Lateral Epicondylitis

LATERAL EPICONDYLITIS & TENNIS ELBOW

...INTRODUCTION • Overuse injury that results in micro tearing & 

scar tissue formation of the common wrist  extensor tissue. • Peak incidence between the ages of 40 & 50. • 50% of all tennis players experience tennis 

elbow .

By Saravanan Krishnan

…ANATOMY

By Saravanan Krishnan

…ANATOMY

By Saravanan Krishnan

…ANATOMY

By Saravanan Krishnan

…DEFINITION Inflammation of the tissue at the lower end of the humerous  at  the  elbow    joint,  caused  by  the  repetitive flexion &  extension of the wrist against resistance is called   lateral epicondylitis (LE). The primary structure involved:‐ Is the tendon of the ECRB muscle & less frequently,   the ECRL muscle.

By Saravanan Krishnan

…PREVELANCE Although tennis elbow commonly affects tennis players,  it  also  affects  other  athletes  &  people  who participate in leisure / work activities that require repetitive arm, elbow, & wrist movement.  Examples  include  golfers,  baseball  players,  bowlers,  gardeners  /  landscapers,  house  /  office  cleaners  (because  of  vacuuming,  sweeping  &  scrubbing),  carpenters,  mechanics,  &  assembly‐ line workers. By Saravanan Krishnan

…AETIOLOGY • Occurs idiopathically. • Primarily  considered  to  be  a  mechanical 

disorder of the elbow. • Onset  of  pain  usually  occurs  due  to  exertion 

i.e.  characterized  by  repetitive  /  forced  extension  of  the  wrist  combined  with  squeezing / grasping. By Saravanan Krishnan

…RISK FACTORS 1. Intrinsic tendon overuse 2. Inadequate conditioning 3. Constitutional Factors 4. Decreased flexibility of muscles 5. Physical activities 6. Forceful grasping 7. Tennis player with poor playing style 8. Poor backhand stroke 9. Incorrect equipment By Saravanan Krishnan

…PATHOMECHANICS • Acute traumatic origin. • Micro damage is increased due to increased 

internal strain to tendon fibers over time. • Occur  with  normal  activity  levels  if  the 

tendons capacity to attenuate tensile loads  is reduced.

By Saravanan Krishnan

…TYPES • Type 1: A lesion of the muscular origin of the

ECRL , just proximal to the lateral epicondyle.

• Type 2: Is the most frequent type of tennis

elbow. It is an insertion tendinopathy of the ECRB

• Type 3: A tendonitis of the

ECRB tendon at the level of the radial head. Cont... By Saravanan Krishnan

…TYPES y Type 4: A sprain of the musculotendinous

junction / proximal part of  the muscle belly of the ECRB.  y Type 5: Occurs frequently.

The origin of the ED at the laterodistal aspect of the lateral epicondyle is affected.

By Saravanan Krishnan

…CLINICAL PRESENTATION • SIGNS:

• Pain ie localized at the anterior aspect of the 

lateral epicondyle.

• Exertion, characterized by repetitive/ forced 

extension of the wrist 

• Pain with athletic activity  • Pain with movement  • Pain when forcibly gripping an object or lifting By Saravanan Krishnan

…SYMPTOMS • Pain may radiate down the dorsal aspect of

the forearm to the wrist / the dorsum of the hand, & sometimes the middle & ring fingers. • Occasional dysesthesia / numbness from the

elbow to the hand . • A limitation of ADL due to severe symptoms

may result in approximately 1/3rd of cases. By Saravanan Krishnan

…CLINICAL FINDINGS • Well‐localized  tenderness  is  present  at  the 

lateral epicondyle . • Myofascial trigger points in the wrist extensor 

muscles . • Due  to  fibrosis  &  loss  of  tissue  extensibility, 

there may be a loss of passive wrist flexion.

By Saravanan Krishnan

…SPECIAL TEST • Mills’  test  : A  passive  stretch  of  the  extensor 

tendons  produced  by  full  elbow  extension,  forearm  pronation,  wrist  flexion  &    ulna  deviation. • Cozen’s Test  :  Resisted  extension  of  the  wrist 

performed  with  the  elbow  &  wrist  fully  extended & pronated. • Maudsley’s Test  :  Resisted  extension  of  the 

middle finger with the elbow fully extended. By Saravanan Krishnan

…SPECIAL TEST Kaplan’s Test : • With  the  upper  limb  extended  straight  forward,  the 

patient  squeezes  a  grip  strength  dynanometer as  hard as possible. • The  test  is  then  repeated  with  the  examiner  firmly 

encircling  the  patient’s  forearm  with  both  hands  (1‐2  inches below the antecubital crease). • A  positive  test  for  lateral  epicondylitis  is  indicated  if 

the  induced  pain  is  reduced  &  the  grip  strength  is  increased  when  the  muscles  of  the  proximal  forearm  are compressed. By Saravanan Krishnan

…EVIDENCE The Short‐term Efficacy of Laser, Brace, & Us Treatment in LE : A Prospective, Randomized, Controlled Trial. Oznur Oken AIM: To evaluate the effects of LLLT & to compare these  with the effects of brace / US treatment in tennis elbow. RESULTS:  In  patients  with  LE,  a  brace  has  a  shorter  beneficial  effect  than  US  &  laser  therapy  in  reducing  pain,  &  that  laser  therapy  is  more  effective  than  the  brace & US treatment in improving grip strength. By Saravanan Krishnan

…EFFECT OF OEMT ON LE JOURNAL OF HAND THERAPY JULY 2008, Mohammed Reza AIM: To investigate the effect of OMET on pain , grip strength & functional abilities of subjects with chronic LE. OUTCOME MEASURE: Dynamometer, patient specific functional scale, numerical rating scale. By Saravanan Krishnan

…EFFECT OF OEMT ON LE RESULTS: OEMT seems to be viable, effective & efficient alternative treatment for LE.

By Saravanan Krishnan

COMPARISON OF EFFECTS OF CYRIAX PT , A SUPERVISED EXS. PROGRAM & POLARISED POLYCHROMATIC NON COHERENT LIGHT FOR RX OF LE Clinical Rehab 2006 Dimitrios Stasinopoulos AIM: To compare effectiveness of cyriax physiotherapy,   a supervised exercise programme & polarized  polychromatic non‐coherent light in treatment of  LE. Cont…. By Saravanan Krishnan

…COMPARISON OF EFFECTS OUTCOMES: Pain  was  evaluated  using  a VAS  &  function  using  VAS & pain free grip strength. CONCLUSION: The supervised exercise  programme  should be 1st treatment option for therapist when they manage  LE  patients.  If  this  is  not  possible  cyriax physiotherapy  &  polarized  polychromatic  non‐ coherent light may be suitable. By Saravanan Krishnan

SHOCK WAVE THERAPY FOR PATIENTS WITH LE OF ELBOW Ching‐ Jen wang. Am J Sports Med 2000. HYPOTHESIS: SWT  is  an  effective  treatment  treatment  for  patients  with LE of elbow & long‐ term results will be favorable  as short‐term ones. CONCLUSION: SWT is safe & effective modality in treatment of  patients with LE of elbow. By Saravanan Krishnan

NO EFFECT OF FOREARM BAND & EXTENSOR STRENGTHENING EXS FOR RX OF LE Rolf luginbuhl Feb’08 AIM: To analyse the effect of forearm support band & of  strengthening exercises for Rx of LE. CONCLUSION: No  beneficial  influence  was  found  either  for  strengthening  exercise  or  for  forearm  support  band.  Improvement  seems  to  occur  with  time,  independent  of method of treatment used. By Saravanan Krishnan

…NO EFFECT OF FOREARM OUTCOMES: Pain was evaluated using a VAS & function using VAS & pain free grip strength. CONCLUSION: The  supervised  exercise  programme  should  be  1st treatment option for therapist when they manage  LE  patients.  If  this  is  not  possible  cyriax physiotherapy  &  polarized  polychromatic  non‐ coherent light may be suitable. By Saravanan Krishnan

SHOCK WAVE THERAPY FOR PATIENTS WITH LE OF ELBOW Ching‐ jen wang. Am J Sports Med 2000. HYPOTHESIS: SWT is an effective treatment  for patients with LE of  elbow & long‐ term results will be favorable as short‐ term ones. CONCLUSION:

SWT is safe & effective modality in treatment of  patients with LE of elbow. By Saravanan Krishnan

NO EFFECT OF FOREARM BAND & EXTENSOR STRENGTHENING EXS FOR RX OF LE Rolf luginbuhl Feb’08 AIM: To  analyse  the  effect  of  forearm  support  band  &  of  strengthening exercises for Rx of LE. CONCLUSION: No  beneficial  influence  was  found  either  for  strengthening  exercise  or  for  forearm  support  band.  Improvement seems to occur with time, independent  of method of treatment used. By Saravanan Krishnan

AN EXS PROGRAMME FOR THE MX OF LE British Journal of Sports Medicine 2005 D Stasinopoulos, K Stasinopoulou, M I Johnson AIM:

To  describe  the  use  &  effects  of strengthening  &  stretching exercise programme’s in the treatment of LET. Cont…

By Saravanan Krishnan

AN EXS PROGRAMME FOR THE MX OF LE Discussion: • A  well  designed  trial  is  needed  to  study  the  effectiveness of a supervised exercise programme  for LET consisting of eccentric a& static stretching  exercises. • The  issues  relating  to  the supervised  exercise 

programme  should  be  defined  so  that  therapists can replicate the programme.

By Saravanan Krishnan

EFFECTS OF LLLT & PLYOMETRIC EXS IN Rx OF LE Photomedicine & Laser Surgery. June 2007 Apostolos Stergioulas Objective: This study was undertaken to compare the  effectiveness of a protocol of combination of laser  with plyometric exercises & a protocol of placebo  laser with the same program, in the treatment of  tennis elbow. By Saravanan Krishnan

FFECTS OF LLLT & PLYOMETRIC EXS IN Rx OF LE Conclusion: The results suggested that the combination  of laser with plyometric exercises was more effective treatment than placebo laser with the same Plyometric exercises at the end of the treatment as well as at the follow‐up. By Saravanan Krishnan

A RCT OF EXTRACORPOREAL SWT FOR LE Margret P. Staples, Andrew Forbes JOURNAL OF RHEUMATOLOGY,2005 Objective: The  aims  of  this  double‐blind,  randomized,  placebo  ‐ controlled  trial  were  to  determine  whether  US  ‐guided  extracorporeal  SWT(ESWT)  reduced  pain  &  improved  function in patients with LE in the short term &  intermediate term. By Saravanan Krishnan

A RCT OF EXTRACORPOREAL SWT FOR LE Margret P. Staples, Andrew Forbes JOURNAL OF RHEUMATOLOGY, 2005 Objective: The aims of this double‐blind, randomized, placebo‐controlled trial were to determine whether US‐guided extracorporeal SWT(ESWT) reduced pain & improved function in patients with LE in the short term & intermediate term. By Saravanan Krishnan

A RCT OF EXTRACORPOREAL SWT FOR LE Conclusion: Our study found little evidence to support the use of ESWT for the treatment of lateral epicondylitis.

By Saravanan Krishnan

AN ISOKINETIC ECCENTRIC PROG. FOR Mx OF CHRONIC LE British Journal of Sports Medicine, April 2007. Croisier, Jean‐Louis Objective:  To compare the outcome of patients performing  an isokinetic eccentric training with that of age,  gender, activity‐matched patients receiving a  non‐strengthening classical rehabilitation. Cont… By Saravanan Krishnan

AN ISOKINETIC ECCENTRIC PROG. FOR Mx OF CHRONIC LE Conclusion:  These results highlight the relevance of implementing isokinetic adapted eccentric training in the management of chronic lateral epicondylar tendinopathy

By Saravanan Krishnan

AN ALTERNATIVE APPROACH TO TREAT LE: A RANDOMIZED , PLACEBOCONTROLLED, DOUBLE – BLINDED STUDY Clinical Rehab 2008 Reza Nourbakhsh , Fearon OBJECTIVE: To  investigate  the  effect  of  noxious  level  ES  on  pain,  grip  strength  &  functional  abilities  in  subjects  with  chronic LE.

DESIGN: Randomized, placebo – control, double‐blinded study. By Saravanan Krishnan

AN ALTERNATIVE APPROACH TO TREAT LE: A RANDOMIZED , PLACEBO CONTROLLED, DOUBLE – BLINDED STUDY MAIN MEASUREMENTS: Grip  strength,  functional  status,  pain  intensity  &  limited activity due to pain were assessed before  & after treatment. CONCLUSION: The results of this study indicated that symptoms  of chronic LE could be effectively treated by  noxious level low‐frequency ES. By Saravanan Krishnan