Post graduate lecture series for orthopaedics

1. TENNIS
ELBOW
BY ATANU KAYAL
JR dept of ORTHOPAEDICS,
BMC&H

2. WHAT IS TENNIS
ELBOW(LATERA
L
EPICONDYLITIS)
?
Tennis elbow describe myriad symptoms around lateral
aspect of elbow.
Localizing discomfort to the origin of extensor carpi radialis
brevis.
Occurs during activities that require repetitive supination
and pronation of forearm with the elbow in near full
extension.
Tennis elbow occurs more frequently in nonathletes than
athletes.
Peak incidence in early fifth decade with nearly equal
gender.

3. Lateral epicondylitis
RUNGE first describe d the clinical entity in 1873.
Although originally describe as an inflammatory
process actually lateral epicondylitis is initiated as
a microtear , of ECRB.
Microscopic findings shows
ANGIOFIBROBLASTIC HYPERPLASIA.
The pathologic process mainly involves the origin
of ECRB But can involve tendon of ECRL AND
extensor digitorum Communis.

4. CLINICAL DIAGNOSIS
• Diagnosis is made by localizing discomfort to the origin of
ECRB.
• Tenderness typically present over lateral epicondyle
approximately 5 mm distal and anterior to the midpoint of
condyle.
• Pain usually exacerbated by resisted wrist dorsiflexion and
forearm supination and pain when grasping objects.
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5. Clinical test
• COZENS TEST also known as resisted wrist extension test or resistive tennis elbow
test.
• The patient should be seated, with the elbow extended forearm maximal pronation,
wrist radially abducted, and hand in a fist and The doctor should stabilize elbow while
palpating lateral epicondyle, other hand placed on the dorsum of the hand.
• The patient is asked to move the wrist to dorsal flexion and the doctor provides
resistance to this movement,
• The test is said to be positive if a resisted wrist extension triggers pain to the
lateral aspect of elbow.

6. IMAGING
PLAIN
RADIOGRAPHS
usually are negative
occasionally CALCIFIC
TENDONITIS may be
present.
MRI shows tendon
thickening with T1 and
T2 signal intensity

7. Clic
k to
It is a compressive neuropathy of posterior interosseous nerve caused
by any of four different anatomical structures in the radial tunnel
Fibrous band
near the anterior
aspect of radial
head
Avascular
leash of recurrent
radial artery
Distal ECRB tendon
margin
The supinator
margin at the
arcade of Frohse.
Others entities can also produce pain in this general vicinity out of which
most common is RADIAL TUNNEL SYNDROME. The pain of radial
tunnel syndrome is located 3 to 4 cm distal to the lateral epicondyle and
reproduced with long finger extension against resistance.
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8. TREATMENT of tennis elbow
• NONOPERATIVE treatment
• Nonoperative treatment is successful in 95% patients.
• Initial nonoperative treatment includes...REST, ICE, INJECTIONS OF
STEROID,PHYSICAL THERAPHY with ultrasounds, stretching and
strengthening exercise and COUNTERFORCE BRACING and Extra
corporal shock wave therapy(ECSWT)
• PRP injections more effective than corticosteroid injections in
relieving pain and improve function but some studies found
that autologous blood injections were more successful than PRP.
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9. SURGICAL TREATMENT
• IF non operative treatment ineffective more than 6 to 12
months, operative treatment may be considered.
• Percutaneous lateral release has been reported to be
effective as open release.
• Arthroscopic release also equally effective as open
procedures.

10. NIRSCHL, MODIFIED
TECHNIQUE
for correction of tennis
Elbow
Close Close ECRL AND EDC interval with absorbable suture .
Excise Excise abnormal appearing tendon and decorticate a small area of lateral
epicondyle with a osteotome.
Elevate Elevate the brevis portion of conjoint tendon at midportion of lateral
epicondyle.
Identify Identify the ECRL and EDC which partially obscure the origin of deeper
ECRB.
Incise Incise deep fascia and retract it
Make Make a curve incision 5 cm long centered over lateral epicondyle.

11. Postoperative care
Splint is removed within first week of surgery and range of motion
exercise are begun.
After 10 to 14 days therapy is continued...strengthening exercise
given for 3 months.
The rehabilitation protocol is goal dependent with patient passing
from one phase to next after certain goal have been met.

12. REHABILITATION
PROTOCOL for
EPICONDYLITIS
ACUTE PHASE..1
GOAL: reduce inflammation and pain and promote
tissue healing
TREATMENT REGIMEN: cryotherapy, wrist flexion
and extension, elbow flexion and extension . forearm
supination and pronation with friction massage .
Avoid painful movement eg: gripping

13. Phase …..
SUBACUTE..2 .goal
Improve flexibility, increase muscular strength
Increase functional activities.
Continue all previous therapy along with emphasize on
concentric and eccentric strengthening, cryotherapy.
Gradually reintroduce previously painful movements.
PHASE 3..CHRONIC
Increase muscular strength and endurance maintain and
enhance flexibility.
Gradually return patient to sport or high level activities

14. Thank you