Clinical Deep Dive - Lateral Epicondylalgia (Tennis Elbow)

Joseph Smith
1 day ago
3 min read

Joseph Smith

Sports Physiotherapist – MOVE Sports Physiotherapy & Pilates Geelong

Anatomy of Lateral Epicondylalgia (Tennis Elbow)

The muscles most commonly involved in Lateral Epicondylalgia (Tennis Elbow) are extensor carpi radialis brevis as well as extensor digitorum extensor carpi radialis longus and extensor carpi ulnaris. The primary function of the wrist extensors is to stabilise the wrist, to allow maximum hand function. They also play a minor role of aiding in stability at the elbow.

Pathophysiology

There is a hypercellularity found at the tendon in addition to a disorganisation in healing and changes in extracellular matrix, we observe an ingrowth of blood vessels and nerves, which may contribute to tendon pain. These changes are normally only seen in the deep part of the tendon while the rest of the tendon is healthy. These changes can be viewed as a failed healing response in the tendon.

Epidemiology

Tennis elbow affects 1-3% in the general population but can be up to 40% in tennis players and is more common in golfers than golfers elbow. This condition is also very common in manual work tasks. Most common in people aged 35-65 and is very uncommon in people under 30.

5% progress to surgery under WorkCover Australia.

Etiology

Normally caused by repetitive hand tasks is an overload condition.

Anatomy image of Lateral Epicondylalgia (Tennis Elbow)

Pre-disposing factors

Occupational risk factors

Repetitive tasks 4 hours per day
Lifting more than 4.5kg items
Hand tools with awkward wrist/forearm and elbow postures
Overhead work
Repetitive tasks in awkward positions
Injury history

Non-Occupational risk factors

Smoking
Metabolic syndrome
History of steroid injections
Pain may be amplified within the nervous system
Sleep, fatigue, stress, fear avoidance, beliefs about exercise.

Examination

For the Tendon

Resisted isometric wrist extension
Resisted isometric middle finger extension
Palpation of insertion at elbow
Palpation with moving of middle finger (can feel where pain is localized more easily)
Grip strength assessed in extension and pronation ask them to grip as strong as they can without pain, compare this to the unaffected side.
Maximum grip strength can be provocative need to build into this and all tests for this condition.

Shoulder

Shoulder impairment is common in more severe deficits.
Look at shoulder flexion and abduction
Look at abduction at 90 degrees ER and supination then IR and pronation. This does not involve the tendon and indicates increases mechanosensitivity.

Elbow

Active elbow range of motion and pain. Nice way to think if there is an articular component
Passive elbow ROM. This should be unimpaired.

Upper limb tension tests

Good way to test for mechanosensitivity and potential neural involvement.

Rule Out Other Factors

Differential Diagnosis

Radial tunnel syndrome (localized tenderness over the radial nerve 5 cm distal to the lateral epicondyle
Posterior interosseus nerve syndrome (pain, weakness involving wrist extension and finger extension, motor deficits)
Referred cervical pain (radiating arm pain, neck pain, numbness P&N, muscle weakness in myotome.
Elbow OA (pain loss of range)

Prognosis/Natural history

Investigations

X-rays are not indicated
Ultrasound can be used to image, majority of people will show pathological changes (healthy or not) unless unsure of diagnosis, this can help rule out tendinopathy.
Reports of tears can be hard to distinguish normal changes in tendon health compared to injry specific.

Management

Exercise
Avoid all pain, very minor pain should subside within 10mins of exercise.
Want to adopt 20 degrees wrist flexion.
Exercise ideally uses a band wrapped around hand in a bent elbow position reducing gripping demands. This can be then extended into a pronated and shoulder flexed position or resistance can be increased.

Mulligan Mobilization with movement (symptom modification)

Exercise isn’t as effective as exercise plus manual therapy (MWM). Can use glides on the elbow to help reduce pain and symptoms. This allows patients to tolerate more pain free loading. Whilst improving pain free function.
Lateral glide of radiohumeral and humeroulnar joint, while gripping, stabilising above and below.
We sustain while holding grip and let go and if effective at increasing grip strength
We can also do a PA of radial head.

Taping

Multiple taping techniques
Spiral taping
Diamond taping (effective for night pain in patients with disrupted sleep).

How often does the patient need treatment

There is a clear positive dose response relationship with more visits and treatments.

Principles

Monitor pain response - reduce load if pain is greater than a 3/10 or pain lingers > 10 mins after ceasing exercise
Add manual therapy as a way to increase exercise capacity
Need to address psychosocial impairments
May need to address postural and shoulder elements