Tennis elbow presentation.

1. TENNIS ELBOW
BY JHARANARANI PRADHAN

2. INTRODUCTION
 It is also known as “lateral epicondylitis ”.
 Tennis elbow is characterised by pain and tenderness at the
common origin of the extensor group of muscles of the forearm.
 It was described by RUNG in 1975 but the accepted one is CYRIAX.
 It occurs due to repetitive upper limb activity like heavy lifting,
awkward stroke during tennis.
 It is usually an over use injury in day to day activities of pulling,
lifting , pushing etc.

3. ANATOMY

4. ETIOLOGY
 Over use of muscle and tendon.
 Repetitive contraction.
 Maladaptation in tendon.
 Direct trauma can injured any structure and later on lead to tennis elbow.
 Degeneration starts after 30yr there by load carrying capacity gradually decreased.

5. PATHOMECHANICS
 3 structure are involved i.e. common extensor tendon, radiocapitular joint & as a
whole the elbow joint.
 Lateral capsular structure, periarticular structure, intra articular structure of
radiocapitular joint such as annular ligament, upper part of radius & lateral lower
part of humerus or capitulum, lateral collateral ligament are commonly affected.
 Pain can be due to 2 factor i.e. Direct inflammation i.e. traumatic tendinitis &
degenerative inflammation/ tendinosis of common extensor tendon.
 Poor circulation to the tissue because of any cause that give rise to
degenerative/inflammation changes and making the tissue avascular lead to early
degeneration followed by wear and tear and healing capacity is less

6.  Direct cumulative trauma disorder:
 It depends upon tissue energy attenuation capacity. It is the ability of the tissue to
observe the shock when it subjected to the stress.
 Load is inversely proportional to cycle or no. of repetition, that describe the
repetitive limit i.e. when the load with in the normal limit but the repetition is
increase lead to micro trauma. If the load is more, cycle is less then also lead to
trauma. If load is less &cycle is more then also lead to trauma, also both is
increased leads to micro trauma of muscle.
 In the players the tendon is subjected to the tensile stress and which aggravates
during the faulty pattern i.e. pattern with forearm pronation, elbow extension and
alternate wrist flexion and extension.
 In 2 factors, it is aggravated depending up on the conditioning of the structure.
1. If the structure in non conditioning i.e. inadequate power , endurance, flexibility of
common extensors to with stand the normal forceful repetitive movement.
2. If the structure are conditioned then the over activity, repeated activity, sudden/
unacustoms activity lead to trauma as well as improper equipment like too large or
too small grip size, tennis ball become more weight, improper weight of racket or
incorrect string pattern either tightly pad/ loosely attached can lead to trauma.

7. PATHOPHYSIOLOGY
 Inflammation occurs through 4 stages
1. Paratendinous inflammation.
2. Angiofibroblastic degeneration i.e. c/f by increased no. of fibroblast formation
following inflammation.
3. Fibrosis – Here healing occurs with the fibrous formation leading to adhesion of
tendon.
4. Calcification- There may be calcification of tendon which can’t be reverse back
definitely leads the surgery.

8. CLASSIFICATION
 BROADLY IT IS 2 TYPES
1. Intrinsic Tennis Elbow- Here the structure around inside the elbow get involved. It
may be of classical & non-classical variety.
• In classical variety, there is only involvement of extensor carpi radialis brevis
muscle.
• In non-classical, all intrinsic muscles/group extensor/tendinitis of all extensor
tendon group i.e. ED, ECRB, ECRL etc. there may be periostatic/periosteal
inflammation, involvement lateral epicondyle of humerus , may be LCL sprain ,
radiohumeral bursitis, degenerative changes of radiohumeral cartilage , annular
ligament sprain.
2. Extrinsic Tennis Elbow- There may be due to cervical radiculopathy mostly
compression of c5,c6 level, incase of due to periarthritis of shoulder, incase of
fibrostitis or myofacial pain syndrome of scapular muscles or incase of fibromyalgia.

9. ASSESSMENT
 DEMOGRAPHIC DATA-NAME
Age
Gender
Address
 OCCUPATION-computer use, labour, sports player etc.
 Chief complain- pain in ADL, swelling, weak grip, inflammation, not able to pronation.
 PAIN HISTORY
 ONSET OF PAIN-It may be sudden or gradual.
 SITE OF PAIN-Lateral epicondyle of humerus .
 INTENSITY OF PAIN- VAS(visual analogue scale) 0 _ _ _ _ _ _ _ _ _ _ 10
 NATURE OF PAIN-Dull aching pain.
 HISTORY OF PRESENT ILLNESS- muscular pain, sharp shooting , pain increase at activity or decrease at rest.
 activity leads to symptom-over use fingers
-pronation or supination
-elbow flexion/extension
relief at rest(no movement)

10.  PAST HISTORY
 TREATMENT HISTORY
 ENVIROMENTAL HISTORY
 OCCUPATIONAL HISTORY
 PHYSICAL EXAMINATION
 OBSERVATION- How the patient come to the department ?
Body built:- Endomorphic , Mesomorphic , Ectomorphic
Posture?
 INSPECTION-
Skin -warm ,glossy, shine
Soft tissue-Swelling
 NEUROMUSCULAR EVALUATION – Check the sensation , tone, reflex , strength , neural
tissue tension test etc
 Palpation for – soft tissue (swelling wasting scar ulcer )
 -skin ( temperature moistness or not etc. )

11. SPECIAL TESTS
 Selective tissue tension test
 Mille’s test
 Cozen’s test
 Functional Test:
 Dumbbell test: Provide 2kg of dumbbell & ask him to lift with the wrist in
extension.
 Chair test- provide around kg of plastic chair ask him to lift with the wrist in same
position.

13. AIM
 RELIEF OF SYMPTOM
 DECREASE PAIN AND INFLAMMATION
 FUNCTIONAL INTEGRATION OF BODY
 PREVENT RECCURENCE
 TO BREAK THE ADHESION

14. MANAGEMENT CONSERVATIVE
OPERATIVE

15. CONSERVATIVE MANAGEMENT
 IN CASE OF ACUTE go for ice intermittently 20 minutes for 3 times a day.
 Use IFT for pain reduction and to promote healing.
 Use the pulsed mode ultrasound, LASER, PSWD,HVPGS but should not apply over
periosteom
 SUBACUTE STAGE: gradual stretching and strengthening.
 After 1 week go for active movement with over pressure OR passive movt with over
pressure.
 CHRONIC STAGE: Break the adhesion by MAITLAND Mobilisation i.e passive
mobilisation and manipulation.
 Maitland caudal distraction with elbow flex to 90° with the movt.i.e forearm pronation
and supination.
 DTFM
 Kneeding with active streaching is needed in case of trigger point palpation.
 MILL’S manipulation and CYRIAX manipulation is also can be given.
 FUNCTIONAL TRAINING

16.  CONSERVATIVE TREATMENT:
• Treatment consist of rest and try to avoid movement that cause pain.
• Nonsteroidal anti-inflammatory drugs(NSAID) and tennis elbow splint are use for
pain relief.
• Local injection of hydrocortisone acetate with local anaesthetic solution relieves
pain in majority cases.

17. SURGICAL
 The extensor muscles are strip from the origin and allow to fall back.
 On above elbow slab with the elbow in 90 in flexion is apply for a period of t
bandage.
 Post operatively the elbow is mobilised.

18.  THANK YOU
THANK YOU