MedSimu Medicine

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[MUSIC PLAYING]
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Welcome to MedSomoo Medicine Podcast.
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I'm your host.
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Hello from me.
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Today we're diving into a really common issue,
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something you'll definitely see, well, all the time really,
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tennis elbow.
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Lateral epicondylitis, yeah, super common.
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Exactly, and crucial for exams too.
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So we're going to break down what it is, how you spot it,
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and the latest on managing it.
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Sounds good.
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We've looked at a fair bit of the current thinking on this.
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- Right.
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The goal is to give everyone listening,
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whether you're studying or already practicing,
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a really solid practical handle on it.
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- Okay, let's jump in.
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The absolute hallmark symptom.
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It's that pain right over the outside part of the elbow.
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- It's a lateral aspect.
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- Precisely.
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And it's typically, well, it can be sharp,
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often comes and goes.
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And the big thing is it gets worse
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with repeated wrist expansion, like really flares it up.
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And patients often feel it traveling down the arm too, don't they?
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They do. Yeah.
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Sometimes radiating along the forearm, maybe even down towards the wrist.
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Now we call it tennis elbow and sometimes it is from a specific thing,
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like a bad backhand.
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Right. The classic trigger.
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But often it seems to creep up more slowly, like from repetitive stuff.
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Exactly. It's often got this insidious onset, you know,
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things like using a screwdriver over and over,
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or even just lots of typing can definitely contribute.
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It doesn't always have to be a sudden injury.
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Okay. And if you had to put your finger right on the most tender spot?
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Usually it's about, hmm, maybe one and a half centimeters distal to where that
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main muscle involved the extensor, carpe radialis brevis,
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ECRB, right. The ECRB where it originates. So just slightly down from the bony bit
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on the outside of the elbow.
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Now here's something interesting. Despite the apiitis and epicondylitis,
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it's not really just inflammation, is it? Especially long-term.
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- That's a key point.
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We used to think of it purely as inflammation,
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but the understanding now is more about microtrauma,
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leading to tendinosis,
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specifically angiophibrablastic tendinosis.
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- So degenerative changes.
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- Yeah, basically it's like wear and tear
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at the tendon origin with abnormal little blood vessels
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and fibroblast cells.
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It's not a classic inflammatory picture
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after the very initial phase.
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- Which explains why just relying on anti-inflammatories
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might not fix the underlying issue.
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- Exactly, it points towards treatments
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that aim more at tissue healing and remodeling.
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And this underlying tendinosis,
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it leads to that other common complaint, weaker grip.
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- Ah, yes.
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Patients often report that, don't they?
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Painful gripping.
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- Definitely.
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Even simple things like turning a door handle,
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lifting a kettle, or carrying shopping bags
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can really bring on the pain
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because gripping tense is that ECRB tendon.
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Prolonged or forceful gripping
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is often a major aggravator.
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- Okay, so let's talk examination.
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When a patient comes in with this lateral elbow pain,
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what are the absolute must checks?
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- Well, number one is palpation.
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You're looking for that specific tenderness
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right over the lateral epicondyle.
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- And like you said, maybe just slightly distal to it.
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- Usually about one to two centimeters distal
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to the ECRB origin,
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that's often the point of maximum tenderness.
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- But it's not just about pressing on it.
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We need to provoke it functionally, right?
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- Absolutely.
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Seeing if you can reproduce their pain
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with resisted wrist extension
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is probably one of the most indicative signs.
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because that directly stresses the ECRB.
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- Exactly, and if you combine that wrist extension
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with having their hand tilted outwards towards the thumb side,
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that's radial deviation and their palm facing down,
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pronation. - Right.
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That puts even more strain on it.
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- It does, it really increases the force
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going through that specific tendon origin.
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So pain with resisted wrist extension,
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especially in that position, is a strong clue.
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- And then we have those specific named tests,
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the provocative maneuvers.
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- Right, the classics.
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the coffee cup test is a simple one.
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Does lifting a full heavy mug
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cause that lateral elbow pain?
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Surprisingly often it does.
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- I can imagine that being quite specific.
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- It seems to be.
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Then there's Mill's test.
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For this one, the examiner passively
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takes the patient's arm, pronates the forearm,
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so palm down, then fully flexes the wrist,
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so bending it down, and then extends the elbow straight,
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all while palpating that lateral epicondyle.
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- And a positive test is?
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- Reproduction of their familiar pain
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right over that spot.
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- Got it.
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- The Maudsley's test, what's that targeting?
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- Maudsley's is looking more at the extensor digitorum muscle,
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which is nearby.
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You ask the patient to keep their elbow straight,
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forearm pronated, and then resist them
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as they try to straighten their middle finger.
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- Just the middle finger?
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- Just the middle finger against resistance.
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If that causes pain at the lateral epicondyle,
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it suggests involvement of that muscle's origin too.
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- Interesting, so multiple ways to stress those extensors.
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- Yeah, they help confirm the diagnosis.
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One thing to note though,
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You don't usually see much swelling or redness
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with tennis elbow. - Yeah.
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- Maybe a tiny bit in the very early acute phase,
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but typically it's not an obvious visual finding.
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- Good point.
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Okay, so we've got a likely diagnosis,
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but elbow pain can come from other places.
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What's on the differential list?
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- Definitely need to think about the neck,
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cervical radiculopathy,
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especially C6 or C7 nerve roots.
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- How would that present differently?
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- Well, you'd be looking for pain radiating for the neck,
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maybe numbness or tingling down the arm,
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potentially specific muscle weakness or reflex changes related to that nerve root.
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It's often a different pattern than just localized elbow pain.
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Right, check the neck exam.
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What else?
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Closer to the elbow?
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Posterior interosseous nerve entrapment.
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Sometimes called radial tunnel syndrome, although they're slightly different.
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PN syndrome causes motor weakness.
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Okay, tell me about that one.
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So the pain might be a bit more distal, say three to four centimeters down from the epicondyle,
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more over the dorsal forearm.
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And crucially, you might see weakness in finger and thumb extension and maybe some wrist extension
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weakness but typically no sensory loss.
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The tenderness is also usually lower down.
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Different location, nerve symptoms.
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What about joint issues?
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Osteoarthritis of the elbow.
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More common in older folks or those with previous injury.
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You expect pain, maybe stiffness, reduced range of motion and potentially that crepitus,
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the grinding feeling on movement.
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Makes sense.
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Anything else?
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Maybe less common.
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Keep in the back of your mind.
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Osteochondritis disicans, that's a cartilage and bone issue,
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often in younger active people,
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causes activity pain, swelling,
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maybe mechanical symptoms like locking or catching.
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Osteonecrosis, bone death basically,
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less common maybe in kids or related to steroid use.
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Insidious pain, worse with activity,
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maybe limited extension.
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And then pica synovialis, synovial fold syndrome.
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- Plica. - Yeah.
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A fold of the joint lining getting pinched
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in athletes causing pain, sometimes clicking or snapping.
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Okay, quite a list. So given all that, when do we actually need imaging? Is it always necessary?
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That's a great question. And the answer is usually no. The diagnosis of tennis elbow is
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overwhelmingly clinical. It's based on the patient's story and what you find on exam.
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So history and physical are key. Absolutely. Lab tests aren't helpful,
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and imaging usually isn't needed for the initial diagnosis.
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But sometimes. Sometimes, yes. If the symptoms have been going out for a long time,
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or if they're not responding to standard treatment, or if there's something atypical about the
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presentation, then imaging might be useful. Like an x-ray. An x-ray can help rule out other things
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like that osteoarthritis we mentioned, or maybe loose bodies, octiochondritis, dissecans, or bone
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spurs. Interestingly, in some chronic resistant cases, x-rays might show calcification in the
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soft tissues near the ECRB origin. Okay, and MRI, when would that come into play? MRI is generally
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reserved for situations where you have a strong suspicion of something else going on that
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the x-ray didn't show, like a more subtle cartilage issue, a stress fracture, or maybe
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to get a better look at the tendon itself if you're considering surgery or if the diagnosis
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is really unclear, but it's not routine.
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Right.
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Diagnosis is mainly clinical.
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So let's move to management.
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We've diagnosed tennis elbow.
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What are the first steps?
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First off, identify and stop, or at least significantly modify the activities that are
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clearly aggravating the pain.
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crucial. Makes sense. Avoid poking the bear. Exactly. And in the early stages,
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sometimes just watchful waiting combined with that activity modification is
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enough. But, and this is important, you don't want complete inactivity or
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immobilization. Why not? Seems intuitive to rest it completely. Because prolonged
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rest leads to disused atrophy. The muscles get weak and weaker muscles can
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actually make recovery harder and take longer. So it's about modifying, not
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totally stopping movement finding ways to do things differently maybe with less
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force or repetition. Good distinction what about simple symptom relief? Ice is
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often helpful especially early on or after activity just applying an ice pack
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for say 15-20 minutes can reduce pain and maybe some local inflammation through
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vasoconstriction. And those straps people wear counterforce braces? Yes those can
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be quite effective for some people it's a strap worn around the forearm usually
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about 10 centimeters, maybe four inches,
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below the elbow joint.
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- How do they work?
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- The idea is that they change the pull of the muscles.
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They create a sort of new artificial origin point
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for the muscle force, reducing the tension
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right at the inflamed epicondyle attachment.
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Studies show they can improve rest pain
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and even increase grip strength after a few weeks.
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- Okay, so activity mod, ice, maybe bracing.
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What about medications?
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- NSAIDs, nonsteroidal anti-inflammatory drugs,
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are often the first go-to for pain relief.
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both topical gels or creams applied directly to the area,
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and oral pills.
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- Do they fix the underlying problem
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given it's more tendinosis?
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- They mainly help with pain, especially early on.
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But looking longer term, some evidence suggests
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that using oral NSAIDs combined with physiotherapy
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actually provides better pain relief
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than corticosteroid injections down the line.
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- Ah, steroid injections, always a popular topic.
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What's the verdict on those for tennis elbow?
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- Well, they can give pretty impressive short-term relief.
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Patients often feel much better quite quickly in terms of pain and function.
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But there's a catch.
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There seems to be, yes.
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The evidence points towards a higher recurrence rate.
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So the pain is more likely to come back, say around six weeks or a few months later, compared
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to if they'd used NSAIDs or just bracing and physio.
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And repeated injections.
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Generally discouraged.
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They seem to become less effective each time, and there's some concern they might actually
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weaken the tendon over time.
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Plus, they carry risks like post-injection flare-ups, skin thinning or discoloration
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at the site, and maybe even a slightly higher chance of needing surgery eventually if they
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don't work.
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So good for a quick fix sometimes, but maybe not the best long-term strategy.
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That seems to be the consensus, yeah.
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Yeah.
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Use them judiciously, if at all, and educate patients about the potential downsides versus
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the short-term gain.
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Okay.
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What about other modalities?
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Shockwave therapy?
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ECSWT?
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Extracorporeal Shockwave Therapy.
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It's used for some tendon issues, but for tennis elbow, the evidence is a bit, eh, generally
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considered less effective than other options we've discussed.
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Not usually a first line choice.
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Right, but physiotherapy sounds like a mainstay.
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Oh, absolutely.
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Physio is crucial.
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A good program will involve several elements.
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Like what?
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Things like therapeutic ultrasound, maybe phonophoresis that's using ultrasound to help
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drive topical meds deeper.
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Electrical stimulation can sometimes help with pain.
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therapy is huge soft tissue mobilization, maybe some joint manipulation if needed,
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friction massage over the tendon. Stretching and strengthening too, presumably.
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Definitely. Specific exercises to gradually load and strengthen the wrist
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extensors and improve forearm muscle balance. They might also address things
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like neural tension, if that's contributing, and maybe techniques like
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instrument assisted soft tissue mobilization like Graston. And does
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physio generally work well? Yes. The success rates reported are actually very
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good. With a comprehensive program and patient adherence, a large majority of patients see
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significant improvement within about a year.
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That's encouraging. What about less conventional things? Acupuncture, laser.
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Acupuncture. Well, the evidence is pretty limited. Some small studies suggested maybe
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some pain improvement for a couple months, but it's not strong evidence overall. Kind
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of homeopathic in nature for this condition based on current data.
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And laser therapy.
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situation. The data on low-level laser therapy for tennis elbow is really
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inconclusive for both short and long-term benefits, not something strongly
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recommended based on evidence. Okay, then there are the injections using the
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patient's own blood products PRP. Right, autologous whole blood injections or
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platelet-rich plasma PRP. The theory is sound concentrate the growth factors
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from the patient's own blood and inject them into the damaged tendon to
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stimulate a healing response.
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Does it work better than steroid injections?
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The research is still ongoing and somewhat mixed,
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but there's growing interest.
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Some studies suggest it might offer better long-term results
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than corticosteroids, but it's often more expensive
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and might require multiple injections.
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It's an area that's definitely evolving.
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So lots of non-surgical options,
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but what if none of them work?
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When is surgery considered?
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Surgery is really reserved for cases
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where patients have had persistent, significant pain
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and functional limitation for at least six months,
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despite a good try at comprehensive conservative management.
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- Six months is the usual benchmark.
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- Generally, yes.
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Six to 12 months of failed non-operative treatment.
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And of course, you absolutely have to be sure
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you've ruled out other causes of pain before proceeding.
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- Makes sense.
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What surgical options are there?
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- There are a few main approaches.
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One is arthroscopic surgery.
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Using a camera and small instruments inside the joint
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allows the surgeon to debride or clean up
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the pathological tendinosis tissue at the ECRB origin.
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Sometimes they might release part of the tendon.
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- Minimally invasive.
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- Right.
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Another common method is open surgery.
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This usually involves a small incision
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over the lateral epicondyle.
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The surgeon identifies the ECRB tendon, releases it,
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excises the diseased portion of the gray degenerated tissue,
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maybe drill small holes in the bone
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to promote bleeding and healing,
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and then repairs the defect or reattach as healthy tendon.
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- And how successful is open surgery?
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Generally quite good. Success rates, meaning significant pain relief and improved function,
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are often reported in the range of 85 to 90 percent.
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That's pretty high. Any other techniques?
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There's also a newer, minimally invasive technique called percutaneous needle tenotomy, often
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guided by ultrasound.
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How does that work?
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Under local anesthetic, the physician uses ultrasound to guide a needle repeatedly into
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the tendinotic area of the ECRB. This fenestration, making multiple small punctures, aims to break
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disease tissue and stimulate a healing response.
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If there's calcification, the needle can help fragment it.
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They might also abrade the bone surface slightly.
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Often they'll inject a bit of steroid and local anesthetic at the end.
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And how does that compare to open surgery?
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Some studies suggest it might offer similar or even slightly better short-term outcomes
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compared to open surgery, likely with a faster recovery being less invasive.
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But long-term comparative data is still being gathered.
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Wow.
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We've really covered a huge amount there, from the basics right through to surgical
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details.
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Yeah, it's a common condition, but there's quite a bit to understanding the pathology
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and the range of treatments.
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Absolutely.
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It really highlights how what seems like a simple elbow pain involves understanding tendon
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biology, biomechanics, and a whole spectrum of management options.
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Hopefully this deep dive has given everyone listening a much clearer picture for their
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exams and for managing patients effectively.
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Definitely.
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clinical assessment is paramount,
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and then tailoring the treatment based on the patient,
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the duration of symptoms,
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and the evidence for each approach.
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- So just to quickly recap the key takeaways,
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tennis elbow means pain on the outside of the elbow,
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typically from tendinosis of the ECRB,
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worsened by wrist extension and gripping, diagnosis.
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Primarily, clinical look for tenderness
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near the lateral epicondyle,
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and pain with resisted tests
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like wrist extension, mills, or modzales.
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Management starts conservative,
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modify activities, maybe ice or bracing.
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Physio is key, NSIDs can help pain,
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steroid injections give short-term relief
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but have higher recurrence.
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PRP is an option being studied.
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Surgery is usually only for persistent cases
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after six months of failed conservative care.
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- Good summary.
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- Thinking about all this,
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what factors do you find most critical
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when deciding on the management path
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for your patients with this?
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Something for our listeners
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to consider in their own practice.
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- That's a great reflective question.
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patient expectations, activity levels, previous treatments.
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It's very individual.
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- Indeed.
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Well, that brings us to the end of this deep dive.
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- Hope it was useful.
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- Join us next time on "Metsumu Medicine Podcast"
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for another exploration of a key medical topic.
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