Practical laboratory exercise for elbow, forearm, and wrist anatomy

¶ … Elbow, forearm and wrist

According to the national data book (2008) there are more than 24 million people who play recreational tennis in the United States. (U.S. Census Bureau, 2008) Playing Tennis has been related to many health benefits such as better fitness level, lower risk of increase in percentage of body fat, an improved lipid profiles, less risk of cardiovascular disease as well as stronger bones (Pluim BM, 2007). It is possible that the increasing popularity of tennis in United States be due to these health benefits associated with it. Yet, as is case with all other supports, tense is no exception and as arm and particularly elbow is used more in this game so the injury of elbow is common.

Current essay is a practical laboratory report based on the case of Jan. Jan is a mid-week recreational tennis player and she has developed lateral elbow pain with sharp tenderness on the lateral epicondyle of the humerus. The author will discuss the potential anatomical structures that may be affected in this region. Also the potential for other joints and structures not confined to the true elbow that may also contribute to this pathology will be discussed?

Analysis of the Case

Lateral elbow pain is very common in tennis player and research reveals that almost 40% of tennis players usually develop lateral elbow pain at certain point of their lifetime. Lateral epicondylalgia (LE) is considered very common upper extremity injury among players of tennis. LE is defined as an injury which caused by overuse of the elbow and is usually chronic. There are many potential factors of LE. There is possibility of presence of both internal and external mechanisms that may cause injury before the appearance of injury of commencement of symptoms. External risk factors may be mistakes related to the techniques of tennis game, environmental circumstances and also the equipment that may change the outside forces being applied to the extremity and after some period of time may cause injury. (Maffulli N, 2003)

Besides the external or extrinsic factors there are many intrinsic risk factors including distorted joint arthrokinematics, weakness or imbalance of muscles in the upper extremity that may bring about microtrauma to the related tissues.

EPIDEMIOLOGY of LATERAL EPICONDYLALGIA

There is possibility that Elbow pain Jan is feeling is because of the acute or chronic injury to the soft tissue or osseous structures of the elbow. There have been many risk factors associated with LE that have been proposed by researcher including overuse, recurring movements, using elbow or wrist for extreme postures and defects in the strength and flexibility of the forearm.( Hume PA, 2006) In 1997, the National Institute for Occupational Safety and Health (NIOSH) (1997) after reviewing many research studies related to epidemiology of LE found that there is a correlations between these risk factor and development of LE in particular the extreme postures of forearm. This has been further evidenced in studies beyond the field of epidemiology such as sports and biomechanical research. (Werner, 2005)

Research has found that playing time and age of tennis players are the factors that have contribution to LE. It has been found that the development and reoccurrence of LE increases with the age of player. Similarly increased playing time is also associated with increase in elbow pain from LE at younger ages. The researchers concluded that LE is a degenerative process and this process augments if the arm and elbow is overused (Gruchow and Pelletie)

Pathophysiology of Lateral Epicondylalgia

Identifying the cause of the lateral elbow pain precisely is very important. There are different pathological conditions that mimic LE symptoms. Therefore it is necessary to exclude the referred pain. Often pain in Neck radiating below the elbow is an understated signs of a cervical spine disorder and it can confused as LE. Pain that is felt at the lateral angle of an elbow radiating into the forearm can have a similarity with the pattern of symptoms found in a C6- or C7-radiculopathy. To differentiate the ridiculer pain from LE there is a need to perform Cervical ROM testing, and provocative tests. (Akuthota, 2004)

Lateral elbow pain can also develop because of irritation to the posterior interosseous branch of the radial nerve. Irritation and pain at lateral elbow is due to the fibrotic edge of the supinator muscle, the arcade of Frohse entrap this limb of the radial nerve at the elbow (Figure 1). If there are symptoms like imitation of pain along with powerful resisted supination and maximal softness at the foremost edge of the supinator instead of at the lateral epicondyle are signs of Radial Tunnel Syndrome. ( Henry M, Stutz C, 2006)

Figure 1-The fibrotic edge of the supinator muscle (the arcade of Frohse) can cause irritation to the radial nerve at the elbow. (SRN= superficial radial nerve, PIN= posterior interosseous nerve) resulting in pain at the lateral elbow

If there are symptoms like difficulty to extend full elbow, crepitus, clicking or swelling at elbow joint, there is need to examine the elbow joint or ligament pathology form example radiocapitellar chondromalacia, synovitis, osteochondritis dissecans of the capitellum or lateral collateral ligament incompetency. Although literature related to the LE has suggested imaging, usually they are not performed except the patient not succeed managing conventionally and there is a need of surgery; that is why a complete examination is necessary for making the clinical differential diagnosis.(Fedorczyk JM, 2006)

Figure 2- epicondylalgia vs. radial tunnel the difference in the location of pain for both diseases

There area of Maximal tenderness must be above the ECRB tendon 1 to 2 centimeters distal and frontal to the lateral epicondyle more willingly than above the supinator muscle or the posterior elbow (Figure 2) LE can be diagnosed if pain educed at the lateral epicondyle along with resistance found in wrist extension and the Mill's Test maneuver (in this test pain is replicated through the extension of wrist or pronation, wrist flexion, and ulnar deviation)