Tennis Elbow Diagnosis and Treatment Quiz

Elbow Epicondylitis

• Also known as "Tennis Elbow" or "Golfer's Elbow"
• Lateral epicondylitis (Tennis Elbow): Pain on the outside of the elbow.
• Medial epicondylitis (Golfer's Elbow): Pain on the inside of the elbow.

Objectives

• Students should be able to memorize the definition, etiology (cause), and risk factors for lateral epicondylitis.
• Students should be able to recognize and understand the tennis elbow provocative test and its clinical presentation.
• Students should be able to recognize and understand the treatment for lateral epicondylitis.
• Students should be able to memorize the definition, etiology, clinical presentation, and treatment for medial epicondylitis.

Lateral Epicondylitis

• Also called Lateral Elbow (or Epicondyle) Tendinopathy (LET)
• The most common overuse syndrome in the elbow.
• Usually not an inflammatory condition, but a tendinopathy (tendinosis and tendon degeneration)
• Involves the extensor muscles of the forearm, originating from the lateral epicondylar of the distal humerus.
• Contractile overloads that chronically stress the tendon near its humeral attachment are the primary cause.
• The injury is not always related to tennis (only 5-10% of cases).
• Typically affects adults between the ages of 35-50.
• Affects approximately 1-3% of the population.
• Equally common in both sexes.

Lateral Epicondylitis (cont.)

• The dominant arm is more prone to the condition
• 20% of cases persist for more than a year.
• Caused by repetitive microtrauma from concentric or eccentric overload of the wrist extensors.
• The extensor carpi radialis brevis (ECRB) is the most commonly affected muscle. The supinator and other wrist extensor muscles (extensor carpi radialis longus, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) can also be affected.

Tennis Elbow Risk Factors

• Handling tools heavier than 1 kg
• Handling loads heavier than 20 kg at least 10 times per day
• Repetitive movements for more than 2 hours per day
• Training errors
• Heavy rackets
• Inappropriate grip size
• High string tension
• Poor technique
• Misalignments
• Flexibility problems
• Age
• Poor circulation
• Strength deficits
• Muscle imbalance
• Psychological factors

Etiology (Lateral Epicondylitis)

• Direct blow to the lateral epicondyle or sudden extreme effort/activity
• Overuse: Repeated, gradual stresses on the wrist extensors (primarily the ECRB).
• Work-related: any activity involving wrist extension, pronation, or supination.
• Household activities and hobbies can also contribute

Clinical Presentation (Lateral Epicondylitis)

• Primary symptom: pain
• Pain is elicited by palpation of the extensor muscle origin on the lateral epicondyle.
• Pain radiates up the upper arm and down the outside of the forearm.
• Onset is gradual, related to increased wrist extensor activity.
• Dull aching at rest; can become sharp during activity.
• Morning stiffness; occasional night pain.
• Other symptoms: Pain with active or resisted wrist extension, pain with grasping objects, decreased movement with passive elbow extension or ulnar deviation and pronation, dropping objects/weak grip, deficient flexibility and strength in wrist extensors and posterior shoulder muscles.

Tennis Elbow Provocative Tests

• Cozen's test (resisted wrist extension test): Elbow at 90° flexion, therapist palpates lateral epicondyle while the patient resists wrist extension with a fisted hand, Positive if sharp sudden severe pain over lateral epicondyle.
• Mill's test: Passive extension of the elbow while the forearm is pronated and wrist flexed causes pain over the lateral epicondyle.
• Maudsley test (resisted middle finger extension): Pain with resisted middle finger extension suggesting involvement of the extensor digitorum communis, which shares a common tendon origin with the ECRB.

Tennis Elbow Provocative Tests (cont.)

• Chair lift test: Patient tries to lift chair using three-finger pinch grip with elbow fully extended; pain at the lateral epicondyle suggests a positive test.
• The coffee cup test: Perform an activity (picking up a full cup of coffee or milk) requiring wrist extension and rate your pain.

Diagnosis

• Combining medical history, physical examination.
• Helpful: Ultrasound (evaluates tendon damage and bursa), Plain X-rays (to rule out arthritis or calcification).
• Electromyography (EMG) - excludes nerve compression.
• MRI - potential tendon-osseous enthesis abnormalities.

Treatments

• Anti-inflammatory medications (NSAIDs) for acute cases.
• Cortisone injections. (May trigger inflammatory cascade and may not have long-term effectiveness)
• Autologous blood injection (potentially for healing)
• Platelet Rich Plasma (PRP) injections (similar to ABI but uses platelets)
• Platelets play a critical role in connective tissue repair and regeneration.
• Physical therapy, splinting (protects and decreases stress on the tendon)
• Surgery (used in cases not responding to conservative treatment)
• Excision of abnormal tissue or release and/or reattachment of the tendon.

Physical Therapy Goals

• Acute stage: Reduce pain and inflammation, promote tissue healing, maintain flexibility and range of motion (ROM), and prevent muscle atrophy.
• Chronic stage: Improve flexibility, increase muscular strength/endurance, increase functional activities.

Physiotherapy Management

• Protection through braces/splinting(wrist cock-up splint)
• Counter-force brace (arm band/epicondylar splints; limits muscle expansion to decrease compressive force at the true origin)
• Rest
• Ice – 3x/day for 15min
• Elevation
• Kinesiotaping- apply from insertion to origin of ECRB
• Other management modalities: Electrical or thermal modalities, phonophoresis, laser, etc.

Activity Modifications

• Avoid lifting with palms down
• Best- palm turned up; while holding
• Avoid pronation

Equipment Checks

• Proper equipment fit (stiff/loose strings on racquets)
• Choosing the correct racquet grip size to prevent recurring symptoms.

Shockwave Therapy

• A method for treating tendonopathies like lateral epicondylitis.
• Uses strong mechanical wave impulses that promote the body's natural healing processes
• Useful for cases that haven't responded to conservative treatment.

Manual Therapy

• Myofascial Release: Address fascial restrictions causing tension elsewhere in the body due to continuity.
• Deep Friction Massage: Palpate the area and apply pressure and cross fiber massage, increasing intensity as inflammation decreases.

Cervicothoracic Joint Mobilization

• Recent research shows that joint mobilization/manipulation of the cervical and thoracic spine, combined with local treatment, can improve strength, pain, and tolerance towards activities.

Exercise Therapy

• Focuses on improving mobility, strength, and endurance once pain and inflammation are under control.
• Includes stretching exercises (like the best position with the elbow in extension, forearm pronated, wrist in flexion).
• Use the appropriate mobilization and stretching exercises in pain-free ranges.

Strengthening Exercises

• Low-intensity isometric exercises to improve the shortened position and flexion and extension movement to achieve full motion.
• Exercises move forward to free weights, elastic resistances for concentric/eccentric exercises within a pain-free range.

Eccentric Exercises

• Therapeutic eccentric exercises are effective for treating diverse tendinopathies.
• Eccentric exercises effectively lengthen the tendon and muscle, increase tendon hypertrophy and tensile strength, and increase fibroblast activity
• Various equipment such as resistance bands, flexbars, or free weights can be used.

Flexbar Exercises

• Sequence to perform eccentric extension and improve wrist flexion, while holding the other end in a stable position.
• Allow the bar to 'untwist' by bringing the involved wrist into flexion (using eccentric contraction of the wrist extensors)

Cyriax Physiotherapy

• A common intervention that combines deep transverse friction (DTF) with Mill's manipulations to treat lateral epicondylitis.
• Used with success by Cyriax.
• Three times a week for four weeks, in sequence.
• DTF: a connective tissue massage applied at the point of injury for 10 min to relieve pain and prepare the area for manipulation technique
• Note the contraindications (active infections, disorders of nerve structures, other.)

Mills Mobilization

• A soft tissue manipulation targeting the tendon origin of the common extensor tendon.
• Aim is to elongate scar tissue and resolve adhesions within the teno-muscular junction.
• Performed when full pain-free elbow extension is achievable.

High-Velocity Low-Amplitude (HVLA) Thrust

• A quick movement at the end range of elbow extension.
• May produce some discomfort, but serves to treat the issue during the intervention period of 4-12 sessions.

Medial Epicondylitis (Golfer's Elbow)

• Pathologic condition affecting the common flexor tendon at the medial epicondyle.
• Commonly results from repetitive microtrauma to the pronator teres and flexor carpi muscles during pronation and flexion of the wrist.
• Pain is intensified by resisted pronation, wrist flexion, or passive wrist extension with the elbow extended.
• Less common than lateral epicondylitis.

Medial Epicondylitis (Etiology)

• Repetitive valgus stress & pronation/wrist flexion.
• Often caused from occupations that involve repetitive wrist flexion such as carpentry, plumbing, meat cutting
• Trauma (sudden violence to the tendons).

Medial Epicondylitis (Clinical Presentation)

• Pain in the elbow distal to the medial epicondyle.
• Pain radiates up and down the arm, commonly on the ulnar side of the forearm, wrist, and occasionally finger.
• Evoked by resisted wrist flexion or pronation.
• Often accompanied by weakness of grip strength.
• Can be sudden or gradually develop
• Sever cases: discomfort when shaking hands/opening doors
• Often accompanied by tenderness, pain, local swelling, and warmth & ROM loss

Medial Epicondylitis (Tests)

• Passive Test: Therapist extends the wrist with elbow extended.
• Active Test: Wrist flexion resistance test with elbow extended.
• Golfer's Elbow test: Patient contract the wrist flexors isometrically, resistance.

Medial Epicondylitis (Treatment)

• Similar to lateral epicondylitis, but focusing on the correct muscles (pronator teres and flexor carpi radialis).