Why accurate diagnosis of elbow pain matters with Dr Leanne Bisset

In this episode with Dr Leanne Bisset, we discuss the assessment and management of elbow pain. We discuss elbow anatomy and how this makes the joint different from treating other parts of the body. We also discuss acute vs chronic elbow issues and how these need to be treated appropriately and how and when imaging can be used for diagnosis. 

This episode is closely tied to Leanne’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Leanne’s Practical here with our 7-day free trial: https://physio.network/practicals-bisset

Dr Leanne Bisset is an Associate Professor and Academic Lead in Physiotherapy at Griffith University. She is also a Musculoskeletal Physiotherapist as awarded by the Australian College of Physiotherapists. Dr Bisset's combined academic and clinical track record is underpinned by her clinical and research experience in chronic musculoskeletal pain. 

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Our host is @James_Armstrong_Physio

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Transcript

SPEAKER_02 0:00

Tendinopathy is certainly the most prevalent condition that is reported in the literature and that you'll probably see in this working aged population. But I think if we consider other mechanisms, for example, based on pain mechanisms... then I think it refocuses our priorities and it refocuses the approach we might take to managing patients who present with elbow pain.

SPEAKER_00 0:36

Are we moving away from specific diagnosis in clinic? Should we be specific or is it okay to not focus on a diagnosis? In this episode, we look at the importance of an accurate diagnosis in achieving great results with elbow pain. We're joined by Dr. Leanne Bissett, who is an associate professor and academic lead in physiotherapy at Griffith University. Leanne's combined academic and clinical track record is underpinned by her clinical and research experience in chronic musculoskeletal pain. Leanne has done a practical with Physio Network on the assessment and the management of elbow pain where you can dive a lot deeper into this area than we are able to in this episode. Click the link in the show notes to watch Leanne's practical for free with our seven-day trial. I'm sure you're going to love this episode as we discuss when and if you need that specific diagnosis or is there something else you should be looking for? I'm James Armstrong and this is Physio Explained. Leanne, thank you so much for coming on to the podcast today. It's great to have you on. How are you today? Hi,

SPEAKER_02 1:39

James. I'm well. Thank you for having me.

SPEAKER_00 1:42

This is an exciting podcast because we're going to be chatting about elbow pain today. And this is directly related to a practical that you've recently done with us for Physio Network.

SPEAKER_02 1:54

Yeah, that was a fantastic opportunity, actually. And I'm really glad that I got that chance to present that video of the assessment and the management of elbow conditions.

SPEAKER_00 2:05

Brilliant. And these practicals are really helping give an insight into people with a special interest and experts in their field and how they assess and treat different areas of the body, which is fantastic. So today we're going to be looking at just how important an accurate diagnosis is in achieving good results with elbow pain. So first of all, a diagnosis in the elbow, how important do you feel it is in treating elbow pain and patients who present with elbow pain?

SPEAKER_02 2:34

It's a really good question, James, because in a lot of areas now we're moving away from diagnostic categories, largely because that biomedical opinion seems to be less and less relevant to then directing our management plan for patients. I think particularly in the elbow, our challenge is that if your patient goes to see their general practitioner, and they're over 40 years of age, chances are that they will be diagnosed with one of the most common elbow conditions, which is a tendinopathy. And it seems to be patients present to the clinic with this diagnosis of tendinopathy, be it medial or lateral elbow tendinopathy, and they may have signs on imaging, but that's not the source of their symptoms. And yet, if the approach is that we just manage it based on our favourite diagnosis or favourite hypotheses, then the end result is our treatment outcomes are not optimised.

SPEAKER_00 3:40

With the diagnosis, I suppose, are you right in thinking we're biasing towards what we want to maybe see or what we prefer treating rather than what actually may be going on? And how do we get around that?

SPEAKER_02 3:52

I think it's also... the prevalence of those conditions is driving some of these preferred diagnoses as well. So tendinopathy is certainly the most prevalent condition that is reported in the literature and that you'll probably see in this working aged population. But I think if we consider other mechanisms, for example, based on pain mechanisms, then I think it refocuses our priorities and it refocuses the approach we might take to managing patients who present with elbow pain. And it's not necessarily the acute ones who turn up with an acute history, a particular trauma, a mechanism that we know of and we manage based on potentially our biomedical principles of tissue healing and repair. Those ones are fairly straightforward, but it's more the insidious onset the chronic overload type of injuries that present with more of a conundrum around how we manage them. Because I'm sure everyone's had this experience. Well, we seem to have these relatively simple clinical presentations. If we manage everybody with the same clinical presentation, they don't all get better. Some might respond well and then others don't respond well. That's the part we really need to try and uncover or improve our understanding is why don't those individuals respond well? We have an understanding of risk factors. If we use that in combination with our mechanisms, our pain mechanisms, so understanding what is driving their symptoms and consider less relevant or lower the importance of the imaging findings that then I think we've got an opportunity to probably improve our outcomes for our treatments.

SPEAKER_00 5:40

You're zooming away from the elbow a little bit and looking at the patient and maybe looking at what their goals are, what their loss of function is and how that can be helped or improved maybe?

SPEAKER_02 5:50

Yeah, certainly looking at that, taking that holistic approach. But incorporating into that and this is going to sound a little bit counterintuitive but incorporating into it a really good understanding of anatomy because I think this is where the elbow is different to some of the other joints around the body is that we've got a fairly small area in which there are three major peripheral nerves passing around through between the other musculoskeletal structures. And we don't always take account of those peripheral nerves and the role that they may have in generating symptoms in our patients. So yes, it's taking that holistic approach. Yes, it is addressing those other broader factors that we know are important, particularly in persistent pain, but also marrying that up with what is going on actually in the tissues and And in the surrounding tissue, so not just in the tendons or in the joints or in the ligaments, but also considering this relationship that those structures have with those peripheral nerves and how that might influence the patient's presentation.

SPEAKER_00 7:07

Right. That's really interesting. Forgive me if I've got this wrong, maybe, but maybe saying that it's not necessarily just about the diagnosis, but it's about the tissues that are potentially causing the issue. And that might well change your treatment massively. So not just pinning a diagnosis, but just say, actually, this structure is involved. Therefore, this is going to direct me down this route.

SPEAKER_02 7:27

Yeah. And thinking about it as tissue. Is this a nociceptive type of pain presentation? Is it neuropathic? Is it nociplastic? Or is it a combination of one or more of those pain mechanisms? And how does that direct or influence my treatment plan?

UNKNOWN 7:50

Music

SPEAKER_01 7:50

Want an easier way to improve your assessment and treatment skills? Introducing Practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with Practicals by Physio Network. Click the link in the show notes to try it for free today.

SPEAKER_00 8:22

And would you say it's just as important in the acute stage? So when we've got someone who's come in with an onset of elbow pain just a week ago, looking at that diagnosis and looking at your differentials, is it maybe more important or less important?

SPEAKER_02 8:35

Yeah, James, it's a good question because I started off by saying acute injuries were really simple because there was a mechanism associated with it. But you're absolutely right. If there is space-occupying changes, for example, edema, it can influence those other structures. those other peripheral nerves and other structures in the area. So yes, it still does apply to the acute presentations as well. having a thorough understanding of obviously the mechanism of injury and then imaging findings may be relevant as well in the acute stage. But I think that you'd still use those similar principles and knowledge of anatomy to try and work out what is at play here with these symptoms, what are the mechanisms underpinning the symptoms and managing those accordingly. And also important, I guess, really important to try and help stop these patients moving into that persistent pain pathway, which they're risk gold with elbow pain.

SPEAKER_00 9:32

So catching them nice and early is, I suppose, is an opportunity to maybe halt that progression down a long-term problem. Okay, that's great. And then in the practicals, you really nicely go through that differential. You bring in really nicely anatomy as well into the practicals as well, but not in a heavy way. It's in a practical, obviously, and relevant way throughout the practicals. Did you enjoy doing the practicals? What do you think is going to be useful for people who watch it?

SPEAKER_02 9:59

Yeah, look, I did enjoy doing the practicals. It's part of my core business. I obviously teach universities, but also deliver these workshops is a really... big passion of mine. I want to see our profession develop and grow and be known for best practice management. So I bring together that research, that evidence base, as well as the clinical skills side of things. I still work clinically myself in practice as well. So I really enjoy getting my hands on patients, but also in teaching clinicians, some of the approaches that I've developed over the years and in partnership with my research colleagues, of course. The work I do has been driven by a big body of work that involves a lot of people, a lot more than just myself in that space, especially in the research space. But it's great to be able to demonstrate the skills that we have as clinicians and apply those skills and be creative in the application of those skills because we're applying it to the individual patients. So it's about teaching or encouraging clinicians to be a little bit creative with how they do it while still having an evidence base and a clinical reasoning process behind what it is that they're doing and right down to the assessment and then prescription of exercises that's really nuanced for the elbow.

SPEAKER_00 11:26

Yeah, well, you've done that superbly and it's accelerated my knowledge of the elbow for certain. It just builds a bit of confidence as well for us because it's an area, as you rightly say, there's some structures in there that are key and differentiating between those two really, or between those many structures can make a big difference into how you then go forward with your treatment. And you've also really nicely looked at those kind of ingenuity of treatment as well and how you take a patient forward so you can make it unique to them. So it's really worth checking out the practicals that Leanne's done for us and And thank you very much for your time today, Leanne. Thanks, James. So a reminder that if you want to learn more about the elbow and the assessment, the management and the treatment of the elbow, then be sure to check out the practicals that we've linked in the show notes down below. Leanne, once again, thank you very much for coming on. I'm sure we'll have you on again soon.

SPEAKER_02 12:14

Great. Thank you for the opportunity.