Lateral Elbow Musculotendinous Injury & Tendinopathy

Lateral Epicondylitis/Epicondylalgia

Tendinosis/itis/opathy of the common extensor tendon aka

Tennis Elbow

Lateral Elbow Pain AKA Lateral Epicondylalgia or Tennis Elbow is the

most common chronic condition affecting the elbow

Lateral Elbow Pain incidence and prevalence

Lifetime incidence of 40%

Prevalence of 1.3%

Lateral Elbow Tendinopathy of the common extensor tendon can present

w/ & w/o inflammatory cytokines (substance P)

what is the most common tendon involved in lateral epicondylitis?

Extensor carpi radialis brevis

Risk Factors for Lateral Elbow Pain

Females>males

35-54 y/o

UE athletes: 50% tennis players

Manual laborers: 17%

Other: Low levels of social support, Office Work (repetitive micromvmts), Concurrent shoulder pathology, Tobacco use

Lateral Epicondylalgia Clinical Course/Natural History

6 months to 2 years

50% report not being recovered at 12 months

20% reported ongoing sxs for 3-5 yrs

High baseline severity ↑ risk of chronic sxs

Lateral Elbow Epicondylalgia Presentation is Lateral Elbow pain that can radiate into dorsal forearm, most commonly in the dominant arm. Point tenderness found over the lateral humerus: 1cm distal to lateral epicondyle. Signs & sxs include

Painful gripping (grip w/ wrist ext for optimal LTR)

Pain w/ passive stretching (wrist flexion): Elbow ext > Flexion

Pain w/ active wrist ext: Elbow ext > Flexion

Dull or sharp pains: Rest should be pain free or reduce sxs

Lateral Elbow Pain Differential Diagnosis**

-Cervical radiculopathy C6-7 (insidious)

-Radial Tunnel Syndrome (also supinator entrapment, if pain more distal more likely RTS)

-PLRI (trauma hx)
-Posterior IO Syndrome: Muscle weakness of finger & thumb extensors

-Intra-articular Disease

Lateral Elbow Pain/Epicondylalgia Etiology is an overload of common extensor tendon due to

Repetitive gripping

Insidious onset w/out specific event

Lateral Elbow Pain/Epicondylalgia Etiology: if a Tendinitis progresses to a Tendinosis, inflammatory markers

are not always present

Tendinopathy Theories: Overload, Vascular (angiogenesis), Neural

Ultrasound Imaging & MRI for Lateral Elbow Pain/Epicondylalgia can show

Focal hypoechoic regions

Tendon thickening

Neovascularization

Intrasubstance tears (→)

50% of age matched controls demonstrate musculotendinous changes of lateral elbow, which means imaging is

sensitive to detecting presence of Lateral Epicondylalgia, Not specific

Lateral Elbow Pain/Epicondylalgia impairments include

Central pain processing changes: Central Sensitization → Hyperalgesia

↑ Cervical Thoracic impairments: Pain & limited ROM, Adverse neural dynamics

Load intolerance of extensor musculature: Pain free grip ↓ by 43-64%

Weakness of entire UE

Lateral Elbow Pain/Epicondylalgia Special Tests

Radial Bias Neurodynamic Assessment

Cozen’s Test

Grip Strength & Pain free griping

Mill’s Test

3rd Finger Resistance Test

Palpation

Lateral Elbow Pain/Epicondylalgia Management includes

Load management: activity modification

Progressive exercise to focus on improving load tolerance: eccentric vs isotonic may not matter. Pain should subside w/in 24hrs to progress.

MT for pain modulation

Wrist/Hand Orthosis

Counter force bracing

Injections

Lateral Epicondylalgia Load Management education should include a

natural history of the dx, may take some time

Prolonged recovery

Lateral Epicondylalgia Load Management/Activity modification

Change in gripping: Supinated better than pronated

Racquets or club positioning (forward hand better)

Maybe fat grips

Changes in job related tasks

Job reassignment

Changes in exercise or work volume

Lateral Epicondyle exercise has shown to be superior to passive treatments alone. These exercises include

Stretching & Isometric: Highly reactive/irritable

Isotonic exercise

Eccentric exercise: Lower reactivity/lower irritability

Painful loading

Exercise for entire UE: Don’t only focus on extensor tendons

Wrist/Elbow Manual Therapy for lateral epicondylalgia (Board mwm)

Mill’s Manipulation

MWM: Pain free griping (sustained glide 3×10 squeezes)

Friction Massage

Cervical Thoracic MT for lateral epicondylalgia improves Cervical Thoracic pain & ROM; for lateral epicondylalgia it ↑

pain Pressure Threshold at the lateral epicondyle

Neurodynamic Interventions for Lateral Epicondylalgia w/ mixed presentation in order to decrease

neural sensitivity (change way pain is conducted)

Orthosis & Taping for lateral epicondylalgia

Wrist orthosis (into optimal gripping position)

Counterforce Brace: Not superior to exercise, = to CSI in short term

taping: limited evidence

lateral epicondylalgia Low Risk Group factors:

Lower perceived disability

High control of painful tasks or jobs

Lower overall pain severity

Lateral epicondylalgia Low Risk Group Interventions:

Activity Modification

Oral medication for pain

Modalities

Wait & see

lateral epicondylalgia Moderate Group Factors:

Mod perceived disability

Lower job control: Repetitive higher loading

Mod levels of pain & irritability

Greater MSK impairments

Interventions for those in the moderate irritability group of Lateral epicondylalgia:

Activity Modification

Oral medication for pain

Modalities

Active management: MT, Exercise: Isotonics → eccentrics

Lateral Epicondylalgia High Risk Group Factors:

High perceived disability

no control of painful tasks or jobs

High overall pain severity & irritability

Comorbid neck & shoulder pain

Signs of central sensitization

Lateral epicondylalgia High Risk Group Interventions:

Activity Modification

Oral meds for pain

Modalities

Regional MT

Regional UE exercise: Isometrics → isotonics

Corticosteroid Injection (CSI) Therapy for later epicondylalgia has

Short term improvements in pain

Limited effect on function

Long term pts who received CSI may be worse off than those who did not

PRP Injections for lateral epicondylalgia

Try this before corticosteroid inj

Not superior to placebo (Saline): Simental-Mendia 2020 SR/MA

Long term PRP > CSI: Natural hx

Indications for lateral epicondylalgia Surgical Intervention

Failure to respond to extensive conservative mgmt

Failure to respond to injections

Substantial imaging findings: RCL tear &/or CET tear

Lateral Epicondylalgia Surgical Intervention procedures

Extensor Carpi Brevis debridement, repair or release

RCL repair/reconstruction

Lateral epicondylalgia surgical Intervention Outcomes have

limited evidence & mixed outcomes: good outcomes in recalcitrant cases