales CP, Placzek JD, Malone KJ, Vaupel Z and Arnoczky SP. Microvascular supply of the lateral epicondyle and common extensor origin. J Shoulder Elbow Surg. 2007 Jul-Aug; 16(4): 497-501 • Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb; 81(2): 259-78 • Fedorczyk JM. Tennis elbow: blending basic science with clinical practice. J Hand Ther. 2006 Apr-Jun;19(2):146-53 • Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med. 2003 Oct;22(4):813-36 • Vicenzino B. Lateral epicondilalgia: a musculoskeletal physiotherapy perspective. Man Ther. 2003 May;8(2):66-79 • Mayoral O, De Felipe JA, Fernández JM, Torres M. Study of attachment and taut band tendemess of epicondyle muscles in epicondylitis. Journal of Musculoskeletal Pain 2001;9(Supl. 5):90 • Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. Br J Sports Med. 2009;43:252-258 • Torres R. Chronic myofascial pain: pathophysiology and therapeutic approach. Fisioterapia. 2005 Mar;27(2)
  17. 17. •Slater H, Arendt-Nielsen L, Wright A, et al. Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness. Pain. 2005;114:118–130 • Coombes BK, Bisset L, Vicenzino B. Thermal hyperalgesia distinguishes those with severe pain and disability in unilateral lateral epicondylalgia. Clin J Pain. 2012 Sept;28(7):595-601 • Fernandez-Carnero J, Fernandez-de-las-Penas C, Sterling M, et al. Exploration of the extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J Pain. 2009;10:1179–1185 • Fernández-Carnero J, Fernández-de-las-Peñas C, de la Llave-Rincón AI, Ge HY, Arendt- Nielsen L. Widespread pressure pain hyperalgesia as sign of central sensitization in unilateral epicondylalgia: a blinded, controlled study. Clin J pain 2009. Sep;25(7):555-61 • Fernández-Carnero J, Fernández-de-Las-Peñas C, de la Llave-Rincón AI, Ge HY, Arendt- Nielsen L. Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain. 2007 May;23(4):353-60 • Simons D, Travell J, Simons L. Dolor y disfunción miofascial. El manual de los puntos gatillo. 2.ª ed. Madrid: Editorial Médica Panamericana; 2002. BIBLIOGRAFIA:
  18. 18. Thank You!!!