lateral elbow tendinopathy

Question 1

Lateral tendinopathy

Answer 1

Pathophysiology
• Insertional tendinopathy of the common extensor tendon (often ECRB) - tendon rubs over capitellum during contraction, causing abrasion.
Reactive: acute overload
Degenerative: failed healing, non-inflammatory

Motor system impairment
• Impairment will not just be local to the elbow, it will affect the whole UL

• Pain system changes
• Nociceptive neurotransmitters
• Hyperalgesia: mechanical/pressure, thermal (cold)
• Central sensitisation - symp. bilaterally even though only one side is symptomatic

Question 2

MOI OF LET

Answer 2

ages 40-60 more common
•under 30: consider posterolateral impingement
• Young athletes with repetitive wrist extension e.g. amateur tennis players (poor technique)

Patient history
• MOI
o Most common = insidious onset of localised pain around lateral epicondyle (usually after unaccustomed activity
o Acute onset of pain associated with a single instance of wrist extension exertion
o Increased repetitive loading from activities involving repeated wrist extension
EG Carpentry, brick laying, computer work, tennis

Complaints
• Sharp, rubbing/burning, intermittent pain that increased with periods of physical activity of wrist and elbow
• Pain and loss of strength with gripping or lifting (especially with the forearm pronated e.g. 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 proximally as distally

Question 3

LET Ax

Answer 3

palp:
o Pain distal and anterior to lateral epicondyle (insertion of common extensor tendon) on palpation
o Tenderness on palpation along ECRB (determines midsubstance vs insertional)
o Hypersensitivity of both elbows on palpation
• Pain into forearms but not in fingers
• Gripping
o Pain with gripping in wrist extension and pronation
o Decreased grip strength (pain-free and maximal)
o Wrist held in a more flexed position (10 degrees more wrist flexion)

• mvmt exam
o Pain/weakness with resisted wrist, 3rd or 2nd finger extension
- pain on stretch - passive flexion
o Possibly pain with elbow extension (but generally full ROM)
o If chronic, potenitally joint stiffness
o Decreased strength at elbow, wrist and shoulder
o Decreased reaction time/ speed of movement
o Altered muscle recruitment during functional tasks
o May present with cervical pain

Differential diagnosis
•	Referred pain (C5-6)
•	Radiohumeral joint problems
•	PIN entrapment - Weakness in thumb and wrist, sensitivity, broader area of pain, resting pain, night pain
•	LCL strain

MRI gold standard

Question 4

LET Mx

Answer 4

Aims
• Decrease pain during and ability to perform identified functional activities.
• Decrease pain and improve strength with gripping = need improvements of 50%
• 8 sessions of manual therapy and exercise over 6 weeks

Advice and education
• About the pathology
o Degenerative, not inflammatory.
• Medical
1. Activity modification
o Decrease load and work in pain-free threshold
- Education on sports/work biomechanics
- Cross on the back of the hand to stop lifting with a pronated arm
- Line between forearm and hand must be straight
- Thumb towards the sky when gripping

Address degeneration
• Need to load progressive to encourage the laying down of new tissue and improve the healing capacity of the tendon through exercise

Question 5

Deload technique for LET

Answer 5

Deload technique

1. Elbow brace
   - pull the bulk of the tendon superiorly (to deload) and Make it tight but not so tight that they can’t contract their muscle
2. Wrist extension splint
   - Shown to have a positive effect on lateral epicondylalgia
3. Deloading tape (diamond)
   - Can be used as a TDT
   - Improved pain-free grip strength by 24% compared to controls (Vicenzino)
4. Lateral glide tape
   - Can be used as a TDT

Question 6

LTE MT

Answer 6

1. Address decrease in ROM
   - Self-lateral glide
   - Relieve pain
   - Lateral or radial glide as MWM with gripping (TDT)
   - P-A humeroradial glide - glide of the radius or can do self P-A glide
   o Lateral or radial glide as MWM with elbow flexion/extension (TDT)
   o Then do these glides in isolation
2. Address decrease in strength
   • Progressive resistance of extension of the wrist - sitting with forearm supported and wrist over bench w/ weight
   * add coordination training of forearm muscles
   • Stretching -
   • Self-lateral glide
   • Global upper limb strengthening
3. Address sensorimotor and strength deficits (observed bilaterally)
   • Reaction time
   • Speed of movement

4.Motor control training
• Correct the flexed wrist posture when gripping (seen in these patients)
o retrain: patients want to overuse their finger extensors when gripping

Question 7

Suggested staged exercise approach

Answer 7

• Pain free during and after exercise low load
• Slow contraction (8 seconds) both concentric and eccentric
• First 2-3 weeks take an ENDURANCE focus
o Light load > 15 reps
• Next 4-6 weeks, take an ENDURANCE-STRENGTH focus
o 15-10 >8-10 reps, 3 sets, short rest
• May need to progress to high strength
4-6 reps, 3 sets, long rest (may need to have a rest day in between)
** start with elbow flexed and limited wrist flexion i.e. not past neutral
o Progress into elbow extension and from endurance to strength training

Question 8

prognosis

Answer 8

Prognosis
• Not an easy fix because it is degenerative: 6 months to two years
• Worse outcome if:
o High baseline pain
o Cold hyperalgesia
o Concomitant neck pain
o Manual workers (high load, gripping and lifting)
• Studies have shown that, with physiotherapy, 60% of patients were completely recovered or much improved at six weeks
• At 12 months, wait and see was better than corticosteroid injection
** no long term benefit with/without physio physiotherapy provides greatest short term benefit without the need for medications