Don’t be a yellow flag therapist

An update of an evidence-based clinical guideline � � Predisposing factors 🔭 •When treating patients with an acute LAS, modifiable risk factors such as deficiencies in proprioception and ROM should be identified and if possible included in a prevention and/or rehabilitation program to mitigate the risk for recurrent sprains. •Extrinsic risk factors(type of sport practiced) although outside of the patient, may provide a significant increase in the risk at sustaining a LAS. *Prognostic factors Adequate attention should be directed towards the patient’s current level of pain, their workload and level of sports participation. These may all negatively influence recovery and increase the risk of future injury recurrence. * Diagnostics 🔬 Regarding the clinical assessment of damage to the anterior talofibular ligament, the sensitivity (8️⃣4️⃣%) and specificity (9️⃣6️⃣%) of assessment using the anterior drawer are optimised if clinical assessment is delayed for between 4️⃣ and 5️⃣ days post injury. In case of a suspected fracture, the OAR should be applied. * Treatment •Rest Ice Compression Elevation (RICE)♨️ There is no evidence that RICE alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function. •Non-steroidal anti-inflammatory drugs💊 NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications and may suppress or delay the natural healing process. •Immobilisation🚷 Use of functional support and exercise therapy is preferred as it provides better outcomes compared with immobilisation. If immobilisation is applied to treat pain or oedema, it should be for a maximum of 10 days after which functional treatment should be commenced. *Functional treatment •Functional support Use of functional support for 4–6 weeks is preferred over immobilisation. The use of an ankle brace shows the greatest effects compared with other types of functional support. •Exercise Exercise therapy should be commenced after LAS to optimise recovery of joint functionality. Whether exercise therapy should be supervised or not remains unclear. •Manual mobilisation👋 A combination with other treatment modalities, such as exercise therapy, enhances the efficacy of manual joint mobilisation and is therefore advised. •Surgical therapy Despite good clinical outcomes of surgery after both chronic injuries and an acute complete lateral ligament rupture, functional treatment is still the preferred method as not all patients require surgical treatment. •Other therapies As no strong evidence exists on the effectiveness of these treatment modalities, they are not advised in the treatment of acute LAS * Prevention •Functional support💪 Both tape and brace have a role in the prevention of recurrent LAS (limited evidence). •Exercise therapy It is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy should be included into regular training activities as much as possible as home-based exercise. •Footwear👟 No recommendations can be made concerning shoe wear. •Return to work To speed up return to work, a brace and immediate functional treatment in combination with a return to work schedule are advised. •Return to sports Supervised exercises focusing on a variety of exercises such as proprioception, strength, coordination and function will lead to a faster return to sport.

The aim is to reduce pain and improve function. No single treatment has proven to be totally effective, treatment selection depends on the patient's clinical picture and informed by current best evidence. 1- Advice and education: About the nature of the problem how to modify and control pain and activity till pain and function are regained. 2- Exercises: The gold standard is eccentric exercises using small weight or theraband. 3- manual therapy; Mobilization for elbow and radioulnar joints mobilization with movement: lateral glide with or without belt or pain release phenomenon (stretching or resisted wrist extension 20 seconds) mobilization of cervical (mostly C5, 6) or upper thoracic spine 4- Taping: usually in lateral direction 5- Dry needling: 6- Braces/Splints/Strap: has no clear evidence 7- electrotherapeutic modalities: like TENS, shock wave. Has mixed evidence in short term some has little evidence like ultrasound.

Tennis elbow, also known as lateral epicondylitis, is a condition in which the lateral aspect of the elbow becomes painful and tender. The pain may also extend into the posterior aspect of the forearm and grip strength may be weak. Onset of symptoms is generally gradual. Diagnosis is typically based on the symptoms with medical imaging used to rule out other potential causes. Signs and symptoms: - Pain on the lateral aspect of the elbow (lateral epicondyle). - Point tenderness over the lateral epicondyle and there may be trigger points in the wrist muscles. - Pain from gripping and movements of the wrist, especially resisted wrist/finger extension. (e.g. turning a screwdriver) and lifting movements. Pain can also be present when the muscles are stretched. Pathophysiology: Histopathological findings have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen with formation of reparative tissue (angiofibroblastic hyperplasia) . Therefore, the disorder is more appropriately referred to as tendinopathy rather than tendinitis. Common Causes include: - Unaccustomed hand use. eg painting a fence, hammering, lots of typing. - Excessive gripping or wringing activities. - Poor forearm muscle strength or tight muscles. - pain referred from cervical spine . The most common segment that refers to lateral elbow is C5,6. Differential Diagnosis: - Radial Tunnel Syndrome - Cervical Radiculopathy - Posterior Interosseus Syndrome Outcome Measures pain: Numeric Pain Rating Scale (NPRS) or visual Analogue Scale (VAS). Self-reported functional Questionnaires: - Quick DASH (Disabilities of the Arm Shoulder and Hand) - The Upper Limb Functional Index (ULFI). - Patient Rated Tennis Elbow Evaluation (PRTEE)