Lateral Elbow Tendinopathy

Question 1

Pathophysiology

Answer 1

• Insertion tendinopathy of extensor tendon (often ECRB)
• Local tendon pathology: fraying of tendon fibrils, tenocytes cellular change, neovascularisation
• Extensor tendon rubs over capitulum curing contraction, causing abrasion.

Question 2

Prevalence

Answer 2

• Mid-life “crisis of tendon” (40-60 more common)
• is under 30 check posterolateral impingement
• Young athletes repetitive wrist extension eg amateur tennis players (poor technique)

Question 3

MOI

Answer 3

• most common= insidious onset of localised pain around lateral epicondyle (usually after unaccustomed activity)
• acute onset of pain associated with a single instance of wrist extension exertion
• increased repetitive loading from activities involving repeated wrist extension
• search history: load, positional, methodological changes
• Carpentry, brick laying, computer work, tennis

Question 4

Symptoms

Answer 4

• sharp, rubbing/buring, intermittent pain increased with period of physical activity of wrist and elbow
• pain and loss of strength with gripping or lifting (especially with forearm pronated eg kettle)
• pain when using tools or holding a racquet
• pain and difficulty with tasks involving manipulation (computer work and sewing)
• Pain at lateral elbow that radiates 5cm prop to distal

Question 5

Physical examination findings

Palpation

Gripping

Movement Exam

Answer 5

• Pain on palpation distal and anterior to lateral epicondyle (insertion of common extensor tendon)
• Tenderness palpation along ECRB (mid substance vs insertional)
• hypersensitivity of both elbows on palpation
• pain into forearms but not fingers
• pain with gripping in wrist extension and pronation, decreased grip strength, wrist held in more flexed position
• Pain/weakness with resisted wrist, 3rd or 2nd finger ext
• Generally pain through full ROM
• Chronic=joint stiffness
• decreased strength elbow, wrist and shoulder
• Decreased reaction time
• altered muscle recruitment during functional activities

Question 6

Differential Diagnosis

Answer 6

• Referred pain (C5-6)= pain radiating down from neck, palpation an AROM of neck can reproduce symptoms
• Radiohumeral joint problems
• PIN entrapment / radial tunnel syndrome= weakness in thumb and wrist, sensitivity, broader area of pain, resting pain, night pain
• LCL sprain

Question 7

Imaging

Answer 7

• MRI gold standard

Question 8

Treatment Aims

Answer 8

Aims

• decrease pain during and ability to perform identified functional activities
• decreased pain and improve strength with gripping–> need improvements of 50%
• 8 sessions of manual therapy and exercise over 6 wks

Question 9

Treatment A& E

Answer 9

• About pathology - degenerative not inflammatory
• Medical= pain management (NSAIDs for REACTIVE tendinopathy)
• Activity modification- decrease load and work in pain-free threshold
• Education on sports/work biomechanics= cross on back of wrist to stop lifting with pronated arm, line between forearm and hand must be straight, thumb towards the sky when gripping

-Address degeneration= progressively load to encourage the laying down of new tissue and improve the healing capacity of the tendon through exercise

Question 10

Treatment Deload

Answer 10

• Elbow brace
• wrist ext splint
• Deloading tape (diamond)
• lateral glide tape

Question 11

Treatment Manual therapy

Answer 11

Address decrease in ROM = self-lateral glide

Relieve pain

• Lateral or radial glide as MWM with gripping
• (P-A) humeroradial glide
• lateral or radial glide as MWM w/ elbow flex/ext
• glides in isolation

Strength

Question 12

HEP

Answer 12

• progressive resistance of ext of wrist
• stretching
• occupational exercises –> MC
• self-lateral glide

Question 13

Suggested staged Exercise program

Answer 13

• Pain free during & after exercise–> low load
• Slow contraction (8 secs)= both acc & con
• first 2-3wks take an endurance focus= light load >15 reps
• next 4-6 wks, endurance strength= 10-15–> 8-10 reps, 3 sets, short rest
• higher strength= 4-6 reps, 3 sets, long rest

Start with elbow flexed and limit wrist flex not past neutral–> progress into elbow ext and from endurance to strength

Global UL strengthening

Question 14

Treatment other considerations

Answer 14

• Address sensorimotor and strength= reaction time and speed of movement
• Motor control training= correct the flexed wrist posture when gripping, decrease overuse of finger extensors when gripping

Question 15

Prognosis

Answer 15

-not easy fix it is degenerative= 6 mths to two years

Worse outcome if:

• high baseline pain
• cold hyperalgesia
• concomitant neck pain
• manual workers

Studies show 60% completely or much improved six weeks