Tennis Elbow - clinical pattern sheet PDF

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Condition Lateral Epicondylitis (Tennis Elbow) Definition / Description Lateral epicondylitis is the most common overuse syndrome in the elbow. It is an injury involving the extensor muscles of the forearm. These muscles originate on the lateral epicondylar region of the distal of the humerus. In a lot of cases, the insertion of the extensor carpi radialis brevis is involved. Contractile overloads that chronically tension or stress the tendon near the attachment on the humerus are the primary cause of epicondylitis. Populations / Risk Factors Only 5% of people suffering from tennis elbow relate the injury to tennis. It's estimated that as many as one in three people have tennis elbow at any given time. It occurs often in repetitive upper extremity activities such as computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration. Despite the name you will also commonly see this chronic condition in other sports such as squash, badminton, baseball, swimming and field throwing events. People whit one-side movements in their jobs such as electricians, carpenters, gardener and those who practice needlework. A systematic review identified 3 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. Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors. Symptoms 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. The pain can radiate upwards along the upper arm and downwards along the outside of the forearm and in rare cases even to the third and fourth fingers.  Pain and tenderness on the lateral side of the upper forearm, typically just below the elbow joint. This pain will commonly also travel down the forearm into the wrist. Pain can range from mild discomfort to sever pain and can be experienced at any time, whether the elbow is mobile or at rest.  Pain in elbow flexion, when the arm is loaded  Pain when gripping small objects or writing i.e. holding a pen.  Pain when twisting the forearm i.e. turning a door handle  Pain and stiffness when extending the elbow

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Repetitive movements that include gripping and twisting can aggravate pain Weakness felt in the forearm muscles and hand grip of affected arm

Although the term epicondylitis implies the presence of an inflammatory condition, inflammation is present only in the earliest stages of the disease process. Furthermore, it is also often seen that the flexibility and strength in the wrist extensor and posterior shoulder muscles are deficient. At least patients report weakness in their grip strength or difficulty carrying objects in their hand, especially with the elbow extended. This weakness is due to finger extensor and supinator weakness. Some people have a sense of paralysis but this is rare. there are four stages on the development of this injury with regard to the intensity of the symptoms. 1. Faint pain a couple of hours after the provoking activity. 2. Pain at the end of or immediately after the provoking activity. 3. Pain during the provoking activity, which intensifies after ceasing that activity. 4. Constant pain, which prohibits any activity. Symptoms last, on average, from 2 weeks to 2 years. 89% of the patients recover within 1 year without any treatment except perhaps avoidance of the painful movements. Clinical Signs Localized pain and swelling (in early acute stages) over lateral epicondylar area. Decreased elbow AROM, especially elbow extension. Decreased strength of forearm muscles, especially wrist extensors Decreased hand grip strength Cozen’s test; is also known as the resisted wrist extension test. The elbow is 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 is asked to resist wrist extension. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle. Mill’s Test; The patient is seated with the upper extremity relaxed at side and the elbow extended. The examiner passively stretches the wrist in flexion and pronation. Pain at the lateral epicondyle or proximal musculotendinous junction of wrist extensors is positive for lateral epicondylitis. Maudsley’s test; The examiner resist extension of the third digit of the hand, while palpating the lateral epicondyle. A positive test is indicated by pain over the lateral epicondyle. The coffee cup test; The coffee cup test (by Coonrad and Hooper): 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. History Timescale of onset of pain; usually slow onset (see stages above) Aggravating and easing factors Any repetitive movements in ADL’s that contribute/replicate pain Specific region of pain Any specific mechanism of injury Partaking of any sports that require excessive/repetitive upper limb use Repetitive upper extremity use: computer, sewing, wiring, gardening etc. Noticeable weakness and inability to lift objects, turn door handles etc Investigations Special Tests; Cozen’s, Grip strength, Mill’s, Maudsley’s, coffee cup  X-rays: These may be taken to rule out arthritis of the elbow  Magnetic Resonance Imaging (MRI): if the symptoms are related to a neck problem, an MRI scan may be ordered. This will show if there is a possible herniated disk or arthritis in your neck. Both conditions often produce arm pain.  Electromyography (EMG): An EMG is 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. Atypical Presentations Radial Tunnel Syndrome: Pain in the posterolateral area of the forearm Pain sometimes spreads to the dorsal side of the wrist Paresthesia Weakness (overuse injuries of the musculoskeletal system) Posterior Interosseous Syndrome: Pain Weakness involving wrist extension and finger extension Motor deficits Elbow osteoarthritis: Pain Loss of range of motion Fractures: Distal Radial Fractures Radial Head Fracture Olecranon Fracture

Cervical Radiculopathy Radiating arm pain corresponding to the dermatomes Neck pain Paresthesia Muscle weakness in myotome Reflex impairment/loss Headaches Scapular pain Sensory and motor dysfunction in upper extremities and neck Management Options and Levels of Evidence Exercise therapy is a regimen or plan of physical activities designed and prescribed for specific therapeutic goals. Its purpose is to restore normal musculoskeletal function or to reduce pain caused by diseases or injuries. Strength, stamina and mobility should be improved by exercises once the pain and inflammation are under control. Non-Operative; medical management of lateral epicondylitis is initially based on the following principles: relieving pain and controlling inflammation. Relieving pain can be countered by rest and avoiding painful activities. Inflammation on the other hand can be prevented by NSAIDs in the acute cases. 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 increasing vasoconstriction. Elevation of the extremity is also indicated if an edema of the wrist or fingers is present. The use of an elbow counterforce brace can be helpful because it plays the role of a secondary muscle attachment site and relieves tension on the insertion at the lateral epicondyle. Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect. Operative; If the symptoms of epicondylitis lateralis will prove to be resistant surgical treatment is indicated. Usually this is after a failed conservative treatment for more than 6 months. Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone. Physiotherapy: Stretching: The literature on the treatment of a Lateral Epicondylitis suggests that strengthening and stretching exercises are the most important components of exercise programmes, for the reason that tendons should not only be strong but also flexible. 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, per the patient’s tolerance. This stretching should be held for 30- 45 s and 3 times before and after the eccentric exercises, during each treatment session with a 30 s rest interval. Exercise: Theraband exercises (or exercises with a small weight) are performed each day for 3 sets of 10. You fix one side of the theraband under your feet or another place and you take the other side in your hand or you have a small weight in your hand. The patient starts the exercise in wrist flexion, then he/she does a wrist extension and comes back to the start position very slowly. This exercise is an concentric en eccentric exercise for the wrist extensors. They concluded that supervised exercise consisting of static stretching and eccentric strengthening produced the largest effect in reducing pain, strength and improving function. Once the patients can do this, they can progress to another colour of theraband or you increase the weight.

Cyriax Physiotherapy; It’s a very common intervention that combines the use of deep transverse friction (DTF) with Mill’s manipulations. 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. Pain during the friction massage is considered as a wrong indication. Mill's manipulation is the most common technique used by physiotherapists and is a 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. It’s used to imitate the mechanism of spontaneous recovery. This manipulation must only be performed if a fully pain-free elbow extension can be achieved, and with a properly technique. To prevent symptoms worsening, full wrist flexion must be achieved during the procedure. Useful Resources http://www.nhs.uk/Conditions/Tennis-elbow/Pages/Introduction.aspx http://www.physiopedia.com/Lateral_Epicondylitis#Characteristics.2FClinical_Presentation http://www.csp.org.uk/publications/tennis-elbow-exercises...