by Amanda Tilley
Description:1-7
Lateral epicondylitis or “tennis elbow” is an overuse syndrome of the common extensor tendon of the forearm. This syndrome has been documented as one of the most prevalent disorders of the arm. This injury is seen as a degenerative syndrome of the extensor tendon at the lateral epicondyle. Epicondylitis is defined as pain and inflammation of the epicondyle. Since inflammation has not been classified as one of the main factors in epicondylitis, research has started to classify symptoms more related to tendinosis. Pain is felt over the lateral epicondyle and radiates down forearm. Lateral epicondylitis was originally called “Lawn-Tennis elbow “1882 by Morris due to associations with the sport. Today, lateral epicondylitis can be seen across the working population, with repetitive arm type occupations. Individuals affected may have trouble with daily activities including opening doors, lifting or gripping objects.
(http://www.tandurust.com/images/tandurust/tennis-elbow-pain-300x227.gif)
Anatomy:2,4,8
The elbow is a hinge joint consisting of three bones: the humerus, radius and ulna. Movement at the elbow is flexion, extension and rotation of the forearm (supination & pronation). Muscles, ligaments and tendons are the structural support for the elbow joint. The elbow is the location of origin for the muscle of the forearm, the common extensor muscles at the lateral epicondyle and the common flexor muscles at the medial epicondyle of the humerus. The biceps and brachioradialis muscles also attach to the elbow joint region.
(http://images.medicinenet.com/images/ccf/arthritis_tennis_elbow.jpg)
Anatomy related to lateral epicondylitis:
The lateral epicondyle has been described as a pyramid shaped bony prominence. The attachment site for what is called the common extensor tendon is located at the lateral epicondyle. Muscles that collectively form the common extensor tendon include the extensor digiti minimi, the supinator merging with extensor carpi radialis brevis (ECRB), the extensor digitorum communis, and the extensor carpi ulnaris. The anterior aspect of lateral epicondyle and supracondylar ridge are adjacent origin sites for the brachioradialis and the extensor carpi radialis longus.
(http://perfectgolfswingreview.net/ElbowJoint.jpg)
Other anatomical structures originating from the lateral epicondyle is the lateral collateral ligament complex, composed of the lateral unlar collateral ligament (LUCL), the radial collateral ligament (RCL) and the annular ligament. Thickening and tearing of the LUCL and RCL along with capsular injury have been associated with severe lateral epicondylitis cases. The radial nerve path comes proximal to the elbow located between the brachialis and brachioradialis muscle. At the region of the elbow, the radial nerve divides into two branches: the deep and superficial branch. The Posterior interosseous nerve (PIN) is a continuation of the deep branch of the radial nerve. The terminal branches are a continuation of the superficial branch of the radial nerve at the posterior wrist. As the PIN enters the supinator muscle or “radial tunnel,” compression can occur and has been documented in cases of refractory lateral epicondylitis.
Incidence/Prevalence:2,4,6,9,10
Lateral epicondylitis is typically seen in individuals ranging from ages 40 to 50 and is seen equally among males and females. Research has begun to document that females may be more prone to lateral epicondylitis than males, but little evidence is available to truly confirm these findings. Annual incidence is 1 to 3 percent of the population per year. Lateral epicondylitis occurs 7 to 10 times more often than medial epicondylitis or “golfer’s elbow”. Populations at increased risk of injuries are workers in highly repetitive hand task industries, which include computer workers and construction workers. Half of tennis players will at some point have elbow pain and 75 to 80 percent of these players’ elbow pain will be related to lateral epicondylsis.
Clinical Presentation:2,4,5,8
A patient’s history will often describe repetitive activities causing symptoms, yet onset of lateral epicondylitis commonly occurs with no injury but more a gradual onset of symptoms. Patients’ complaints typically include, pain at the location of the lateral epicondyle, sharp type pain that is exacerbated with gripping activities, pain in the morning and at times when the wrist is held in flexion. Also, patients typically complain of an inability to grip objects.
On clinical examination, signs of lateral epicondylitis include the following: point tenderness and pain over origin of common extensor tendon, and maximal tenderness anteriorly and just distal at the origin of the ECRB and ECD muscles. Additional findings are reduced strength with resisted grip, supination, and extension of the wrist.
Potential Etiologies:1,2,10
The literature has documented many possible theories on the origin of lateral epicondylitis. Potential causes include:
- Inflammation of an extra-articular radial humeral bursa
- Radial nerve entrapment or Radial Tunnel Syndrome
- Dysfunction of cervical spine at levels C5-6 or C6-7 referring as elbow pain
- Traumatic periostitis
- Osteochondral radiocapitellar lesion
Currently, the literature suggests the origin occurs at the superficial and deep fibers of the ECRB site of origin involving repetitive micro tears or micro-trauma, which forms scar tissue and increases the risk of further tearing. Some studies have identified EDC as the site of initial trauma. Repeated contractions of the forearm extensor muscles and improper gripping of rackets or equipment, and repetitive activities continue to tear the damage tendon and increase symptoms. Literature describes that inflammation is not a significant factor in the progression of injury and the term tendinosis is preferred over epicondylitis or tendinitis.
Diagnostic Tests:4,5,10,12
Lateral epicondylitis, to date, is usually based on clinical diagnosis and diagnostic testing is not routinely used. When diagnostic tests are performed, they are used in more complicated cases or to identity abnormalities and progression of damage to the common extensor tendon.
Few studies have been performed to show the sensitivity and specificity of the use of MRI as a diagnostic tool. Determined the sensitivity of MRI for detection of lateral epicondylitis ranges from 90 to 100 percent. MRI can be used to evaluate suspected intra-articular processes, for assessment of the RCL and to identify the level of tearing at the extensor origin. If used pre-treatment, MRI can show edema and thickening in 90 percent of symptomatic lateral epicondylitis patients.
(http://www.medicexchange.com/news/wp-content/uploads/2011/06/lateral-epicondylitis.jpeg)
Ultrasongraphy (US) studies have determined sensitivity and specificity for use in detection of symptomatic lateral epicondylitis. Studies conducted have identified the sensitivity and specify of use of US in detection of symptomatic lateral epicondylitis as ranging from 72 to 88 percent and 36 to 48.5 percent respectively. US is used to determine calcification, tendon thickening and bone irregularities.
Evaluation/Special Orthopedic Tests:2,4,5,10,11,13
Diagnosis of lateral epicondylitis is clinically based in most cases. The following evaluation findings will help determine a diagnosis of lateral epicondylitis;
- History of pain at the lateral elbow during recreational or occupational activities, repetitive activities, and insidious onset.
- Reproduced with resisted supination, wrist extension and in full arm extension.
- Point tenderness at location of origin of common extension tendon
- Reduced grip strength
Special tests to be perform include:
Cozen's Test:
Mill's or Tennis Elbow Test: ( Lateral epicondylitis test)
Lateral Epicondylitis “tennis elbow” Test:
Chair test :Patient is asked to lift themselves out of a chair with a pronated hand. Pain at lateral epicondyle indicates a positive test.
Coffee cup test: Patient is asked to hold a cup in their hand Pain at the lateral elbow indicates a positive test.
Conservative Treatment:2,4,7,9-11, 15
Research has outlined successful of treatment of lateral epicondylitis with conservative or non-operative techniques. Successful outcomes resulting from conservative treatment have been documented at rates of 89 to 90 percent, however recent literature indicates this rate might be higher than the actual rate of successful outcomes. Aim of conservative treatment of lateral epicondylitis is to reduce pain and to reduce inflammation. Cessation of activities that cause symptoms occurs in the initial stage of treatment, usually for 2 to 3 weeks, yet immobilization should be avoided due to the potential to lead to disuse atrophy. For the first 14 days RICE (rest, ice, compression and elevation) should be followed. The second phase of treatment is to treatment can last from 6 months to 1 year, depending upon the severity of lateral epicondylitis. During this stage of treatment, goals are to increase range, strength and lifestyle changes, i.e. equipment changes and learning proper form.
There are numerous treatment techniques that can be used, but little research has been collected on which strategies have the best outcomes and the long term effects of treatment. Listed below are possible conservative treatments and descriptions of what each treatment entails:
Rest, Wait and NSAIDS:
This form of treatment consists of avoiding aggravating activities, using non-steroids anti-inflammory drugs (NSAIDS) and icing. This treatment is usually used to manage acute lateral epicondylitis. Studies have shown significant short-term pain relief effects for lateral epicondylitis yet; this method can take up to 12 month to allow relief all symptoms.
Injection Therapy:
Many types of injection therapy are being researched in treatment of acute lateral epicondylitis. Steroid and Botulinum toxin injections are two therapies being performed. Literature on steroid injections has documented pain relief 5 days after initial injection. Yet, 12 week to 12 month results show worsening or the same results as those of other treatment techniques. Botulinum toxin injections have been researched with conflicting results of true clinical benefit.
Physical Therapy:
Physical therapy is commonly prescribed for treatment of lateral epicondylitis. A standard protocol for rehabilitation of lateral epicondylitis has not been documented. The main goals of physical therapy focus on reducing pain, increasing range of motion, strength, and grip strength, and stretching of the forearm. Research has outlined different protocols. Cyraix’s protocol uses Mill’s manipulation technique combined with deep transverse friction (DTF). Studies have shown eccentric strengthening is better than concentric treatment of lateral epicondylitis. Other modalities used by physical therapists for treatment of lateral epicondylitis are ultrasound and electrotherapies (inotophoresis EMT).
(http://magisnef.files.wordpress.com/2007/03/xtennise.gif)
Orthoses:
Prescribed types of orthoses are proximal forearm band and cock up wrist splints. The goals of these devices are to reduce tension at the common extensor tendon and to allow time for healing to occur.
Laser therapy & Acupuncture :
For laser therapy short follow up studies have found conflicting results, and six months to one year follow up studies have reported no evidence in positive effects on LE. Acupuncture studies have reported short term benefits yet benefits only last for few weeks.
(http://www.rehabmart.com/imagesfromNC/NC15340-1.jpg)
Physical Therapy Management of Lateral Epicondylitis
Surgery & Post-op Treatment:2,4,7,10,11
Surgical intervention for lateral epicondylitis is rarely performed and usually is a last resort. If symptoms are not relieved in 6 to 12 months, non-surgical options are recommended. There are many surgical approaches used by orthopedic surgeons. Open or arthroscopic debridement is used to remove degenerative tissue of the ECRB by making an incision at the lateral epicondyle, and once damaged tissue is removed, re-attaching the remaining tendon. In some cases, a surgical technique is used to release the common extensor tendon. Surgical intervention has been documented with positive outcomes and symptoms are typically relieved with one operative treatment.
Post-operative treatment varies little across surgical approaches. Sling, splint or soft bandages are recommended in the first 10 to 14 days after operation. Goals of rehabilitative treatment after this point are to increase range of motion and to strengthen for 4 to 6 weeks.
Elbow Surgery:
Arthroscopic Tennis Elbow Surgery
Additional Web Based Resources:
PudMed Health:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001485/
AAOS:
http://orthoinfo.aaos.org/topic.cfm?topic=a00068
Mayo Clinic:
http://www.mayoclinic.com/health/tennis-elbow/DS00469
Wheeles’s:
http://www.wheelessonline.com/ortho/tennis_elbow_lateral_epicondylitis
Nicholas Institute of Sports Medicine and Athletic Trauma:
http://www.nismat.org/ptcor/tennis_elbow
Related Videos:
Images:
1.http://www.tandurust.com/images/tandurust/tennis-elbow-pain-300x227.gif
2. http://images.medicinenet.com/images/ccf/arthritis_tennis_elbow.jpg
3.http://perfectgolfswingreview.net/ElbowJoint.jpg
4.http://www.radsource.us/_images/1103_6.jpg
5. http://www.medicexchange.com/news/wp-content/uploads/2011/06/lateral-epicondylitis.jpeg
6.http://2.bp.blogspot.com/-FiFy6WSehqg/TjqV1vPbh3I/AAAAAAAAAI8/3s7sqFFEbB8/s1600/xtennise.gi
7.http://www.rehabmart.com/imagesfromNC/NC15340-1.jpg
8.http://www.handctr.com/cons1_307_132.gif
References:
1.Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Phys Ther. 2002;82(11):1077-1086
2.Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: Pathogenesis, imaging, and treatment. Radiographics. 2010;30(1):167-184
3.Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: A population study. Am J Epidemiol. 2006;164(11):1065-1074
4.Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg. 2008;16(1):19-29
5.Levin D, Nazarian LN, Miller TT, et al. Lateral epicondylitis of the elbow: US findings. Radiology. 2005;237(1):230-234
6.Mellor S, Treatment of tennis elbow: the evidence. BMJ.2003.327(9):330
7.Thurston AJ. Conservative and surgical treatment of tennis elbow: A study of outcome. Aust N Z J Surg. 1998;68(8):568-5728. Moore KL, Moore KL, Dalley AF. Clinically oriented anatomy image collection. [Hagerstown, MD]: Lippincott Williams & Wilkins; 2000
9.Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411-422
10. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physicia. 200; 76:843-848,849-50;853.
11.Jobe F, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg. 1994;2:1-8.
12.Shahabpour M, Kichouh M, Laridon E, Gielen JL, De Mey J. The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow. Eur J Radiol. 2008;65(2):194-200
13. Magee DJ. Orthopedic physical assessment. St. Louis, Miss.: Saunders Elsevier; 2008:361-395.
14.Korthals-de Bos I,B.C., Smidt N, van Tulder M,W., et al. Cost effectiveness of interventions for lateral epicondylitis: Results from a randomised controlled trial in primary care. Pharmacoeconomics. 2004;22(3):185-195.
15.Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 2004;38(6):675-677
