Tennis Elbow (lateral epicondylalgia)

Lateral epicondyle tendinopathy (LET) or lateral epicondylalgia, commonly known as tennis elbow, is a condition affecting the wrist extensor tendons that attach into the lateral aspect of the elbow and is aggravated with activities that involve repetitive gripping. Elbow tendon injuries are most commonly a result of overuse, compressive or shear forces, and most commonly presents in people between the ages of 35-54 years. Despite what the name suggests, this pathology occurs predominantly in the working population, affecting both desk-based and manual labour occupations. Any repetitive task (i.e., carrying, gripping or typing) involving the wrist extensors can contribute to the development of LET


Signs and symptoms of Tennis Elbow Pain?

Tennis Elbow (or lateral epicondylitis) was first diagnosed more than 120 years ago. Today nearly half of all tennis players will suffer from this disorder at some point. Interestingly though, tennis players actually account for less than 5 percent of all reported cases making the term for this condition something of a misnomer. A large percentage of sufferers attain the injury from an overuse injury such as computer mouse, typing, hammering, digging etc

The lateral epicondyle is located on the lateral aspect of the humerus, close in proximity to the elbow joint. This bony landmark serves as an attachment point for many of the wrist extensor tendons, known as the common extensor tendon. Of these wrist extensor tendons, the one most commonly implicated in LET is the tendon of extensor carpi radialis brevis (ECRB). This muscle is involved in extension and lateral movement of the wrist and hand. Wrist extension is a key component of grip and function of the fingers when typing, as to why the ECRB is commonly associated with this injury.

Contrary to common belief, LET has no inflammatory component,  rather the pathology occurs due to cellular changes within the tendon. These changes within the cells result in tendon dysfunction and immature healing. The pain felt from LET then occurs from reactive nerve fibres .

There are also tears that can occur involving the lateral elbow tendons, however this is a completely separate injury to LET.


Anatomy/Cause of lateral Elbow Pain

Somewhat obviously, pain over the lateral aspect of the elbow during repetitive or high load tasks is the most common symptom of LET. It is also common to experience pain into the back of the forearm. Pain is often aggravated by gripping objects or by extending the middle finger.
 

Investigations

In the majority of cases, clinical diagnosis of LET is all that is needed. In chronic cases that have lasted longer than 12 months, Doppler ultrasound imaging may be useful to confirm the clinical diagnosis. In rare cases, imaging or blood tests may also be involved to rule out other possible conditions.

ASSESSMENT

A diagnosis of LET is made based on clinical examination findings:
·    Tenderness on palpation over the lateral epicondyle
·    Pain with grip (measure of grip strength using hand-held dynamometer)
·    Pain with resisted extension of the wrist, 2nd or 3rd finger.

Whilst the examination procedure to diagnose LET is simple, complex clinical reasoning skills and other tests must be performed as other conditions of the neck, shoulder and elbow can commonly mimic the symptoms of LET.

LET also has different stages, degenerative or reactive. These stages are not mutually exclusive and can occur together. It is important that the stage of disease is identified as it greatly effects treatment.

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How is lateral elbow pain treated?

Management of LET is highly dependent on the stage of the condition.

 

Reactive LET

The reactive stage of LET can be best thought of as a ‘flare-up’ of symptoms.

The best treatment options for LET in this stage include:

·    Soft tissue massage

·    Elbow joint mobilisations

·    Rest – relative to the tasks or activities that can aggravate symptoms

·    Ice

·    Anti-inflammatory medication (despite the lack of inflammatory markers in this condition it has been shown that some people still benefit from taking this type of medication)

·    Isometric exercises of the wrist extensors

·    Treatment of other potentially contributing areas

In many cases, patients with LET have underlying degenerative components that must be addressed (as discussed below) once the reactive stage has settled.

Degenrative LET

In order for the cellular structure of the tendon to remodel and symptoms to reduce, the effected tendons must be loaded. The question of how much load is both important and difficult, and should be determined through thorough clinical assessment.

Research has shown, the degenerative stage of LET can generally be managed well with exercises for the wrist extensors.

Exercise programs should incorporate:

·    Both concentric and eccentric strengthening exercises of the wrist extensors

·    Supination and pronation exercises

·    Strength and control exercises of the shoulder, neck and thorax (if appropriate)

·    Functional exercises (task/activity specific retraining)

Patients may also find benefits from soft tissue massage and joint mobilisations, as similar in the reactive stage.

Whilst medical options are limited for this condition, in some cases patients can have cortisone or platelet rich plasma (PRP) injections into the lateral elbow, however the evidence supporting it’s use is limited. In very rare cases, patients have opted for surgery. Though the effectiveness of this approach is largely scrutinised.

All Physica practitioners have received extra training in the diagnosis and management of Tennis Elbow, as the research suggests, exercise programmes designed and guided by physiotherapists are the first line treatment of choice.

SELF HELP


Acute Management 0-48 hrs

Initially, the RICE principles should be applied in the first 48-72 hours:
Rest – Rest from activities that cause pain

Ice – Ice the affected area 20 mins every 2 hours

Compress – Use a compression bandage to minimise swelling,

Elevate – Elevate the lower limb to minimise swelling

Treatment

Gentle exercises can be commenced soon after the injury occurs. Rehabilitation will include a range of manual techniques as well as strengthening, stretches, sport specific drills and a graded return to sport. Strengthening of the muscle is essential to enable and optimal recovery and these exercises are progressed as the muscle heals.

When can I return to activity

  • 01

    Your Physiotherapist will advise you as to when you are safe to return to sport/activity.

  • 03

    If you do not have a Physiotherapist download a program below and contact uswith any questions you may have?

  • 02

    You can speed things up by an accurate rehabilitation program. Your Physiotherapist will provide you with exercsies and a management plan.

How do I make an appointment?

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Other causes of elbow pain

Golfers Elbow medial epicondylalgia)

The causes of golfer’s elbow are similar to tennis elbow but pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint’s bony prominence.

Signs and symptoms of Golfers Elbow?

The causes of golfer’s elbow are similar to tennis elbow but pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint’s bony prominence.

ASSESSMENT

• Recurring pain on the inside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist.
• Pain caused by gripping , often worse with an flexed elbow.
• Difficulty bending and straightening the arm .
• Pain that typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or as long as several years.



Bursitis

Often due to excessive leaning on the joint or a direct blow or fall onto the tip of the elbow.
A lump can often be seen and the elbow is painful at the back of the joint.

Signs and symptoms of Olecranon Bursitis?

Often due to excessive leaning on the joint or a direct blow or fall onto the tip of the elbow.
A lump can often be seen and the elbow is painful at the back of the joint.

ASSESSMENT

The diagnosis is very easy and simple and your physiotherapist or medical practitioner will be able to diagnose.


The causes of golfer’s elbow are similar to tennis elbow but pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint’s bony prominence.

Signs and symptoms of Golfers Elbow?

Somewhat obviously, pain over the lateral aspect of the elbow during repetitive or high load tasks is the most common symptom of LET. It is also common to experience pain into the back of the forearm. Pain is often aggravated by gripping objects or by extending the middle finger.
 

ASSESSMENT

• Recurring pain on the inside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist.
• Pain caused by gripping , often worse with an flexed elbow.
• Difficulty bending and straightening the arm .
• Pain that typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or as long as several years.