Lateral epicondylitis, commonly known as tennis elbow, is a painful condition caused by overuse and microtears of the tendons that connect the forearm muscles to the lateral epicondyle of the humerus. The condition results in pain at the outside of the elbow. Conservative treatments include activity modification, bracing, stretching, strengthening exercises, and shock wave therapy. Surgical intervention is considered if conservative treatments fail to provide relief after 6 months.

1. Lateral Epicondylitis
Rajesh Periyakaruppan
25/04/2012

2. What is Lateral Epicondylitis (tennis
elbow)
• Lateral Epicondylitis is a common clinical entity
characterized by pain and tenderness at the common
origin of the extensor group muscles of the
forearm,usually as a result of a specific strain, overuse,
or a direct bang.It is considered a cumulative trauma
injury that occurs over time from repeated use of the
muscles of the arm and forearm, leading to small tears
of the tendons (Tendonitis).
• The condition that is commonly associated with playing
tennis and other racket sports, though the injury can
happen to almost anybody

3. Pathophysiology of Lateral
Epicondylitis
• The tendinous origin of extensor carpi radialis
brevis (ECRB) is the area of most pathologic
changes. Changes can also be found at
musculotendinous structures of the extensor
carpi radialis longus, extensor carpi
ulnaris and extensor digitorum communis.
Overuse and repetitive trauma in this area causes
fibrosis and micro tears in the involved tissues.
Nirschl referred to the micro tears and the
vascular in growth of the involved tissues
as angiofibroblastic hyperplasia.

4. • A tear occurs at the teno-muscular junction, in the
tendon, or at the teno-periosteal junction. The
resulting inflammation produces exudate in which
fibrin forms to heal the torn tissue.Repeated activity
causes microtrauma, with subsequent granulation
tissue formation on the underside of the tendon unit
and at the teno-periosteal junction. The granulation
tissue formed appears to contain large number of free
nerve endings, hence the pain of the condition. The
major problem is that the granulation tissue does not
progress quickly to a mature form, and so healing fails
to take place, almost a type oftendinous 'nonunion'.

5. • The most common cause of Lateral Epicondylitis in tennis players is
a 'late' mechanically poor backhand, that places excess force across
the extensor wad, that is, the elbow leads the arm. Other
contributing factors include incorrect grip size,string tension, poor
racket dampening, and underlying weak muscles of the
shoulder,elbow and arm.Tennis grips that are too small often
exacerbate or cause tennis elbow.
• Often a history of repetitive flexion-extension or pronation-supination
activity and overuse is obtained (eg.,twisting a screw
driver, lifting heavy luggage with the palm down). Tightly gripping a
heavy briefcase is a very common cause.Raking leaves, baseball,
golfing, gardening, and bowling can also cause Lateral Epicondylitis.
Less commonly,tendonitis is simply a result of single acute injury.

6. Clinical Presentation
• At first, the athlete may be aware of only fatigue
and spasm of dorsal forearm muscles related to
unaccustomed activity. Then they may note the
onset of aching lateral elbow pain after playing.
Eventually the pain may become so constant and
severe so as to stop the athlete from further
playing and to interfere with activities of daily
living, such as carrying a briefcase, wringing wet
clothes or even holding a cup of tea. Grip
becomes weak.Morning stiffness may be felt

7. Physical Examination
• -Point tenderness over or just distal to the lateral humeral
epicondyle (the bony attachment of the common extensor
tendon) which gives rise to burning sensation when
pressure is applied.
• -Tenderness over muscles of dorsal forearm.
• -Pain with resisted wrist extension, finger extension and
resisted radial deviation.
• -Pain with passive stretching of wrist extensors.
• -With long standing symptoms, there is likely to be
considerable atrophy and weakness of extensor muscles
and limitation of passive wrist flexion. Accessory
movements of the elbow and superior radio-ulnar joint
may be reduced in along term problem.

8. Special tests for Lateral Epicondylitis
• 1)Cozen's test- The patient's elbow is stabilized by the examiner's
thumb, which rests on the patient's lateral epicondyle. The patient
is then asked to make a fist, pronate the forearm and radially
deviate and extend the wrist while the examiner resists the motion.
A positive sign is indicated by sudden severe pain in the area of
lateral epicondyle of the humerus.
• 2)Mill's test-While palpating the lateral epicondyle, the examiner
pronates the patient's forearm, and flexes the wrist fully and
extends the elbow. A positive test is indicated by pain over the
lateral epicondyle of humerus.
• 3)Maudsley's test- The examiner resists extension of the 3rd digit
of the hand, stressing the extensor digitorum muscle and tendon. A
positive test is indicated by pain over the lateral epicondyle of the
humerus.

9. Differential Diagnosis
• -Evaluation should note possible sensory paresthesias in
the superficial radial nerve distribution to rule out Radial
tunnel syndrome.It is the most common cause of refractory
lateral pain and coexists with Lateral Epicondylitis in 10% of
the patients.
• -The cervical nerve roots should be examined to rule
out cervical radiculopathy.
• -Other conditions that should be considered include
bursitis of the bursa below the conjoined tendon, chronic
irritation of the radiohumeral joint or capsule,
radiocapitellar chondromalacia or arthritis, radial neck
fracture, panner's disease, little league elbow and
osteochondritis dissecans of the elbow.

10. Investigations
• X-rays are not necessary. Rarely, magnetic
resonance imaging (MRI) scans may be used to
show changes in the tendon at the site of
attachment onto the bone. MRI typically shows
fluid in the ECRB origin. There may also be a
defect in this tissue. The use of the word "tear" to
refer to this defect can be misleading. The word
"tear" implies injury and the need for repair--
both of which are probably inaccurate and
inappropriate for this degenerative enthesopathy.

11. Treatments currently used for tennis
elbow
•
1. Conservative bracing
2. Eccentric strengthening exercises
3. Dry needling / acupuncture
4. Nitrate patches
5. Shock wave treatment
6. Cortisone injections
7. Platelet Rich Plasma Injections
8. Surgery

12. Conservative treatment of Lateral
Epicondylitis
• Activity Modification
• -In non-athletes, elimination of activities that are painful is key to
improvement (eg., repetitive valve opening).
• -Treatment such as ice and NSAIDs may lessen the inflammation,
but continued repetition of the aggravating motion will prolong any
recovery.
• -Often repetitive pronation-supination motions and lifting heavy
weights at work can be modified or eliminated. Activity
modifications such as avoidance of grasping in pronation and
substituting controlled supination lifting instead may relieve
symptoms.
• -Lifting should be done with the palm up whenever possible, and
both upper extremities should be used in a manner that reduces
forcible elbow extension, supination and wrist extension.

13. Correction of mechanics
• If a late poor backhand causes pain, correction of
mechanics of the game is warranted.Avoidance of ball
impact that lacks a forward body weight transference is
stressed.
• -If typing with unsupported arms exacerbates the pain,
placing the elbows on stalked towels for support will
help.
• -Calculation of grip-The distance from the proximal
palmar crease to the tip of the middle finger determine
the proper grip size.The figure obtained represents the
circumference of the racket handl

14. Stretching
• ROM of exercises emphasizing end-range and passive stretching
(elbow in full extension and wrist in flexion with slight ulnar
deviation).
• Forearm extensor stretch may be performed with the athlete facing
the wall.The dorsum of the hand is placed on the wall, and the
elbow remains locked. By leaning forward the wrist is forced into 90
degree of flexion,stretching the posterior forearm tissues.
• Wrist flexion may be combined with a pronation stretch.Keeping
the elbow locked, the forearm is maximally pronated and wrist
flexed.Overpressure is applied by other hand and static stretch is
performed.
• The scar tissue is more pliable when warm. So stretching exercises
can be given after some superficial heating modality

15. Counterforce Bracing
• Brace is used only during actual play or aggravating
activity. The tension is adjusted to comfort while the
muscles are relaxed so that maximal contraction of the
finger and wrist extensors is inhibited by the band. The
band is placed 2 finger breadths distal to the painful
area of the lateral epicondyle.
• Some authors recommend 6-8 weeks use of a wrist
splint positioned at 45 degree of dorsiflexion.
• Range of Motion Exercises
• Exercises emphasize end-range and passive stretching
(elbow in full extension and wrist in flexion with slight
ulnar deviation).

16. Strengthening exercises for Lateral
Epicondylitis
• A gentle strengthening program should be used for grip strength, wrist
extensors, wrist flexors, biceps, triceps, and rotator cuff strengthening.
• However,the acute inflammatory phase must have resolved first, with
two weeks of no pain before initiation of graduated strengthening
exercises.Development of symptoms (pain) modifies the exercise
progression, with a lower level of intensity and more icing if pain recurs.
• The exercise program includes-
• -Active motion and submaximal isometrics.
• -Isotonic eccentric hand exercises with graduated weights not to exceed 5
pounds.
• -Theraband extension is performed with athlete sitting.One end of the
band is placed under the foot and the other end is gripped.
• -Wrist curls-Sit with the hand over the knee.With palm up, bend the wrist
10 times holding a 1-2 pound weight.Increase to two sets of 10 daily; then
increase the weight by 1 pound upto 5-6 pounds. Repeat this with palm
down, but progress to only 4 pounds.

17. Forearm strengthening
• Hold the arm out in front of the body, palm
down. The patient clenches the fingers, bends the
wrist up, and holds it tight for 10 seconds. Next
with the other hand, the patient attempts to
push the hand down. Hold for 10 seconds, 5
repetitions, slowly increasing to 20 repetitions 2-
3 times a day.
• -Elbow flexion and extension exercises.
• -Squeeze a sponge ball repetitively for forearm
and hand strength.

18. Mobilization with movement (MWM)
• In this a sustained mobilization is applied to a
joint. The mobilization is applied at the same
time the patient performs a painful action with
the affected joint (extension of wrist).
• -Progress strength, flexibility, and endurance in a
graduated fashion with slow-velocity exercises
involving application of gradually increasing
resistance. Later on upper limb plyometrics,
closed chain activities and sport specific activities
are done.