Elbow Epicondylitis 2025 PDF

Elbow Epicondylitis By Dina Othman Shokri Objectives: By the end of this lecture, the student should be able to: ❑ Memorize definition, etiology and risk factors for lateral epicondylitis. ❑ Recognize and understand the tennis elbow provocative test and its clinical presentation. ❑ R...

Elbow Epicondylitis By Dina Othman Shokri Objectives: By the end of this lecture, the student should be able to: ❑ Memorize definition, etiology and risk factors for lateral epicondylitis. ❑ Recognize and understand the tennis elbow provocative test and its clinical presentation. ❑ Recognize and understand treatment of lateral epicondylitis. ❑ Memorize definition , etiology, clinical presentation and treatment for medial epicondylitis.  Lateral Epicondylitis Lateral Epicondylitis, also known as "Tennis Elbow", and lately proposed as Lateral Elbow (or Epicondyle) Tendinopathy (LET) is the most common overuse syndrome in the elbow. As the last description implies, LE is usually not an inflammatory condition. It is a tendinopathy (tendinosis and tendon degeneration) injury involving the extensor muscles of the forearm, Which originated from the lateral epicondylar of the distal humerus. Contractile overloads that chronically stress the tendon near the attachment on the humerus are the primary cause of epicondylitis. it should be remembered that only 5% to 10% of people suffering from tennis elbow relate the injury to tennis. Lateral epicondylitis generally occurs in adults between the ages of 35-50. It affects between 1%-3% of the population. Lateral epicondylitis is equally common in both sexes, obtaining of the condition at the both lateral epicondyle is rare. The dominant arm has the greatest chance of the occurrence of lateral epicondylitis, twenty percent of cases persist for more than a year. It occurs with repetitive microtrauma that results from either concentric or eccentric overload of the wrist extensors. It is a lesion affecting the tendinous origin of the wrist extensor (common extensor origin at lateral epicondyle). primarily the extensor carpi radialis brevis (ECRB) being the most affected muscle. The supinator and other wrist extensor muscles including, the extensor carpi radialis longus, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris can also be involved. The extensor carpi radialis brevis (ECRB) muscle has a small origin, helps stabilize the wrist when the elbow is straight. It is stretched over radial head when the elbow is extended and fully pronated. This fulcrum effect may partially explain its susceptibility to chronic inflammation at or near its attachment. In addition, The ECRB is under greatest strain when its fibers contract whilst in forearm pronation coupled with wrist flexion and ulnar deviation while the elbow extended. Tennis elbow risk factors: handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times per day, and repetitive movements for more than 2 hours per day, training errors, heavy raquets, inappropriate grip size, high string tension, poor technique, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors. 5 Etiology: 1-Direct blow to the lateral epicondyle, or a sudden extreme effort or activity. 2-Overuse: Any activity causing repeated, gradual stresses to the wrist extensors, primarily the ECRB can lead to the acute or chronic overuse syndrome. This injury is often work-related, any activity involving wrist extension, pronation or supination during manual labour, housework and hobbies are considered as important causal factors. Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle. Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. There are several opinions concerning the cause of lateral epicondylitis: 1.Inflammation 2. Microscopic tearing 3. Degenerative Process 4. Hypovascularity 6  Clinical presentation The most prominent symptom of lateral epicondylitis is pain, this pain can be produced by palpation on the extensor muscles origin on the lateral epicondyle (anterior and distal to it).The pain can radiate upwards along the upper arm and downwards along the outside of the forearm. Onset is usually gradual and is related to increase activity of the wrist extensor. Dull aching at rest, which may converted to sharp pain during activity, morning stiffness, occasional night pain. Location of pain in lateral epicondylitis. o Pain w/active or resisted wrist extension. o Pain w/ grasping objects with the effected hand o Pain and/or decreased movement on passive elbow extension, wrist flexion and ulnar deviation and pronation. o Dropping of objects/ weak grip strength or difficulty carrying objects in the hand, especially with the elbow extended. o Flexibility and strength in the wrist extensor and posterior shoulder muscles are deficient. o An evaluation of the entire upper extremity kinetic chain can be needed. A particular focus goes to the shoulder and the scapular strength, motion and stabilization. Overuse injuries in the elbow often occur with shoulder or scapular dysfunction  Tennis elbow provocative tests Cozen’s test is also known as the resisted wrist extension test. The elbow is extended or stabilized in 90° flexion. The therapist palpates the lateral epicondyle and the other hand positions the patient’s hand into radial deviation and forearm pronation. Then the patient with fisted hand is asked to resist wrist extension. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle. 9 Mill’s Tennis Elbow Test: Positive test when sharp lateral epicondyle pain is elicited during passive extension of the elbow while the forearm is pronated and wrist flexed. This test stretch the tendon. Maudsley (Resisted middle finger extension) test: A positive test is pain with resisted middle finger. It May elicit pain due to the extensor digitorum sharing a common tendon with the ECRB. It indicate affection of the extensor digitorum communis. Chair lift test: The patient grasps the back of the chair while standing behind it and attempts to lift the chair by using a three finger pinch (thumb, index, long fingers) and the elbow fully extended. The test is positive when pain occurs at the lateral epicondyle. The coffee cup test : The test is performed while doing a specific activity such as picking up a full cup of coffee or a milk bottle. The patient is asked to rate their pain on a scale of zero to ten.  Diagnosis Medical history and the physical exam provide enough information to make a diagnosis of tennis elbow. Ultrasound examination may be used in the investigation of patients with lateral elbow pain to demonstrate the degree of tendon damage as well as the presence of a bursa. In longstanding cases, plain X-ray (AP and lateral views) of the elbow may be taken to rule out arthritis of the elbow. Calcification along the lateral epicondyle, osteochondritis dissecans, degenerative joint changes or evidence of heterotopic calcification are among the common findings Electromyography (EMG) may be used to rule out nerve compression. Many nerves travel around the elbow, and the symptoms of nerve compression are similar to those of tennis elbow. MRI may also show thickening, hypoechogenicity or defects in the tendo- osseous enthesis in the case of LET, but the presence of these findings should be interpreted with caution when directing clinical decisions.  Treatments -Anti inflammatory medication (NSAIDs in the acute cases) -Injections of cortisone. -Autologous blood injection: May trigger the inflammatory cascade and initiate healing. -Injection of blood products :Platelet Rich Plasma (PRP). Slightly similar to the ABI but in this method blood is placed in a centrifuge, platelets are then selectively removed and used for injection. Platelets play a significant role in the repair and regeneration of connective tissue. 13 Surgery: Option ONLY after 6 to 12 months of conservative, Excision of abnormal tissue within the CETO, release and/or reattachment of the tendon via open or arthroscopic surgery. Goal of physical therapy: o During the acute stage. -Decreased pain and inflammation, -Promote tissue healing, -Maintain flexibility and ROM -Retard muscle atrophy o During chronic stage. -Improve flexibility -increase the muscular strength and endurance and increase functional activities and return to function.  Physiotherapy Management ❖ PRICE to control the inflammatory condition Protection via Braces/Splints/Straps Wrist cock-up splint may be used to decrease stress to the tendon, If the patient presents with acute symptoms immobilizing the wrist, hand, and fingers (not the elbow) in a resting splint, since this obviates the need for the wrist extensors to contract when the finger flexors are used. Counter- force brace also called arm band or epicondylar splint, its concept, limit full muscular expansion ,and reduces the contraction force of the muscle. It applied distal to ECRB origin. Provides a compressive force and creates a secondary origin of the extensor tendons, thus unloading the true origin at the lateral epicondyle. Counter- force brace Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks. The use of ice three times per day for 15 minutes is also recommended because it reduces the inflammatory response by decreasing the level of chemical activity and by vasoconstriction, which reduces the swelling. Elevation of the extremity is also indicated if an oedema of the wrist or fingers is present wrist cock-up splint ❖ Kinesio tape: Applied on a pronated arm, with wrist flexed. Not stretching the tape, apply from the insertion to origin of ECRB. Diamond taping method by rigid tape may be useful for reducing pain and improving grip strength and functional performance ❖ Education/Advice-Educating patient regarding their injury, pain control and/or modification of activities, Other lifestyle changes to reduce aggravating activities, ergonomic counseling. ❖ Activity modifications: Example of activity modifications, Avoid lifting with palm turn down. Hand turned up is better. Hand grasping while in supination, Avoid pronation motions Avoid lifting with a straight elbow, maintain a bent elbow and keep item close to body when lifting. Efforts should be made to educate tennis players on techniques for correctly executing a backhand in tennis. It is often observed that a tennis player will use two hands to prevent overload to the wrist extensors. If a second hand isn’t used as support and the arm is straight, the loading on the extensor tendon when the ball impacts the racquet can be very high. An alternative is to execute the shot with a flexed elbow where possible, to reduce this impact loading Incorrect backhand technique in tennis ❖ Equipment check. If you participate in a racquet sport, checking your equipment for proper fit. Stiffer and looser strung racquets often can reduce the stress on the forearm. which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring. Selecting the correct tennis racquet grip size ❖ Modalities: Electrical and thermal modalities, US iontophoresis or phonophoresis, laser. Shockwave Therapy is a method of treatment for multiple tendonopathies that can be used for the treatment of lateral epicondylitis. ESTW is a treatment technique in which patients are exposed to a strong mechanical wave impulses which can be used on a fairly accurate position. These waves create “microtrauma” that promote the body’s natural healing processes. 21 ❖ Manual therapy Myofascial release: Fascial restrictions undue tension in the other parts of the body due to fascial continuity. Deep friction massage. Palpate the scar, then apply pressure and cross fiber massage, increase of intensity of massage as inflammation decrease. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. While the true physiological effects of manipulative therapy may not yet be clearly elucidated, it is tempting to speculate on the physiological rationale as to why patients with LE respond favorably to such techniques directed at different anatomical regions. First, it is speculated that the pain associated with LE might be associated with altered neuronal afferent input to the spine. Perhaps applying manipulation techniques to the elbow, wrist, and cervicothoracic spine may assist in reducing abnormal afferent input, resulting in a reduction of the symptoms associated with LE. Cervicothoracic joint mobilization: Recent research regarding cervicothoracic joint mobilization/manipulation in conjunction with local treatment for lateral epicondylalgia has shown improvements in strength, pain, and tolerance to activity compared to local treatment alone. Mulligan - Mobilisation with movement Postero-anterior glide of the radial head ❖ Exercise therapy: Mobility, strength and endurance should be improved by exercises once the pain and inflammation are under control. The stretching exercises are intended to improve the flexibility of the extensor group of the wrist. The best stretching position for the Extensor Carpi Radialis Brevis tendon, is reached with the elbow in extension, forearm in pronation, wrist in flexion and with ulnar deviation of the wrist, according to the patient’s tolerance. Use agonist contraction, hold relax, and passive stretching to elongate the tight muscle to the end of its range. Mobilization and stretching should be in pain free ranges. ❖ Strengthening exercises: Low intensity isometric exercises at first, begin with gentle isometric contractions with the wrist extensors in the shorted position. At first with elbow flexed, forearm pronated and resting on table, and the wrist in extension then move the wrist toward flexion. when full wrist flexion is obtained without pain in the lateral epicondyle, progress by placing the elbow in greater degrees of extension and repeat the isometric contraction to wrist extensor. Progress the exercises to using free weights and elastic resistance through pain free ranges (Concentric and eccentric exercises). ❖ Eccentric exercises: Therapeutic eccentric exercise (TEE) has been found to be an effective intervention for a variety of tendinopathies. Eccentric exercise effectively “lengthened” the muscle-tendon complex resulting in structural remodeling of the tendon with hypertrophy and increased tensile strength of the tendon, increase fibroblast activity. It can be done by thera band, flexbar or free weight. Sample eccentric exercises for tennis elbow Flexbar® Exercises A. Hold FlexBar® in involved (right) hand in maximum wrist extension B. Grab other end of FlexBar® with uninvolved (left) hand C. Twist FlexBar® with noninvolved wrist while holding the involved wrist in extension D. Bring arms in front of body with elbows in extension while maintaining twist in FlexBar® by holding with noninvolved wrist in full flexion and the involved wrist in full extension E. Slowly allow FlexBar® to ‘untwist’ by allowing involved wrist to move into flexion (eccentric contraction of the involved wrist extensors). Eccentric exercise using a bucket with water (allowing for adjustable resistance) ❖ Cyriax Physiotherapy: It’s a very common intervention that combines the use of deep transverse friction (DTF) with Mill’s manipulations, which was used with success by Cyriax for treating lateral epicondylitis. Both the treatment components mentioned above must be used jointly in the sequence specified. Patient must follow the protocol three times a week for four weeks. There are several contraindications regard to this therapy: active infections, bursitis, disorders of the nerve structures, ossification and calcification of the soft tissues, active rheumatoid arthritis, anticoagulant. Deep transverse friction is a specific type of connective tissue massage applied precisely to the soft tissue structures. The therapist must try to reach an analgesic effect applying the DTF at the point of the lesion for 10 min till a numbing effect has been reached, that all for preparing the tendon for Mill’s manipulations. Mills Mobilization: Mills manipulation is not a class of manipulation target hypomobile joint or joint capsule but it is soft tissue manipulation target the tendon origin of the common extensor tendon. Small-amplitude high-velocity thrust performed at the end of elbow extension while the wrist and hand are held flexed. The aim of this technique is to elongate the scar tissue by rupturing adhesions within the teno-oseous junction, making the area mobile and pain free. This manipulation must only be performed if a fully pain-free elbow extension can be achieved, and with a properly technique. Patient seated with the affected extremity in 90° abduction and internal rotation (olecranon faced up).Therapist stands behind the patient, stabilized the patient’s wrist in full pronation and flexion, while the other hand is placed on the olecranon. The maintenance of full wrist flexion is important. The high-velocity low amplitude (HVLA) thrust at the end range of elbow extension, is a quick movement in the direction illustrated. This manipulation may produce mild discomfort at the instant of its performance. The clinician applies this procedure a 2-3 times a week until cure, with a range of 4-12 sessions.  Medial epicondylitis/ Golfer’s elbow Medial epicondylitis (golfer’s elbow, racquetball elbow, medial tennis elbow). It is pathologic condition of the common flexor tendon at the medial epicondyle. Generally occurs as a result of repetitive micro trauma to the pronator teres and the flexor carpi radialis muscles during pronation and flexion of the wrist. There is tenderness at the medial epicondyle, and pain is exacerbated with resisted pronation, resisted flexion of the wrist, or passive extension of the wrist with the elbow extended. Medial epicondylitis has a lower incidence than lateral epicondylitis. Epicondylitis occurs at least five times more often and predominantly occurs on the lateral rather than on the medial aspect of the joint, with a 4:1 to 7:1 ratio. 32  Etiology Over use syndrome related to repetitive valgus stress along with pronation and wrist flexion. Because chronic repetitive concentric or eccentric contractile loading of the wrist flexors and pronator are the most common etiology. Occupations such as carpentry, plumbing and meat cutting have also been implicated. The pathology may also be produced by sudden violence to these tendons in a single traumatic event. In many cases trauma at work had been identified as the cause of the symptoms.  Clinical presentation The patient usually complains about pain of the elbow distal to the medial epicondyle of the humerus with radiation up and down the arm, most common on the ulnar side of the forearm, the wrist and occasionally in the finger. The pain is evoked by resisted flexion of the wrist and by pronation. The pain is usually accompanied by a weakness of hand grip. Pain can begin suddenly or can develop gradually over time. In severe cases of epicondylitis, the patient will complain of pain when he simply shakes hands or pulls an open door. Tenderness to palpation (usually over pronator teres and flexor carpi radialis) Local swelling and warmth Range of motion in the beginning of the disease can be full, but later on there is a possibility of a decreased range of motion. -An evaluation of the entire upper extremity kinetic chain can be needed. A particular focus goes to the shoulder and the scapular strength, motion and stabilization. Overuse injuries in the elbow often occur with shoulder or scapular dysfunction. - Medial epicondylitis test: It includes a passive and an active test to determine medial epicondylitis. For the passive test, the therapist extends the wrist with the elbow extended. For the active resistance test, the patient should resist wrist flexion. This must be carried out with elbow extended while fully supinating the forearm. Golfer’s elbow test: The patient contracts the wrist flexors isometrically as strongly as possible against resistance. A positive test is indicated by reproduction of pain over the medial aspect of the elbow.  Treatment Similar to that outlined for lateral epicondylitis with the difference in the affected muscles(pronator teres and the flexor carpi radialis). Count’R-Force Medial Elbow Brace Thanks