Tennis Elbow

Rheumatology

Clinicals - History

Fact Explanation
Pain over the lateral elbow Sharp and intermittent pain over the lateral elbow which aggravates with repeated extension of the wrist. Pain usually radiates along the extensor surface of the forearm towards the wrist. Pain is of insidious onset while the acute pain can recur following activities that involve repeated pronation of the forearm with the elbow extended. eg:- playing a backhand in tennis, using a screwdriver, playing the violin, carrying a heavy briefcase, shaking hands or typing.
Patient usually pinpoints pain at 1.5 cm distal to the origin of the Extensor carpi radialis brevis (ECRB). This is due to microtrauma and subsequent tendinosis at the origin of ECRB with or without involvement of the extensor digitorum communis (EDC). This is often called ‘‘angiofibroblastic tendinosis’’ which is a degenerative process characterized by an abundance of fibroblasts,vascular hyperplasia and unstructured collagen rather than an inflammatory reaction. ,
Pain over the lateral elbow
Sharp and intermittent pain over the lateral elbow which aggravates with repeated extension of the wrist. Pain usually radiates along the extensor surface of the forearm towards the wrist. Pain is of insidious onset while the acute pain can recur following activities that involve repeated pronation of the forearm with the elbow extended. eg:- playing a backhand in tennis, using a screwdriver, playing the violin, carrying a heavy briefcase, shaking hands or typing.
Patient usually pinpoints pain at 1.5 cm distal to the origin of the Extensor carpi radialis brevis (ECRB). This is due to microtrauma and subsequent tendinosis at the origin of ECRB with or without involvement of the extensor digitorum communis (EDC). This is often called ‘‘angiofibroblastic tendinosis’’ which is a degenerative process characterized by an abundance of fibroblasts,vascular hyperplasia and unstructured collagen rather than an inflammatory reaction. ,
Weak grip The elbow pain is made worse by gripping activities and, in some cases, simple things like turning a door handle can cause intense pain.Gripping either too hard or for too long can cause exacerbations of pain. Weak grip
The elbow pain is made worse by gripping activities and, in some cases, simple things like turning a door handle can cause intense pain.Gripping either too hard or for too long can cause exacerbations of pain.

Clinicals - Examination

Fact Explanation
Tenderness at the lateral epicondyle. Maximum tenderness is 1-2 cm distal to the origin of the ECRB (Extensor carpi radialis brevis) where the tendinosis occurs. Tenderness at the lateral epicondyle.
Maximum tenderness is 1-2 cm distal to the origin of the ECRB (Extensor carpi radialis brevis) where the tendinosis occurs.
Pain increases when the wrist is extended against resistance When the wrist is extended, with the wrist radially deviated and pronated more force is exerted on affected ECRB origin. Pain increases when the wrist is extended against resistance
When the wrist is extended, with the wrist radially deviated and pronated more force is exerted on affected ECRB origin.
Coffee cup test Patient feels pain at the lateral epicondyle when picking up a heavy cup of coffee. Coffee cup test
Patient feels pain at the lateral epicondyle when picking up a heavy cup of coffee.
Mills' test The examiner palpates the patient’s lateral epicondyle with his/her thumb while passively pronating the forearm, flexing the wrist and extending the elbow. A positive test would be the reproduction of pain near the lateral epicondyle. Mills' test
The examiner palpates the patient’s lateral epicondyle with his/her thumb while passively pronating the forearm, flexing the wrist and extending the elbow. A positive test would be the reproduction of pain near the lateral epicondyle.
Maudsley's test Extension against resistance of the middle finger when the elbow is fully extended and
the forearm is pronated. This causes stress to the extensor digitorum muscle and tendon. A positive sign would be pain or discomfort in the region of the lateral epicondyle
Maudsley's test
Extension against resistance of the middle finger when the elbow is fully extended and
the forearm is pronated. This causes stress to the extensor digitorum muscle and tendon. A positive sign would be pain or discomfort in the region of the lateral epicondyle
Swelling and Redness Occurs rarely; due to inflammation during the early stages of lateral epicondylitis. Swelling and Redness
Occurs rarely; due to inflammation during the early stages of lateral epicondylitis.

Investigations - Diagnosis

Fact Explanation
X-Ray Elbow Diagnosis based primarily on clinical findings.Laboratory and Imaging studies are rarely useful but may be needed in chronic cases to exclude the other causes such as osteochondritis dissecans, osteophyte fomration and degenerative disease.
In treatment resistant patients; calcification of soft tissues around the lateral epicondyle has been reported in 22% of cases.
X-Ray Elbow
Diagnosis based primarily on clinical findings.Laboratory and Imaging studies are rarely useful but may be needed in chronic cases to exclude the other causes such as osteochondritis dissecans, osteophyte fomration and degenerative disease.
In treatment resistant patients; calcification of soft tissues around the lateral epicondyle has been reported in 22% of cases.
MRI To evaluate and exclude osteochondritis dissecans or stress fractures. MRI
To evaluate and exclude osteochondritis dissecans or stress fractures.

Management - Supportive

Fact Explanation
Cessation of any offending activities and practice watchful waiting. Appropriate as initial management; however complete inactivity or immobilization should be avoided to avoid the possibility of disuse atrophy, which will affect rehabilitation. Cessation of any offending activities and practice watchful waiting.
Appropriate as initial management; however complete inactivity or immobilization should be avoided to avoid the possibility of disuse atrophy, which will affect rehabilitation.
Application of ice Provides local vasoconstrictive and analgesic effects. Application of ice
Provides local vasoconstrictive and analgesic effects.
Counter-force bracing. Reduce the forces on the wrist extensor tendons. Significantly Improve rest pain.
This should be applied firmly 10 cm distal to the elbow joint. Counter-force bracing is found to increase grip strength at 3 weeks.
Counter-force bracing.
Reduce the forces on the wrist extensor tendons. Significantly Improve rest pain.
This should be applied firmly 10 cm distal to the elbow joint. Counter-force bracing is found to increase grip strength at 3 weeks.

Management - Specific

Fact Explanation
Non-steroidal anti-inflammatory drugs. (NSAID) The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's. In the long term, oral NSAIDs with physiotherapy is more effective than corticosteroid injections in providing analgesia. Non-steroidal anti-inflammatory drugs. (NSAID)
The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's. In the long term, oral NSAIDs with physiotherapy is more effective than corticosteroid injections in providing analgesia.
Corticosteroid injections. Improves pain and functional limitation due to tennis elbow in the short term.
But has a higher recurrence rate at 6 weeks, when compared to NSAID's or othoses.
Repeated corticosteroid injections are ineffective in reducing pain and It increases the need for surgical intervention.
Post-injection pain and local skin atrophy are possible complications.
Corticosteroid injections.
Improves pain and functional limitation due to tennis elbow in the short term.
But has a higher recurrence rate at 6 weeks, when compared to NSAID's or othoses.
Repeated corticosteroid injections are ineffective in reducing pain and It increases the need for surgical intervention.
Post-injection pain and local skin atrophy are possible complications.
Extracorporeal shock wave therapy. (ECSWT) Not commonly used, it is less effective in reducing the pain when compared to other therapeutic options. Extracorporeal shock wave therapy. (ECSWT)
Not commonly used, it is less effective in reducing the pain when compared to other therapeutic options.
Physiotherapy Involves several components: ultrasound, phonophoresis (use of ultrasound to enhance the delivery of topically applied drugs), electrical stimulation,
physical manipulation, soft tissue mobilization, neural tension, friction massage and augmented soft tissue mobilization (ASTM). Success rate at one year is greater than other therapeutic options (91%).
Physiotherapy
Involves several components: ultrasound, phonophoresis (use of ultrasound to enhance the delivery of topically applied drugs), electrical stimulation,
physical manipulation, soft tissue mobilization, neural tension, friction massage and augmented soft tissue mobilization (ASTM). Success rate at one year is greater than other therapeutic options (91%).
Acupuncture A homeopathic technique, only a few studies show evidence of improvement in pain at 2 to 8 weeks. Acupuncture
A homeopathic technique, only a few studies show evidence of improvement in pain at 2 to 8 weeks.
Laser therapy Definitive data on possible short or long term benefits is inconclusive. Laser therapy
Definitive data on possible short or long term benefits is inconclusive.
Autologous whole blood injections and platelet rich plasma. High concentrations of platelet derived growth factors that enhance wound, bone and also tendon healing. Autologous whole blood injections and platelet rich plasma.
High concentrations of platelet derived growth factors that enhance wound, bone and also tendon healing.
Arthroscopuc Surgery A surgical option is indicated if 6 months of conservative management has failed. Prior to surgery it is mandatory to
exclude other possible causes.
Arthroscopic removal of pathological tendinosis tissue is a successful treatment strategy in such cases. Abnormal tissue within the Extensor carpi radialis brevis (ECRB) tendon origin at the lateral epicondyle is either excised or the tendon is released altogether.
Arthroscopuc Surgery
A surgical option is indicated if 6 months of conservative management has failed. Prior to surgery it is mandatory to
exclude other possible causes.
Arthroscopic removal of pathological tendinosis tissue is a successful treatment strategy in such cases. Abnormal tissue within the Extensor carpi radialis brevis (ECRB) tendon origin at the lateral epicondyle is either excised or the tendon is released altogether.
Open Surgery An open approach with release of the tendons of the extensor muscles at the lateral epicondyle is most widely used. Currently this extra-articular technique is popular, with excision of the pathologic portion of the extensor tendon origin, repair of the defect and reattachment of the origin to the lateral epicondyle. Satisfactory results are described in 85% to 90% of the patients. Open Surgery
An open approach with release of the tendons of the extensor muscles at the lateral epicondyle is most widely used. Currently this extra-articular technique is popular, with excision of the pathologic portion of the extensor tendon origin, repair of the defect and reattachment of the origin to the lateral epicondyle. Satisfactory results are described in 85% to 90% of the patients.
Sonographically guided percutanous needle tenotomy Performed under local anesthesia, a sonographically guided a needle is advanced into the common extensor tendon. The tip of the needle is used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, are mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle are abraded. Finally the fenestrated tendon is infiltrated with a mixture of a steroid and a local anesthetic.This method is found to have better short term outcomes than open surgery. Sonographically guided percutanous needle tenotomy
Performed under local anesthesia, a sonographically guided a needle is advanced into the common extensor tendon. The tip of the needle is used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, are mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle are abraded. Finally the fenestrated tendon is infiltrated with a mixture of a steroid and a local anesthetic.This method is found to have better short term outcomes than open surgery.

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