Tennis Elbow Diagnosis and Treatment Quiz

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Questions and Answers

Which test is positive when sharp pain is elicited during passive extension of the elbow while the forearm is pronated and wrist flexed?

Mill’s Tennis Elbow Test (correct)

Cozen’s test

Coffee cup test

Chair lift test

What is the position of the elbow during Cozen’s test?

90° flexion (correct)

Fully extended

Hyperextended

Straight with wrist extended

Which test is described as the resisted middle finger extension test?

Chair lift test

Mill’s Tennis Elbow Test

Cozen’s test

Maudsley test (correct)

In diagnosing tennis elbow, which imaging technique may be utilized to rule out nerve compression?

Electromyography (EMG) Signup and view all the answers

During the Chair lift test, what is the patient required to do?

Use a three-finger pinch to lift a chair Signup and view all the answers

Which common finding may be noted on X-ray in longstanding cases of elbow pain?

Osteochondritis dissecans Signup and view all the answers

What indicates a positive result during the Coffee cup test?

Pain rating of 7 or higher on a scale of 0 to 10 Signup and view all the answers

What is commonly indicated by pain experienced during the resisted wrist extension test?

Tendinopathy of the ECRB Signup and view all the answers

Which treatment option is considered only after 6 to 12 months of conservative treatment?

Surgery Signup and view all the answers

What role do platelets play in the injection of blood products for tendon repair?

They play a significant role in the repair and regeneration of connective tissue. Signup and view all the answers

What is one goal of physical therapy during the acute stage of tendon injury?

Promote tissue healing. Signup and view all the answers

What does the counter-force brace primarily aim to do?

Limit full muscular expansion and reduce contraction force of the muscle. Signup and view all the answers

What is the recommended use of ice for tendon injury management?

Three times per day for 15 minutes. Signup and view all the answers

Why should MRI findings in chronic tendon injuries be interpreted with caution?

They could show improvement in healing despite ongoing symptoms. Signup and view all the answers

What does the acronym PRICE stand for in the context of injury management?

Protection, Rest, Ice, Compression, Elevation. Signup and view all the answers

Which of the following strategies is NOT typically recommended for treatment during the acute stage?

Promoting complete muscle use. Signup and view all the answers

What is a primary goal of exercise therapy once pain and inflammation have subsided?

Improve mobility, strength, and endurance Signup and view all the answers

Which massage technique is recommended when palpating a scar and addressing inflammation?

Cross fiber massage with increasing intensity Signup and view all the answers

What physiological rationale is suggested for the effectiveness of joint manipulation in lateral epicondylalgia (LE)?

Manipulation addresses altered neuronal afferent input to the spine Signup and view all the answers

What stretching position is ideal for targeting the Extensor Carpi Radialis Brevis tendon?

Elbow in extension, forearm in pronation, with wrist in flexion and ulnar deviation Signup and view all the answers

What is the primary goal of therapeutic eccentric exercise for tendinopathies?

To effectively lengthen the muscle-tendon complex Signup and view all the answers

Which method is NOT mentioned as a technique for elongating tight muscles?

Dynamic stretching with repetitive motion Signup and view all the answers

Which of the following statements is true regarding the use of FlexBar® for eccentric exercises?

Eccentric contractions occur when the involved wrist moves into flexion Signup and view all the answers

What is the first step in strengthening exercises for the wrist extensors?

Engage in low intensity isometric exercises Signup and view all the answers

What is the main purpose of deep transverse friction (DTF) in Cyriax physiotherapy?

To apply specific pressure to soft tissue at the lesion site Signup and view all the answers

Which joint regions have been associated with clinical alterations in pain through manipulation?

Elbow, wrist, cervical, and thoracic spine Signup and view all the answers

Which of the following is NOT a contraindication for Cyriax physiotherapy?

Tendinopathy Signup and view all the answers

What should be avoided during mobilization and stretching exercises?

Engaging in exercises when inflammation is high Signup and view all the answers

How often should the patient follow the Cyriax protocol for optimal results?

Three times a week for four weeks Signup and view all the answers

What happens during Mills manipulation in the context of Cyriax physiotherapy?

It focuses on the tendon origin of the common extensor tendon Signup and view all the answers

What is the desired outcome of applying deep transverse friction for 10 minutes?

Reach a numbing effect at the point of the lesion Signup and view all the answers

What is the primary feature of eccentric exercises compared to concentric exercises?

Eccentric exercises lengthen the muscle during contraction Signup and view all the answers

What is the primary location of pain associated with medial epicondylitis?

Distal to the medial epicondyle of the humerus Signup and view all the answers

Which test involves extending the wrist while keeping the elbow extended?

Medial epicondylitis passive test Signup and view all the answers

What symptoms accompany medial epicondylitis aside from pain?

Weakness of hand grip Signup and view all the answers

Which muscle is primarily affected in medial epicondylitis?

Flexor carpi radialis Signup and view all the answers

What typical activity might worsen symptoms in severe cases of medial epicondylitis?

Shaking hands Signup and view all the answers

What is the main purpose of performing a high-velocity low-amplitude thrust at the end of elbow extension?

To elongate scar tissue by rupturing adhesions Signup and view all the answers

When should the high-velocity low-amplitude thrust technique be performed?

Only when full pain-free elbow extension is achievable Signup and view all the answers

What is the primary condition addressed by the described elbow manipulation technique?

Medial epicondylitis Signup and view all the answers

What should the wrist position be when performing the manipulation technique?

Full flexion Signup and view all the answers

How often should the manipulation technique be applied for effective treatment?

2-3 times a week until cure, within a range of 4-12 sessions Signup and view all the answers

What is the distinguishing factor in the incidence rates of medial vs lateral epicondylitis?

Lateral epicondylitis occurs five to seven times more often Signup and view all the answers

What is a significant risk factor that can lead to medial epicondylitis?

Repetitive valgus stress along with pronation and wrist flexion Signup and view all the answers

Study Notes

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).

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Description

Test your knowledge on the diagnosis and treatment of tennis elbow through this comprehensive quiz. Covering topics such as specific tests, imaging techniques, and treatment options, this quiz will help enhance your understanding of managing this common injury. Perfect for healthcare professionals and students alike.