User:Saltrabook/Clinical diagnostic guidelines/Ocupational musculoskeletal diseases/Epicondylitis lateralis

=Epikondylitis (lateral and medial)=

Definition Epikondylitis is a painful condition localized to the attachment of the forearm extensor respectively flexor tendons on the lateral or medial humerusepikondyl (interior / exterior overarmskno). Synonyms: Tennis elbow (lateral) and golfer's elbow (medial).

Pathoanatomy For prolonged epikondylit developed tendinosis (angiofibroblastisk degeneration - fibroblastic and vascular hyperplasia and abnormal collagen). In acute epikondylitis possibly reactive inflammation, but otherwise there are usually no inflammatory changes (1.2).

Diagnostics A clinical diagnosis defined by symptoms such as pain and objective findings in the form of direct and indirect tenderness of the lateral or medial humerusepikondyl. Both pain tenderness must be more than minimal (3). Epikondylit classified as "specific Complaint of arm Neck Shoulder" Clinical test video

Incidence / prevalence Alternating entries depending on whether self-reported elbow pain included, or lens if only spoken about doctor diagnosed cases. Incidence of lateral epikondylit about 1-2% per year. The prevalence of 1-3%. Medial epikondylit rarer, less than 1% (5).

Work Related aetiology Lateral epikondylit occurs more frequently in manually stressed occupations, eg in slaughterhouses, wood or metal industry and crafts. Evidence for association with combined load involving strenuous and repetitive elbow movements. No evidence of movements in the extreme positions of the wrist. Uncertain evidence of vibration and static load. There is evidence for the exposure response relationship with increasing degree of combined load. Simultaneously psychosocial stressful working conditions with little control of the work situation and low support may be associated with higher occurrence. The observed associations are often RR in the order of 2 (5,6,7,8,9,10).

Other Loads cited in privacy or leisure should be remembered. Lateral epikondylit etiology occurs regularly, including without relevant exposure can be identified and elbow pain can be part of other syndromes, such as the onset of symptoms by system diseases such as rheumatoid arthritis or coronary heart disease (rare). Over Frequencies are reported among smokers (5). Individual. Link between diabetes and tendinopathy is well known for shoulder, but vulnerability not elbow (11). Clearing and advice

Exposure Description of appointments with hand and armbelastninger with regard to force exercise (weight), position (extension, flexion, pronation, supination), repetitivitet (cycle time) and duration, including any prolonged static load and especially combined loads. The emphasis is on the loads the last 5 years years and especially the last year before the onset of symptoms. Aggravating conditions as new unfamiliar tasks, time pressure and lack of relief option / breaks in the near temporal relation to the onset of symptoms. Furthermore, any recreational exposure.

Health Symptoms: Load Triggered lateral elbow pain, possibly resting pain. Among patients with tennis elbow indicates 90% at the same time to have pain in the wrist region and or shoulder region (12), and there is often radiating to radial forearm. The pain may be asleep hindrance. Symptoms may start insidious, gradually or more suddenly. They typically fluctuates in intensity over days, weeks or months.

Clinical findings: Rarely swelling and discoloration. Always direct tenderness on or immediately distal to the lateral (or medial) epicondyle, ie the attachment of the forearm extensor (or flexor) muscle group. By lateral epikondylit also indirect tenderness by extension of the wrist against resistance, or handshake. By medial epikondylit indirect tenderness in flexion of the wrist against resistance. Handshake force can be reduced (vigorimetri) relative to the uafficerede arm (pain-related). There are usually accompanying aches proximal forearm ekstensormuskelgruppe which possibly triggered easier paresthesia, sometimes radiating distally to the fingers. If this is particularly prevalent or at distinct tenderness Frohses arcade 5-6 cm distal to epicondylus, considered entrapment of the radial nerve. Reduced mobility of the elbow must give rise to differential diagnostic considerations. Systematic examination of the neck and shoulder region, wrist and hand are always included. Possibly. paraclinical investigations are conducted only in specified indication (suspected inflammatory rheumatic disorder or entrapment, that is possibly IgM rheumatoid factor, ANA screening, CRP, nerve conduction study depending on the ailment suspected). X-ray and MRI may rarely used on suspicion of structural changes in the elbow joint (13). Differential: Myofascial pain in the neck and shoulder with referred pain, cervical disorder. By lateral epikondylit radial tunnel and pronator teres syndrome, medial epikondylit ulnar neuropathy (cubital tunnel syndrome)

Diagnosis Codes M77.1 Epicondylitis lateralis M77.0 Epicondylitis medialis

Prognosis At the request date, most over shorter or longer even sought to remedy prognostic pain through relief of various kinds. Countless factors treatment modalities used. No one has yet shown anything other than short-relieving effect. In most cases, probably "spontaneous" healing regardless given treatment. Pain has a distinctly fluctuating course of weeks, months and possibly years, with load-related resurgence. Over 80% of emerging cases seen in general practice achieves improvement or is healthy after a year. Lack of improvement after one year follow-up was significantly increased by manually-risk and physically demanding work. Continued pain after 1 year is frequently at affection of the dominant arm and the sharp pain from the start. Previous cases of elbow pain and concern (worrying) is also associated with worse outcomes at 1-year follow-up (14,15,16,17).

Counseling There is no evidence that total relief is required, let alone beneficial, as there is no proven efficacy of long-term sick leave, as rather should be discouraged. Treatment is aimed at pain reduction and functional improvement. Centrally stands ergonomic advice and guidance on the reduction or modification of improper load (change of occupation, rotation, relocation, if necessary. Job change) particularly in the recovery phase, possibly also in the long term. There can be implemented visits (18.19) ..

Administrative issues Recognition Criteria: 1) The diagnostic criteria must be met. 2) Effect strenuous and repetitive work movements. Strenuous work movements in awkward positions. Strenuous static work.

Referencer:

1. Ljung BO, Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epikondylitis. J Hand Surg (Br) 1999 Apr;24(2):177-83.

2. 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.

3. Kryger AI, Lassen CF, Andersen JH. The role of physical examinations in studies of musculoskeletal disorders of the elbow. Occup Environ Med 2007;64:776-781.

4. Huisstede BMA, Miedema HS, Verhagen AP, Koes BW, Verhaar JAN. Multidisciplinary consensus on the terminology and classification on complaints of the arm, neck and/or shoulder. Occup Environ Med 2007;64:313-319

5. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and Determinants of Lateral and Medial Epikondylitis: A Population Study. Am J Epidemiol 2006;164:1065-74.

6. Bernard BP. Musculoskeletal disorders and workplace factors. NIOSH 1997; 4,1-48. http://www.cdc.gov/niosh/ergosci1.html

7. Warren N et al. Biomechanical, psychosocial and organizational risk factors for WRMSD: Population based estimates from the CUSP. J Occup Health Psychol 2000 Jan;5(1):164-81.

8. Pedersen LK, Jensen LK. Sammenhæng mellem erhverv og albuesmerter, epikondylitis. Ugeskr Læger 1999;161(34):4751-5.

9. Palmer KT, Harris EC, Coggon D. Compensating occupationally related tenosynovitis and epikondylitis: a literature review. Occupational Medicine 2007;57:67-74.

10. van Rijn RM, Huisstede BMA, Koes BW, Burdorf A. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology 2009;48:528-536.

11. Burner TW, Rosenthal AK. Diabetes and rheumatic diseases. Current Opinion in Rheumatology 2009,21:50-54.

12. Haahr JPL. Tennisalbue. Årsager og brug af primære sundhedstjenesteydelser. Master of Public Health, Aarhus Universitet; 2000.

13. van Kollenburg JAPA, Brouwer KM, Jupiter JB, Ring D. Magnetic resonace imaging signal abnormalities in enthesopathy of the extensor carpi radialis longus origin. J Hand Surg 2009;34A:1094-98..

14. Piligian G et al. Evaluation and management of chronic work related musculoskeletal disorders of the upper extremity. Am Journ Ind Med 2000;37: 75-93.

15.Haahr JPL, Andersen JH. Prognostic factors in lateral epikondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology 2003;42:1216-1225. (http://www.amkherning.dk/pub1.html)

16. Bot SDM et al. Course and prognosis of elbow complaints: a cohort study in general practice. Ann Rhem Dis 2005;64;1331-1336.

17. Feleus A et. Al. Prognostic indicators for non-recovery of non-traumatic complaints at arm, neck and shoulder in general practice – 6 months follow-up. Rheumatology 2007;46:169-176.

18. Johnson GW, Cadwallader K, Scheffel SB, EpperlyTD. Treatment of lateral epikondylitis. American Family Physician 2007;76:843-848.

19. Schmidt N, van der Windt DAWN. Tennis elbow in primary care. BMJ 2006;333:927-28.

Authors: (from Armoni, Denmark) Jens Peder Haahr, Herning, december 2009 Referent: Susanne Wulff Svendsen, Herning, december 2009 Review Ole Carstensen, Esbjerg, juni 2010