The document presents an overview of elbow epicondylitis, detailing its definition, etiology, risk factors, clinical presentations, and treatment options for both lateral (tennis elbow) and medial (golfer's elbow) epicondylitis. It emphasizes that lateral epicondylitis is a common overuse syndrome often affecting adults aged 35-50, where repetitive microtrauma leads to pain in the extensor muscles of the forearm. Treatment approaches include conservative methods like physical therapy, activity modifications, and in some cases, surgical options after conservative measures fail.

1. Elbow Epicondylitis
By
Dina Othman Shokri

2. Objectives:
By the end of this lecture, the student should be able to:
❑ Memorize definition, etiology and risk factors for lateral
epicondylitis.
❑ Recognize and understand the tennis elbow provocative test and
its clinical presentation.
❑ Recognize and understand treatment of lateral epicondylitis.
❑ Memorize definition , etiology, clinical presentation and
treatment for medial epicondylitis.

3. Lateral Epicondylitis, also known as "Tennis Elbow", and lately proposed as
Lateral Elbow (or Epicondyle) Tendinopathy (LET) is the most common
overuse syndrome in the elbow. As the last description implies, LE is usually
not an inflammatory condition. It is a tendinopathy (tendinosis and tendon
degeneration) injury involving the extensor muscles of the forearm, Which
originated from the lateral epicondylar of the distal humerus. Contractile
overloads that chronically stress the tendon near the attachment on
the humerus are the primary cause of epicondylitis. it should be
remembered that only 5% to 10% of people suffering from tennis elbow relate
the injury to tennis. Lateral epicondylitis generally occurs in adults between
the ages of 35-50. It affects between 1%-3% of the population. Lateral
epicondylitis is equally common in both sexes, obtaining of the condition at
the both lateral epicondyle is rare.
Lateral Epicondylitis

4. The dominant arm has the greatest chance of the occurrence of lateral
epicondylitis, twenty percent of cases persist for more than a year.
It occurs with repetitive microtrauma that results from either concentric or
eccentric overload of the wrist extensors. It is a lesion affecting the tendinous
origin of the wrist extensor (common extensor origin at lateral epicondyle).
primarily the extensor carpi radialis brevis (ECRB) being the most affected
muscle. The supinator and other wrist extensor muscles including, the
extensor carpi radialis longus, extensor digitorum, extensor digiti minimi, and
extensor carpi ulnaris can also be involved. The extensor carpi radialis brevis
(ECRB) muscle has a small origin, helps stabilize the wrist when the elbow is
straight.

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It is stretched over radial head when the elbow is extended and fully
pronated. This fulcrum effect may partially explain its susceptibility to chronic
inflammation at or near its attachment. In addition, The ECRB is under greatest
strain when its fibers contract whilst in forearm pronation coupled with wrist
flexion and ulnar deviation while the elbow extended.
Tennis elbow 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, training errors, heavy raquets, inappropriate grip
size, high string tension, poor technique, misalignments, flexibility problems,
aging, poor circulation, strength deficits or muscle imbalance and psychological
factors.

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Etiology:
1-Direct blow to the lateral epicondyle, or a sudden extreme effort or activity.
2-Overuse: Any activity causing repeated, gradual stresses to the wrist extensors,
primarily the ECRB can lead to the acute or chronic overuse syndrome. This
injury is often work-related, any activity involving wrist extension, pronation or
supination during manual labour, housework and hobbies are considered as
important causal factors. Athletes are not the only people who get tennis elbow.
Many people with tennis elbow participate in work or recreational activities that
require repetitive and vigorous use of the forearm muscle. Painters, plumbers,
and carpenters are particularly prone to developing tennis elbow.
There are several opinions concerning the cause of lateral epicondylitis:
1.Inflammation
2. Microscopic tearing
3. Degenerative Process
4. Hypovascularity

7. Location of pain in lateral
epicondylitis.
Clinical presentation
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 (anterior and distal to it).The pain can radiate upwards along the
upper arm and downwards along the outside of the forearm. Onset is usually
gradual and is related to increase activity of the wrist extensor. Dull
aching at rest, which may converted to sharp pain during activity, morning
stiffness, occasional night pain.

8. o Pain w/active or resisted wrist extension.
o Pain w/ grasping objects with the effected hand
o Pain and/or decreased movement on passive elbow extension, wrist flexion
and ulnar deviation and pronation.
o Dropping of objects/ weak grip strength or difficulty carrying objects in
the hand, especially with the elbow extended.
o Flexibility and strength in the wrist extensor and posterior shoulder
muscles are deficient.
o An evaluation of the entire upper extremity kinetic chain can be needed. A
particular focus goes to the shoulder and the scapular strength, motion
and stabilization. Overuse injuries in the elbow often occur with shoulder
or scapular dysfunction

9. Cozen’s test is also known as the resisted wrist extension test. The
elbow is extended or 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 with
fisted hand is asked to resist wrist extension. The test is positive if the
patient experiences a sharp, sudden, severe pain over the lateral
epicondyle.
9
Tennis elbow provocative tests

10. Mill’s Tennis Elbow Test: Positive test when sharp lateral epicondyle pain is
elicited during passive extension of the elbow while the forearm is
pronated and wrist flexed. This test stretch the tendon.
Maudsley (Resisted middle finger extension) test: A positive test is pain
with resisted middle finger. It May elicit pain due to the extensor digitorum
sharing a common tendon with the ECRB. It indicate affection of the extensor
digitorum communis.

11. Chair lift test: The patient grasps the back of the chair while standing
behind it and attempts to lift the chair by using a three finger pinch
(thumb, index, long fingers) and the elbow fully extended. The test is
positive when pain occurs at the lateral epicondyle.
The coffee cup test : The test is performed 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.

12. Diagnosis
Medical history and the physical exam provide enough information to make a
diagnosis of tennis elbow.
Ultrasound examination may be used in the investigation of patients with
lateral elbow pain to demonstrate the degree of tendon damage as well as the
presence of a bursa.
In longstanding cases, plain X-ray (AP and lateral views) of the elbow may
be taken to rule out arthritis of the elbow. Calcification along the lateral
epicondyle, osteochondritis dissecans, degenerative joint changes or
evidence of heterotopic calcification are among the common findings
Electromyography (EMG) may be 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.
MRI may also show thickening, hypoechogenicity or defects in the tendo-
osseous enthesis in the case of LET, but the presence of these findings
should be interpreted with caution when directing clinical decisions.

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-Anti inflammatory medication (NSAIDs in the acute cases)
-Injections of cortisone.
-Autologous blood injection: May trigger the inflammatory cascade and initiate
healing.
-Injection of blood products :Platelet Rich Plasma (PRP). Slightly similar to the
ABI but in this method blood is placed in a centrifuge, platelets are then
selectively removed and used for injection. Platelets play a significant role in
the repair and regeneration of connective tissue.
Treatments

14. Surgery: Option ONLY after 6 to 12 months of conservative, Excision of
abnormal tissue within the CETO, release and/or reattachment of the tendon
via open or arthroscopic surgery .
Goal of physical therapy:
o During the acute stage.
-Decreased pain and inflammation,
-Promote tissue healing,
-Maintain flexibility and ROM
-Retard muscle atrophy
o During chronic stage.
-Improve flexibility
-increase the muscular strength and endurance and increase functional
activities and return to function.

15. Physiotherapy Management
❖ PRICE to control the inflammatory condition
Protection via Braces/Splints/Straps
Wrist cock-up splint may be used to decrease stress to the tendon, If the patient
presents with acute symptoms immobilizing the wrist, hand, and fingers (not the
elbow) in a resting splint, since this obviates the need for the wrist extensors to
contract when the finger flexors are used.
Counter- force brace also called arm band or epicondylar splint, its concept, limit
full muscular expansion ,and reduces the contraction force of the muscle. It applied
distal to ECRB origin. Provides a compressive force and creates a secondary origin
of the extensor tendons, thus unloading the true origin at the lateral epicondyle.
Counter-forcebrace

16. wrist cock-up splint
Rest. The first step toward recovery is to give your arm proper rest. This
means that you will have to stop participation in sports or heavy work
activities for several weeks.
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 by vasoconstriction, which reduces the swelling.
Elevation of the extremity is also indicated if an oedema of the wrist or
fingers is present

17. ❖ Kinesio tape: Applied on a pronated arm, with wrist flexed. Not stretching
the tape, apply from the insertion to origin of ECRB.
Diamond taping method by rigid tape may be useful for reducing pain and
improving grip strength and functional performance

18. ❖ Education/Advice-Educating patient regarding their injury, pain control
and/or modification of activities, Other lifestyle changes to reduce
aggravating activities, ergonomic counseling.
❖ Activity modifications: Example of activity modifications, Avoid lifting
with palm turn down. Hand turned up is better. Hand grasping while in
supination, Avoid pronation motions
Avoid lifting with a straight elbow, maintain a bent elbow and keep item
close to body when lifting.

19. Efforts should be made to educate tennis players on techniques for
correctly executing a backhand in tennis. It is often observed that a tennis
player will use two hands to prevent overload to the wrist extensors. If a
second hand isn’t used as support and the arm is straight, the loading on the
extensor tendon when the ball impacts the racquet can be very high. An
alternative is to execute the shot with a flexed elbow where possible, to
reduce this impact loading
Incorrect backhand technique in tennis

20. ❖ Equipment check. If you participate in a racquet sport, checking your
equipment for proper fit. Stiffer and looser strung racquets often can
reduce the stress on the forearm. which means that the forearm muscles do
not have to work as hard. If you use an oversized racquet, changing to a
smaller head may help prevent symptoms from recurring.
Selecting the correct tennis racquet grip size

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❖ Modalities: Electrical and thermal modalities, US iontophoresis or
phonophoresis, laser.
Shockwave Therapy is a method of treatment for multiple tendonopathies
that can be used for the treatment of lateral epicondylitis. ESTW is a treatment
technique in which patients are exposed to a strong mechanical wave impulses
which can be used on a fairly accurate position. These waves create
“microtrauma” that promote the body’s natural healing processes.

22. ❖ Manual therapy
Myofascial release: Fascial restrictions undue tension in the other parts of
the body due to fascial continuity.
Deep friction massage. Palpate the scar, then apply pressure and cross fiber
massage, increase of intensity of massage as inflammation decrease.

23. Evidence exists demonstrating that joint manipulation directed at the elbow
and wrist as well as at the cervical and thoracic spinal regions results in
clinical alterations in pain and the motor system. While the true physiological
effects of manipulative therapy may not yet be clearly elucidated, it is
tempting to speculate on the physiological rationale as to why patients with
LE respond favorably to such techniques directed at different anatomical
regions. First, it is speculated that the pain associated with LE might be
associated with altered neuronal afferent input to the spine. Perhaps applying
manipulation techniques to the elbow, wrist, and cervicothoracic spine may
assist in reducing abnormal afferent input, resulting in a reduction of the
symptoms associated with LE.

24. Cervicothoracic joint mobilization: Recent research regarding cervicothoracic
joint mobilization/manipulation in conjunction with local treatment for lateral
epicondylalgia has shown improvements in strength, pain, and tolerance to activity
compared to local treatment alone.
Mulligan - Mobilisation with movement
Postero-anterior glide of the radial head

25. ❖ Exercise therapy: Mobility, strength and endurance should be improved
by exercises once the pain and inflammation are under control.
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,
according to the patient’s tolerance.
Use agonist contraction, hold relax, and passive stretching to elongate the
tight muscle to the end of its range. Mobilization and stretching should be in
pain free ranges.

26. ❖ Strengthening exercises: Low intensity isometric exercises at first, begin
with gentle isometric contractions with the wrist extensors in the shorted
position. At first with elbow flexed, forearm pronated and resting on table,
and the wrist in extension then move the wrist toward flexion. when full
wrist flexion is obtained without pain in the lateral epicondyle, progress
by placing the elbow in greater degrees of extension and repeat the
isometric contraction to wrist extensor. Progress the exercises to using
free weights and elastic resistance through pain free ranges (Concentric
and eccentric exercises).

27. ❖ Eccentric exercises: Therapeutic eccentric exercise (TEE) has been found
to be an effective intervention for a variety of tendinopathies. Eccentric
exercise effectively “lengthened” the muscle-tendon complex resulting
in structural remodeling of the tendon with hypertrophy and
increased tensile strength of the tendon, increase fibroblast activity. It
can be done by thera band, flexbar or free weight.
Sample eccentric exercises for tennis elbow

28. Flexbar® Exercises
A. Hold FlexBar® in involved (right) hand in
maximum wrist extension
B. Grab other end of FlexBar® with uninvolved (left)
hand
C. Twist FlexBar® with noninvolved wrist while
holding the involved wrist in extension
D. Bring arms in front of body with elbows in
extension while maintaining twist in FlexBar® by
holding with noninvolved wrist in full flexion and the
involved wrist in full extension
E. Slowly allow FlexBar® to ‘untwist’ by allowing
involved wrist to move into flexion (eccentric
contraction of the involved wrist extensors).
Eccentric exercise using a bucket
with water (allowing for
adjustable resistance)

29. ❖ Cyriax Physiotherapy: It’s a very common intervention that combines
the use of deep transverse friction (DTF) with Mill’s manipulations,
which was used with success by Cyriax for treating lateral epicondylitis.
Both the treatment components mentioned above must be used jointly in
the sequence specified. Patient must follow the protocol three times a
week for four weeks. There are several contraindications regard to this
therapy: active infections, bursitis, disorders of the nerve structures,
ossification and calcification of the soft tissues, active rheumatoid
arthritis, anticoagulant.
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.

30. Mills Mobilization: Mills manipulation is not a class of manipulation
target hypomobile joint or joint capsule but it is soft tissue
manipulation target the tendon origin of the common extensor
tendon. 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. This manipulation must only be performed if a fully pain-free
elbow extension can be achieved, and with a properly technique.
Patient seated with the affected extremity in 90° abduction and internal
rotation (olecranon faced up).Therapist stands behind the patient,
stabilized the patient’s wrist in full pronation and flexion, while the
other hand is placed on the olecranon. The maintenance of full wrist
flexion is important.

31. The high-velocity low amplitude (HVLA) thrust at the end range of elbow
extension, is a quick movement in the direction illustrated. This manipulation
may produce mild discomfort at the instant of its performance. The clinician
applies this procedure a 2-3 times a week until cure, with a range of 4-12
sessions.

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Medial epicondylitis/ Golfer’s elbow
Medial epicondylitis (golfer’s elbow, racquetball elbow, medial tennis
elbow). It is pathologic condition of the common flexor tendon at the medial
epicondyle. Generally occurs as a result of repetitive micro trauma to the
pronator teres and the flexor carpi radialis muscles during pronation and
flexion of the wrist. There is tenderness at the medial epicondyle, and pain is
exacerbated with resisted pronation, resisted flexion of the wrist, or
passive extension of the wrist with the elbow extended. Medial
epicondylitis has a lower incidence than lateral epicondylitis. Epicondylitis
occurs at least five times more often and predominantly occurs on the lateral
rather than on the medial aspect of the joint, with a 4:1 to 7:1 ratio.

33. Etiology
Over use syndrome related to repetitive valgus stress along with
pronation and wrist flexion. Because chronic repetitive concentric or
eccentric contractile loading of the wrist flexors and pronator are the most
common etiology. Occupations such as carpentry, plumbing and meat cutting
have also been implicated. The pathology may also be produced by sudden
violence to these tendons in a single traumatic event. In many cases trauma
at work had been identified as the cause of the symptoms.

34. Clinical presentation
The patient usually complains about pain of the elbow distal to the medial
epicondyle of the humerus with radiation up and down the arm, most
common on the ulnar side of the forearm, the wrist and occasionally in the
finger.
The pain is evoked by resisted flexion of the wrist and by pronation. The
pain is usually accompanied by a weakness of hand grip. Pain can begin
suddenly or can develop gradually over time. In severe cases of
epicondylitis, the patient will complain of pain when he simply shakes
hands or pulls an open door. Tenderness to palpation (usually over
pronator teres and flexor carpi radialis)
Local swelling and warmth
Range of motion in the beginning of the disease can be full, but later on
there is a possibility of a decreased range of motion.

35. -An evaluation of the entire upper extremity kinetic chain can be needed. A
particular focus goes to the shoulder and the scapular strength, motion and
stabilization. Overuse injuries in the elbow often occur with shoulder or scapular
dysfunction.
- Medial epicondylitis test: It includes a passive and an active test to determine
medial epicondylitis.
For the passive test, the therapist extends the wrist with the elbow extended.
For the active resistance test, the patient should resist wrist flexion. This must be
carried out with elbow extended while fully supinating the forearm.
Golfer’s elbow test: The patient contracts the wrist flexors isometrically as
strongly as possible against resistance. A positive test is indicated by reproduction
of pain over the medial aspect of the elbow.

36. Count’R-Force Medial Elbow Brace
Similar to that outlined for lateral epicondylitis with the difference in the
affected muscles(pronator teres and the flexor carpi radialis) .
Treatment

37. Thanks