lateral epicondylitis

LATERAL EPICONDYLITIS & TENNIS ELBOW

...INTRODUCTION

• Overuse injury that results in micro tearing & scar tissue formation of the common wrist extensor tissue.

• Peak incidence between the ages of 40 & 50.

• 50% of all tennis players experience tennis elbow .

By Saravanan Krishnan

…ANATOMY


…DEFINITION

Inflammation of the tissue at the lower end of thehumerous at the elbow joint, caused by the repetitive flexion & extension of the wrist againstresistance is called lateral epicondylitis (LE).

The primary structure involved:‐Is the tendon of the ECRB muscle & lessfrequently, the ECRL muscle.


…PREVELANCE

Although tennis elbow commonly affects tennisplayers, it also affects other athletes & people who participate in leisure / work activities thatrequire repetitive arm, elbow, & wrist movement.

Examples include golfers, baseball players, bowlers, gardeners / landscapers, house / office cleaners (because of vacuuming, sweeping & scrubbing), carpenters, mechanics, & assembly‐line workers.


…AETIOLOGY

• Occurs idiopathically.

• Primarily considered to be a mechanical disorder of the elbow.

• Onset of pain usually occurs due to exertion i.e. characterized by repetitive / forced extension of the wrist combined with squeezing / grasping.


…RISK FACTORS1. Intrinsic tendon overuse

2. Inadequate conditioning

3. Constitutional Factors

4. Decreased flexibility of muscles

5. Physical activities

6. Forceful grasping

7. Tennis player with poor playing style

8. Poor backhand stroke

9. Incorrect equipmentBy Saravanan Krishnan

…PATHOMECHANICS• Acute traumatic origin.

• Micro damage is increased due to increased internal strain to tendon fibers over time.

• Occur with normal activity levels if the tendons capacity to attenuate tensile loads is reduced.


…TYPES

• Type 1: A lesion of the muscular origin of theECRL , just proximal to the lateral epicondyle.

• Type 2: Is the most frequent type of tenniselbow. It is an insertion tendinopathy of theECRB

• Type 3: A tendonitis of theECRB tendon at the level ofthe radial head.

Cont...By Saravanan Krishnan

http://www.walterschiropractic.com/images/back.jpg

…TYPESType 4: A sprain of the musculotendinousjunction / proximal part of the muscle belly of the ECRB.

Type 5: Occurs frequently.The origin of the ED at thelaterodistal aspect of thelateral epicondyle is affected.


…CLINICAL PRESENTATION• SIGNS:

• Pain ie localized at the anterior aspect of the lateral epicondyle.

• Exertion, characterized by repetitive/ forced extension of the wrist

• Pain with athletic activity

• Pain with movement

• Pain when forcibly gripping an object or liftingBy Saravanan Krishnan

…SYMPTOMS• Pain may radiate down the dorsal aspect ofthe forearm to the wrist / the dorsum of thehand, & sometimes themiddle & ring fingers.

• Occasional dysesthesia / numbness from theelbow to the hand .

• A limitation of ADL due to severe symptomsmay result in approximately 1/3rd of cases.


…CLINICAL FINDINGS• Well‐localized tenderness is present at the lateral epicondyle .

• Myofascial trigger points in the wrist extensor muscles .

• Due to fibrosis & loss of tissue extensibility, there may be a loss of passive wrist flexion.


…SPECIAL TEST• Mills’ test : A passive stretch of the extensor tendons produced by full elbow extension, forearm pronation, wrist flexion & ulna deviation.

• Cozen’s Test : Resisted extension of the wrist performed with the elbow & wrist fully extended & pronated.

• Maudsley’s Test : Resisted extension of the middle finger with the elbow fully extended.


…SPECIAL TESTKaplan’s Test :• With the upper limb extended straight forward, the

patient squeezes a grip strength dynanometer as hard as possible.

• The test is then repeated with the examiner firmly encircling the patient’s forearm with both hands (1‐2 inches below the antecubital crease).

• A positive test for lateral epicondylitis is indicated if the induced pain is reduced & the grip strength is increased when the muscles of the proximal forearm are compressed.


…EVIDENCEThe Short‐term Efficacy of Laser, Brace, & UsTreatment in LE : A Prospective, Randomized,Controlled Trial.

OznurOken

AIM: To evaluate the effects of LLLT & to compare these with the effects of brace / US treatment in tennis elbow.

RESULTS: In patients with LE, a brace has a shorter beneficial effect than US & laser therapy in reducing pain, & that laser therapy is more effective than the brace & US treatment in improving grip strength.


…EFFECT OF OEMT ON LEJOURNAL OF HAND THERAPYJULY 2008, Mohammed Reza

AIM:To investigate the effect of OMET on pain , gripstrength & functional abilities of subjects withchronic LE.

OUTCOME MEASURE:Dynamometer, patient specific functional scale,numerical rating scale.


…EFFECT OF OEMT ON LERESULTS:OEMT seems to be viable, effective & efficientalternative treatment for LE.


COMPARISON OF EFFECTS OF CYRIAX PT , A SUPERVISED EXS. PROGRAM &

POLARISED POLYCHROMATIC NON -COHERENT LIGHT FOR RX OF LE

Clinical Rehab 2006 Dimitrios Stasinopoulos

AIM:To compare effectiveness of cyriax physiotherapy, a supervised exercise programme & polarized polychromatic non‐coherent light in treatment of LE.

Cont….


…COMPARISON OF EFFECTSOUTCOMES:Pain was evaluated using a VAS & function using VAS & pain free grip strength.

CONCLUSION:The supervised exercise programme should be 1sttreatment option for therapist when they manage LE patients. If this is not possible cyriaxphysiotherapy & polarized polychromatic non‐coherent light may be suitable.


SHOCK WAVE THERAPY FOR PATIENTS WITH LE OF ELBOW

Ching‐ Jen wang. Am J Sports Med 2000.

HYPOTHESIS:SWT is an effective treatment treatment for patients with LE of elbow & long‐ term results will be favorable as short‐term ones.

CONCLUSION:SWT is safe & effective modality in treatment of patients with LE of elbow.


NO EFFECT OF FOREARM BAND & EXTENSOR STRENGTHENING EXS

FOR RX OF LERolf luginbuhl Feb’08

AIM:To analyse the effect of forearm support band & of strengthening exercises for Rx of LE.

CONCLUSION:No beneficial influence was found either for strengthening exercise or for forearm support band. Improvement seems to occur with time, independent of method of treatment used.


…NO EFFECT OF FOREARMOUTCOMES:Pain was evaluated using a VAS & functionusing VAS & pain free grip strength.

CONCLUSION:The supervised exercise programme should be 1st

treatment option for therapist when they manage LE patients. If this is not possible cyriaxphysiotherapy & polarized polychromatic non‐coherent light may be suitable.


SHOCK WAVE THERAPY FOR PATIENTS WITH LE OF ELBOW

Ching‐ jen wang. Am J Sports Med 2000.

HYPOTHESIS:SWT is an effective treatment for patients with LE of elbow & long‐ term results will be favorable as short‐term ones.

CONCLUSION:

SWT is safe & effective modality in treatment of patients with LE of elbow.


NO EFFECT OF FOREARM BAND & EXTENSOR STRENGTHENING EXS

FOR RX OF LERolf luginbuhl Feb’08

AIM:To analyse the effect of forearm support band & of strengthening exercises for Rx of LE.

CONCLUSION:No beneficial influence was found either for strengthening exercise or for forearm support band. Improvement seems to occur with time, independent of method of treatment used.


AN EXS PROGRAMME FOR THE MX OF LE

British Journal of Sports Medicine 2005

D Stasinopoulos, K Stasinopoulou, M I JohnsonAIM:

To describe the use & effects of strengthening & stretching exercise programme’s in the treatmentof LET.

Cont…


AN EXS PROGRAMME FOR THE MX OF LE

Discussion:• A well designed trial is needed to study the effectiveness of a supervised exercise programme for LET consisting of eccentric a& static stretching exercises.

• The issues relating to the supervised exercise programme should be defined so that therapistscan replicate the programme.


EFFECTS OF LLLT & PLYOMETRICEXS IN Rx OF LE

Photomedicine & Laser Surgery. June 2007

Apostolos Stergioulas

Objective:This study was undertaken to compare the effectiveness of a protocol of combination of laser with plyometric exercises & a protocol of placebo laser with the same program, in the treatment of tennis elbow.


FFECTS OF LLLT & PLYOMETRIC EXS IN Rx OF LE

Conclusion:The results suggested that the combination of laser with plyometric exercises was moreeffective treatment than placebo laser withthe same Plyometricexercises at the end ofthe treatment as well asat the follow‐up.


A RCT OF EXTRACORPOREALSWT FOR LE

Margret P. Staples, Andrew ForbesJOURNAL OF RHEUMATOLOGY,2005

Objective:The aims of this double‐blind, randomized, placebo ‐ controlled trial were to determine whether US ‐guided extracorporeal SWT(ESWT) reduced pain & improved function in patients with LE in the short term & intermediate term.



Margret P. Staples, Andrew ForbesJOURNAL OF RHEUMATOLOGY, 2005

Objective:The aims of this double‐blind, randomized,placebo‐controlled trial were to determinewhether US‐guided extracorporeal SWT(ESWT)reduced pain & improved function in patientswith LE in the short term & intermediate term.



Conclusion:Our study found little evidence to support the useof ESWT for the treatment of lateral epicondylitis.


AN ISOKINETIC ECCENTRIC PROG. FOR Mx OF CHRONIC LE

British Journal of Sports Medicine, April 2007.Croisier, Jean‐Louis

Objective: To compare the outcome of patients performing an isokinetic eccentric training with that of age, gender, activity‐matched patients receiving a non‐strengthening classical rehabilitation.

Cont…By Saravanan Krishnan

AN ISOKINETIC ECCENTRIC PROG. FOR Mx OF CHRONIC LE

Conclusion: These results highlight therelevance of implementingisokinetic adapted eccentrictraining in the managementof chronic lateral epicondylartendinopathy


AN ALTERNATIVE APPROACH TO TREAT LE: A RANDOMIZED , PLACEBO-

CONTROLLED, DOUBLE – BLINDED STUDY

Clinical Rehab 2008Reza Nourbakhsh , Fearon

OBJECTIVE:To investigate the effect of noxious level ES on pain, grip strength & functional abilities in subjects with chronic LE.

DESIGN:Randomized, placebo – control, double‐blinded study.


AN ALTERNATIVE APPROACH TO TREAT LE: A RANDOMIZED , PLACEBO -

CONTROLLED, DOUBLE – BLINDED STUDYMAIN MEASUREMENTS:Grip strength, functional status, pain intensity & limited activity due to pain were assessed before & after treatment.

CONCLUSION:The results of this study indicated that symptoms of chronic LE could be effectively treated by noxious level low‐frequency ES.


lateral epicondylitis

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