Tennis Elbow

Lateral Epicondylitis (Tennis Elbow)

 

Definition

Pain over the lateral aspect of the elbow that is aggravated by movement of the wrist, by direct palpation over the lateral epicondyle and by contraction of the extensor muscles of the wrist (Struijs et al, 2003)

‘The cardinal physical signs of lateral epicondylitis are pain to direct palpation over the lateral epicondyle and reproduction of pain and weakness during grip strength testing’ (Vicenzino,2003)

Epidemiology

1-3% general population affected by tennis elbow (vicenzino, 2003)

4-7% per year in general practice is tennis elbow (Hamilton,1986)

Equal prevalence in both genders but it lasts longer and is more severe is females ( Vicenzino & Wright 1995)

5% risk in populations who perform repetitive manual tasks (Chiang et al,1993)

Aetiology (Causes)

Degenerative changes of the tendon over time usually through repetitive overload, with insufficient recovery time

Repetitive movement of the wrist occupation related injuries (Stratford et al,1993; Vicenzino et al,1996,1998)

Common in repetitive gripping and typing occupations esspecially

What actually happens in the tendon and is it as simple as that?

Fibroblasts proliferation, which causes disorganised collagen to be laid down, which restricts the tissue flexibility and strength (Khan et al,2000)

Vascular hyperplasia

Lack of inflammatory markers, therefore not an inflammatory problem! (Ljung et al,1999; Alfredson et al,2000)

Secondary hyperalgesia (increased pain sensitivity) (Wright et al,1994)

Grip strength weakness (Vicenzino & Wright 1995)

Motor dysfunction (Kelley et al,1994)

ALSO:

Cervical spine involvement (Gunn and Milbrandt,1976)

Upper limb neural involvement (Yaxley and Jull,1993)

So it's not necessarily all about the tendon itself!!! 

3rd most complex MSK disorder to treat after Frozen Shoulder and Plantar Fasciitis          

This is because: 

Misdiagnosis is common

Difficulty addressing all contributing factors  (work, sport, hobbies)      

Often left and therefore seen in chronic stages, at this point there are lots of irreversible changes in the tissues and the nervous system. along with poor postural and movement habits that are harder to alter

Central changes in chronic pain (chronic regional pain syndrome)

Secondary injuries through compensation

Bio psychosocial issues due to work relationship with the injury (Poltawski, Watson & Byrne 2008)

Evidence Based Management

Acupuncture: short term benefit

Steroid injection: Short term benefit

Orthotic therapy: Epi clasps can give some relief while performing gripping activities

Non steroidal anti-inflammatories (NSAID’s): Injection may be more effective than oral steroids in short term. Some support for use of topical steroids in short term

Surgery: last resort

Exercise therapy: Short low load exercises (eccentric or concentric) decreased pain

Deep transverse frictional massage: limited evidence

Mobilisation with movement (MWM): Sustained Lateral glide with pain free grip is very effective in the long and short term with pain, and function

Cervical Lateral Glide: significant improvement in pain

Taping: limited evidence currently

Conclusions

Evidence base is weak for all medical and therapeutic interventions

Steroid injection may be beneficial in first 2-6 weeks

Acupuncture may be helpful in first 2 days

Exercise is effective

MWM’s strong evidence for significant, immediate pain relief and restoration of function

But a combination of approaches is even more effective

So if you suspect that you have tennis elbow then book in to see a Physiotherapist to get a firm diagnosis, treatment and the correct advice and exercises.