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Thank you for joining us uh for uh uh seeing me presentation today. I'm Doctor David Bene E VP of Clinical Value Based Care for Health Care Outcomes Performance Company, also known as Hop Co. Uh Our topic for today is initial management of epicondylitis. Before we get started on the topic of the day as we do for all CM E events. Uh I want to assure the audience I have no financial uh or nonfinancial relationships uh to disclose as it relates to this topic and subsequent uh presentations as a reminder uh to those of you who have attended other CME topics we prevent presented in this uh series. Our objective is to improve the continuum of care uh for outcomes for musculoskeletal patients. Uh by defining the role for primary care providers in musculoskeletal value based care. We also aim to provide diagnostic and management pearls uh to pcps and other providers referring uh to M SK specialists. So the providers who manage the initial presentation of many common M SK issues uh can better um and more accurately diagnose and treat these conditions. Uh In addition, we aim to help providers identify uh red flags or other clinical factors. Um Necessitating urgent uh imaging or specialist referral at the end of today's session, we hope the audience will be able to identify patients at risk for elbow epicondylitis, diagnose lateral and medial epicondylitis. Uh initiate a nonsurgical treatment uh for patients with elbow epicondylitis and determine which patients um would be most likely to benefit from steroid injections, uh DM E diagnostic imaging uh and a specialist referral. In order to achieve uh these objectives, we'll uh briefly review the HCO specialty uh care network tip sheet. Um Then we'll do a brief run through multiple important uh topics in the initial management of elbow epicondylitis, starting with um a generalized uh background and then moving into a discussion about the examination, we'll then do go into tips for conservative treatment uh testing and finally, we'll touch on when a specialist referral may be clinically uh warranted. Mm uh As I've uh uh mentioned in other um uh talks within this series, it's important to recognize why HCO and HOP specialty Care network. Uh HSC N uh believes this information is important to distribute to our referral network, including pcps and all their upstream uh providers. Uh uh Some of you have a different amount of uh with the value based care and the movement towards um uh care that that can be defined uh within a, a value based care continuum. Um by definition of value based care programs, incentivized health care providers. Um to provide improved quality of care while reducing unnecessary cost. Uh Hop O is a leader in this uh field. And HCO specialty care network is a clinically integrated network that's a uh uh type of value based care um program in Arizona, HSEN. Uh It has a full population health program for a Medicare advantage population and has been recently recognized by a top national accreditation uh agency U A uh for its commitment to clinical uh integration and high quality care. Uh And actually, um HSEN is the first specialty network uh in the country um to get the designation for clinical integration um uh excellence. The HSEN network uh compli uh comprises almost all of the orthopedic surgeons uh and many pain providers in Arizona uh who have all joined forces together to uh follow standardized evidence based clinical uh pathways and then HSE and then collaborates with other providers including yourself um who encounter M SK conditions with the goal of improving patient outcomes and experience. Um And as you're well aware, a lot of the initial management of M SK care uh occurs not at the specialist level level but upstream uh at PCP uh visits. Uh And in saying that it's clear the population health um uh program clearly relies on uh PCPs to help reduce unnecessary M SK cost. Um As they're the most common gatekeeper for uh M SK care. Uh before we get into the uh topic O of the day. Uh I also wanna provide some background to this talk um and about the barriers um to provide this information um when talking about specific uh patients is obviously more uh generalized uh in its nature. Um The information shared today though is evidence based and consensus driven with recommended practices designed to be implemented for patients with these M SK conditions, including the one uh discussed today, elbow elbow epicondylitis. Um but it should be said for all clinical programs, clinical discretion should be used with any guideline uh for patients uh especially if they're concomitant, um clinical factors or comorbid conditions that may uh alter the clinical um clinically appropriate treatment path as we always do for the series. Uh We'll, we'll start with a review of the HSEN uh tip sheet. Um uh we sent out this tip sheet to all of you uh who would be attending here uh the CM E event uh today, but if you don't have a copy, feel free uh to email us at uh HCO um uh I'm sorry, HSEN at ho dot com and we could send you a copy so you can have it for your uh clinic as well. Uh The tip sheet is um uh uh made to be specific mostly to the Medicare or Medicare advantage population, the older population. Uh But many tips here are also relevant to a younger population uh as well. Uh Today, we're focusing on elbow epicondylitis. That's the third line on this uh tip sheet, um we will go through each column uh in more detail. Uh but it's a good way to see the overall suggestions um that specialists have for initial uh management. Um As you can see on a tip sheet for elbow pain, specifically, initial management comprises of conservative care which may include therapy and DM E for which we'll discuss uh that in more detail uh within this talk. Um but MRI s and other advanced imaging are not part of initial treatment, uh recommendations. Uh As a review, elbow epicondylitis is an inflammation at the insertion, insertion site of the tendons on either the, the medial, the inside side, uh or the lateral outside epicondyles uh at the elbow. As you can see in the picture here, it's a, a very uh common uh um diagnosis uh condition. Um It's uh specificly lateral epicondylitis is the most common cause uh of elbow pain. Um And while medial epicondylitis is not as common as lateral epicondylitis, it's still quite common. Um And in some cases, um uh people can have uh inflammation of both the media and the lateral side uh concurrently. Um Also, uh of note, um you may be more familiar with lateral alis being uh referred to uh as tennis, elbow and medial api candy litis, uh as golfer's elbow. Uh It's important to note that epica of the media or lateral side is not specific to sport. Number one, and it actually frequently happens outside of sports. Um, like when you're using your computer, a certain mousing, um, uh, activities can do that or using your computer for long periods of time. Uh, and despite the nicknames, uh, it's quite common for golfers and tennis players to have epicondylitis on the opposite side in which their names, uh, would, uh, would indicate. Um, it really depends on, uh, usually abnormal movement, um, of the wrist and the, uh, arm in the setting of improper form or equipment. There are certain factors that increase the risk, uh, of, um, having epicondylitis. Uh, they include age. Um, it's most common in, in, uh, patients of their forties and fifties, uh, equal among men and women actually. Uh, but also patients who smoke, uh, are obese, uh weekend warriors, um, and using certain tools including heavy and vibrating tools. Uh, and also those, uh, those of us who perform repetitive gripping or lifting, uh, activities, um, which I should add a computer work also should be on this list, uh, as well. Uh, well, some patients with epicondylitis can present after trauma. Uh, that's not the most common presentation. Most commonly patients come in with a gradual pain, um, near the muscles, uh, I in the muscles near the elbow. Um, and it could, uh, be that the patient has mild pain that's becoming worse or quite severe pain, uh, that could, uh, um, they're noticing a loss of, of strength, uh, or uh force in the arm uh or in their grip. Um And it usually, the pain usually worsens with certain movements, uh especially repetitive movements of the wrist, uh and the elbow after a thorough um history, uh an examination uh should begin uh with performing a palpation uh e exam to see if the pain um from the elbow is consistent with uh epicondylitis. Uh on palpation exam. Lateral epicondylitis is typically painful and occasionally exquisitely. Uh so on the tip of the lateral epicondyle co condyle is the bony protuberant on the lateral side of the elbow. Um uh for those with medial pain, medial epicondylitis is most painful, distal to the medial epicondyle, uh the bone and protruding from the medial part of the arm with a palm pointed uh towards the sky. And usually the pain is um just distal um to the to the bony area in the muscle. While there of the of the medial uh area of the arm, there are some specific tests uh that help providers determine uh the site and severity um of the condition. Um If you have um uh the patient make a fist uh and try uh to uh extend it uh back against your resistant as you resistance, as you try to push the wrist down toward a more neutral position. Uh patients with lateral epicondylitis frequently note pain near their lateral epicondyle or the dorsal uh forearm. Uh with this maneuver, uh pain can also be mimicked in those with lateral blis with a resisted forearm uh supination which is pushing the wrist downward. While the patient attempts to bring the wrist um up with a palm facing upward for uh medial levi condyle. A uh good test is a resisted uh forearm pronation. Uh Since the pronator muscles attach to the region near the medial lepi condyle uh to do this test, have a patient try to rotate their forearm and wrist into pronation, uh palm facing down while you're trying to resist this motion and push the patient into supination, which is the palm uh facing up after you're pretty um convinced that the patient indeed has uh epicondylitis based on your history and evaluation. It's best to initiate conservative treatment and this conservative treatment is sometimes quite lengthy. Uh for this condition, for some, the pain may decrease over the first couple of weeks. Uh And for others, uh conservative treatment can last for weeks to month prior uh to resolution of the symptoms. Uh For epicondylitis, conservative care consists of relative rest. Um uh especially with activity modification with uh um activities that may be, may be making the condition worse. Um should also include passive stretching. Uh And the goal of increasing strength through acentric base strengthening, uh exercises uh with time uh of not when an activity that may be a aggravating the symptoms performed. Um uh The patient should strive to work on their form and get any equipment that they're using or office tools evaluated, um, to make sure that the equipment they're using is proper and they have um, proper, uh, ergonomic uh form. Uh Additional initial treatment could include, um, a counterforce uh brace, uh, with an elbow strap or sometimes a wrist splint. Um, these can fo be found at a local pharmacy or drugstore. Um, you don't need a, a custom made brace for this condition. It's actually uh quite simple and it's actually quite uh inexpensive if you buy them at a, at a drug store. Uh Also a, a short course of nsaids uh may be useful. Um Ice may also be useful if the condition shows signs of inflammation, uh especially after activity that's making the pain um uh uh worse. Uh And II for this condition, especially education is really important. It is not uncommon for the symptoms to persist for uh many months before resolving. Um It uh but despite this length and time frame for some uh diagnostic testing, uh and invasive invasive treatments are not necessary and not indicated. Uh formal therapy, it can be considered um I in there. So don't get better within the first few weeks of other forms of conservative treatment. Um uh And when therapy is ordered, it's clinically reasonable to have the patient start with only a few sessions at first. Um Instead of writing just eval and treat physical therapy for elbow pain or epicondylitis, um it's probably reasonable to, to actually more specifically prescribe 3 to 4 sessions of therapy or 1 to 2 sessions per week for uh 2 to 3 weeks. Uh at first and note your prescription that there should be a quick uh transition to a home uh exercise program. Um And just a note on uh steroid injections, um steroid injections uh are not recommended as a first line treatment for elbow tendinopathy. Um They're probably not even a second line uh treatment. Uh This is due to inhibition of healing and it can actually lead to worse and long term outcomes. Um Also it's best to defer any injections or treatments uh of the elbow. Um uh that uh has signs of tendinopathy to a specialist due to risk of damaging uh of nearby tissues, uh especially the ulnar nerve as it um uh when considering a treatment for medial epicondylitis, you can hear um diagnostic testing is unnecessary uh for this condition x-rays. Um uh really uh don't change the management uh in, in any way um uh of patient care and the conservative treatment path. Um e even when there are uh findings on x rays including calcification, which you may have uh which is quite common. Um A as patients get a little bit older, especially um that really doesn't change the treatment plan, doesn't make it uh any more likely that that a surgical referral uh would be necessary. So, really try to avoid um uh imaging uh even x-rays um likewise, uh MRI s uh do not alter um the, the treatment plan um for uh almost anyone with uh epicondylitis. Uh even if you had a partial tear, it wouldn't impact uh the treatment plan. Um and EMG S um uh are not uh indicated a rotator uh for um for pathology uh here of the epicondylitis of the epicondyles. Uh One of the reasons for a lengthy time frame uh for conservative care is that um over 90% of cases of elbow, uh tendinopathy resolve uh with uh conservative uh management. Um, patients is required for both the provider and the patient. Uh Unfortunately, for some of the time frame, uh for recovery is slower than desired. Um But sticking with a conservative treatment plan um is successful for most, uh it is rare. Um but there are certain circumstances um that uh referral to an orthopedic specialist is uh warranted. Um If there is concern for issues within the elbow joint itself, uh or the elbow, uh feels unusually loose like it's going to dislocate. Uh There's some anatomical issue with the elbow that's uh new or uh potentially uh any, any trauma associated uh with this pain. Um uh then uh a referral may be clinically uh uh warranted. Um Also ie e more, you know, more common reason for referral if the patient has failed conservative treatment for over six months. Uh Meaning the patient has not in not improving or worsening despite being compliant with treatment, uh, including at that point, uh, more formal uh, physical therapy in an outpatient clinic, then a referral may be clinically appropriate. And as I said in and other talks as well, if the patient is not, uh, um, uh, willing to consider a procedure or surgery, uh, then a surgical referral may not be necessary in that uh, clinical scenario. Uh, and it clearly a, a referral to a specialist has to be taken on a ca case by case basis and should always be considered in the context of the patient's medical condition, work status and other factors that may impact uh their health and uh outcome. Finally, as we do for all of our talks in this series, uh we will end uh on some uh take home points. Uh First of all, conservative treatment prior to specialist referral uh is paramount for these patients uh with symptoms of elbow elbow epicondylitis. Uh This conservative care is lengthy and patients is required for both you and the patient. Um DME may be uh useful for elbow pain with epicondylitis. Um But what's needed in this clinical scenario should not be custom and should be um found if, if needed in a local um uh drug store. And finally, advanced imaging should not be ordered um by a PCP uh as it, it doesn't really impact um initial treatment. Uh if and when a patient does need a specialist, um for which in this condition, it's, it's quite rare. Uh The specialist can order imaging uh as needed. Well, thank you for joining um joining me for the presentation today. Uh I hope you enjoy the, the talk and hope you uh join it again. Uh Join us again soon as we explore other topics in M SK care. Thank you. Have a good day.