Angeles University Foundation
College of Allied Medical Professions
Angeles City
TENNIS
ELBOW
SEMINAR 1
Submitted by :
Castro, Maria Fatima H.
Feliciano, Gian Paul P.
Garcia, Miguel Antonn V.
Liwag, Paula Angela P.
Punzalan, Ruffin Stephanelle O.
Rodriguez, Krishna Yves
Serrano, Kin Marcelene B.
BSTP4
TENNIS ELBOW
I. INTRODUCTION
Injuries to the elbow, specifically humeral epicondylitis, occur frequently in daily activities
as a result of the repetitive loads encountered and in athletes from both repetitive and forceful
muscular activations inherent in throwing, hitting, serving and spiking.
Gradual or acute onset of pain over the lateral epicondyle or wrist extensor muscles, which is
worse when gripping, hitting, dragging, hammering, using a screw-driver or carrying a heavy
briefcase with the palm down. The pinch grip to take down books or files off a shelf is a
common cause. The pain is worse on making a fist, lifting a cup or kettle, or sometimes
writing. Resisted wrist and finger extension are painful.
Lateral epicondylitis, the most common tendinopathy of the elbow, affects the extensor wad,
specifically the extensor carpi radialis brevis (ECRB) origin in the region of the lateral
epicondyle. It can be precipitated by a single event such as direct trauma or repetitive
activities including improper lifting of heavy objects.
This condition is also called tennis elbow but symptoms can result from any excessive
forearm use including gardening, gripping a heavy briefcase, and using a screwdriver.
Infrequently, acute onset may be associated with a direct blow to the lateral elbow.
Posterolateral rotary instability may mimic or be associated with lateral epicondylitis. Lateral
epicondylitis occurs most commonly between the ages of 30 and 55 years. If symptoms are
long-standing or the patient has a history of excessive forearm use, the classification should
be lateral epicondylosis. Treatment includes inflammation control, stretching, postural
training, bracing, and strengthening when the acute inflammatory phase has resolved.
Avoidance of painful activities, modification of provoking activities that cannot be avoided,
and environmental adaptations (at work and leisure) are an integral part of successfully
treating lateral epicondylitis. Infrequently, surgical treatment is utilized to treat patients who
have responded to nonoperative intervention.
II. ANATOMY/PHYSIOLOGY/ETIOLOGY
Involves primarily the ECRB and occasionally, the ECRL and ED
Tendinitis is rarely due to acute trauma; rather, it is because of degeneration. It is a
response to fatigue stresses.
The inflammatory response in an attempt to speed the rate of tissue production to
compensate for an increased rate of tissue microdamage (collagen fiber fracturing)
associated with a loss of mucopolysaccharidechondritin sulfate, which makes the tendon
less extensible.
Due to this, more energy from tensile loading must be absorbed as internal strain to
collagen fibers rather than by deformation of the tissue.
ECRB is susceptible to excessive force overload particularly due to hyperpronation.
Tennis elbow is a type of bursitis that affects the elbow area. This bursitis is not always
caused by playing tennis, as its name suggests. Tennis elbow is a repetitive motion injury.
III. EPIDEMIOLOGY
The annual incidence of the disorder is between 1% to 3% in the general population
and commonly affects people aged from 30 to 55 years old due to age-related tissue
changes. Although often referred to as tennis elbow, 95% of reported cases occur in
individuals other than tennis players. It is more frequently seen in occupations
requiring repetitive upper extremity activities and particularly those involving
computer use, heavy lifting, forceful forearm pronation and supination, and repetitive
vibration.
In athletics, racquet sports are most commonly associated with lateral epicondylitis.
Epidemiologic research on adult tennis players reports incidences of humeral
epicondylitis ranging from 35% to 50%. This incidence is actually far greater than
that reported in elite junior player (11% to 12%) .
The injury is also seen in golf, baseball, and swimming. In tennis, the incidence
appears to be between 30% and 40%. In general, tennis players with symptoms are
older, play more frequently, and tend to be more skilled.
IV. PATHOPHYSIOLOGY
The term “tendinitis” and “epicondylitis” imply an inflammatory process; histologic studies
have confirmed that lateral epicondylitis may not be an inflammatory condition. Tissues
studies of damaged tendons from overuse injuries have not contained large numbers of
inflammatory cells at the time of study demonstrated an increased number of fibroblasts,
vascular, hyperplasia, and disorganized collagen, which is consistent with tendinosis.
This constellation of findings led to coin the phrase “angiofibroblastic hyperplasia”. The
term refers to the degenerative changes that occur when a tendon has failed to heal properly
after an injury or after repetitive microtrauma resulting from overuse.
V. CLINICAL MANIFESTATIONS
Patient will present with lateral elbow and forearm pain experienced during activities such as
lifting, grasping, gripping, hitting a backhand in tennis. The pain associated with lateral
epicondylitis is generally localized to the common extensor origin, but patients may report
pain radiating proximally and distally. Pain is usually worse with resisted wrist extension,
especially with the elbow extended, but can be elicited with radial deviation, finger
extension, or forearm supination.
In the mild stages, the symptoms will develop after completion of an activity. As the severity
progresses, the symptoms are noted soon after starting an activity. In severe cases, the
symptoms will occur with minimal activity such as brushing teeth and shaking hands, and
rest pain may be noted.
This presentation is characterized by pain and point tenderness at the lateral epicondyle and
the involved tendon(s), most commonly the extensor carpi radialis brevis. Pain is worse with
the use of the arm. Reproduction of symptoms will occur with resisted wrist extension and
passive wrist flexion with increased symptoms when the elbow is extended.
VI. CLINICAL COURSE
Grade 1 – generalized soreness with activity, which is most often ignored. A vicious
cycle of irritation, inflammation, pain, weakness and inadequate healing is initiated and
gains full expression in subsequent grades of injury.
Grade 2 – working or playing through the soreness may increase pain, which becomes
localized at the lateral epicondyle or radial head that persists after activity. The lateral
aspect of the joint may become swollen or tender to touch. Pain will interfere with work
or athletic activity. As the condition persists, pain may radiate down the forearm to the
wrist and may extend upward into the upper arm and shoulder.
Grade 3 – simple activities of daily living become more painful and difficult. Continued
activity leads to secondary problems like rotator cuff or low back pain as other joints
attempt to compensate. If ignored, arthritic changes in the proximal radial or humeral-
ulnar joint may occur.
VII. PROGNOSIS
Short term prognosis as follows:
90% to 95% improvement of symptoms
1 to 2 treatments give pain relief with deep tissue massage
92% of patients reported improvement at 4 weeks
Increased grip strength at 6 weeks
Slow progression with greatest improvement at 12 weeks and lasting into
week 52
Long term prognosis includes the following:
91% success at 52 weeks
Approximately 10% recurrence of symptoms.
Rehabilitation may take longer to reduce pain, but results are long term.
VIII. DIAGNOSIS AND EVALUATION PROCEDURES
Patients with lateral tennis elbow present with localized tenderness medial and distal to the
lateral epicondyle. Pain and tenderness extend distally along the muscle mass of the extensor
carpi radialis brevis. Symptoms are exacerbated with provocative stress testing such as active
(resisted) wrist and finger extension with elbow extended (and in advanced cases, with elbow
flexed). Passive wrist flexion can also increase symptoms, especially with the elbow
extended. Radiographs are often normal, but may show calcific deposits in the extensor
aponeurosis.
IX. DIFFERENTIAL DIAGNOSIS
Radial Tunnel Syndrome
Posterior Interosseous Syndrome
Elbow Osteoarthritis
Pain
Loss of range of motion
Fractures
Distal Radial Fractures
Radial Head Fracture
Olecranon Fracture
Cervical Radiculopathy
X. TREATMENT
A. Medical
Central to conservative nonoperative management of lateral epicondylitis are patient
education, protection of the elbow, and avoidance of activities that aggravate pain.
Patients should be taught proper techniques for lifting and other sporting activities. In
general, lifting should be performed with the arms close to the body and supinated. A
“wait-and-see” strategy may be viable treatment strategy for lateral epicondylitis.
Referral to physical or occupational therapy may be helpful in the prevention and
treatment of lateral epicondylitis. In general, therapy consists of three phases. The
first phase emphasizes rest to control pain and decrease disability. In addition to
limiting activities, modalities including heat, ice massage, and ultrasound can be
helpful. The second phase, rehabilitation, involves stretching or flexibility exercises
for the extensor wad muscle tendon units, which are started when the pain has
subsided with rest. Stretching exercises of the extensors are initially performed with
the elbow in flexion and progressed to performing the exercises with the elbow in
extension. In the third phase, a gradual strengthening program is instituted with
isometric followed by isotonic exercises. If pain develops during the program, the
exercises are not progressed; the patient returns to the previous phase until the
symptoms resolve. If lateral epicondylitis has developed from a sporting activity,
proper sport specific counseling should be a part of the rehabilitation process. In
particular, tennis players should consider playing on a soft surface, using new tennis
balls frequently, and selecting the appropriate racket with proper grip size and string
tension. Hitting a backhand while leading with the elbow often is a factor in lateral
epicondylitis; therefore, professional stroke instruction is beneficial.
Elbow bands can be used to reduce pain from lateral epicondylitis. A counterforce
brace applies a compressive force over the extensor mechanism of the forearm. This
band essentially prevents full muscular expansion by creating a new functional origin
of the extensor musculature of the forearm. The efficacy of the device has been
disputed. Studies have shown that elbow bands may decrease pain and increase grip
strength, whereas other studies show no difference when compared with sham
bracing.
Corticosteroid injections have been effective in treating lateral epicondylitis. The
injection consists of a combination of local anesthetics and corticosteroid. The most
common is 0.5 ml methylprednisolone and 0.5 ml lidocaine. In randomized study of
164 patients being treated with corticosteroid injections, naproxen, or placebo, 92%
of patients in the injection group had complete resolution or improvement compared
with 57% in the naproxen group and 50% in the placebo group. Risks associated with
steroid injections include elevation of glucose in patients with diabetes, steroid flare,
and skin changes with subcutaneous fat necrosis, discoloration, and atrophy. Multiple
injections are discouraged because of the risk of collagen degeneration, although
commonly used, benefits seen from corticosteroid use are short term and their long
term effects are uncertain.
B. Surgical
Conservative treatment is generally effective or the vast majority (>90%) of patients
with lateral epicondylitis. Surgical treatment is recommended when the patient
experiences persistent debilitating pain despite 6-12 months of nonsurgical
management, and other causes for the pain have been excluded. Three main
categories of operative treatments have been described and studied in the literature:
open, percutaneous, and arthroscopic. Each has advantages and disadvantages, but
studies comparing the different techniques are limited.
The current standard for most open procedure reported in the literature is the Nirschl
procedure and its modifications. The common thread among these procedures is
identification of abnormal diseased tissue, most commonly at the origin of the ECRB,
followed by excision of the lesion and repair.
The technique, as originally described by Nirschl and Pettrone and subsequently
modified by numerous authors, is as follows. A 5-cm gently curved incision is made
centered just distal to the lateral epicondyle. The deep fascia is incised in line with the
incision, and the common extensor origin is then identified. An interval between
ECRL and EDC is created to visualize the underlying ECRB. Once the ECRB is
exposed, the degenerative tissue, which often appears gray and friable, is sharply
excised. Sometimes a portion of the EDC is involved as well and is removed
concurrently. Nirschl and colleagues described a scratch maneuver using the edge of
the scalpel to scrape away abnormal tendinosis tissue while leaving normal tissue
intact. The remaining normal tendon is sutured back to surrounding fascia or
periosteum. The lateral epicondyle is drilled or decorticated with a rongeur,
purportedly to stimulate bleeding and a healing response. However one level 1 study
compared the Nirschl procedure with and without drilling and found that drilling had
no benefit in their series and cause more pain and stiffness postoperatively. Some
authors have advocated repair of the origin of the ECRB back to the epicondyle using
sutures through bone tunnels or suture anchors, although this is not universally
practiced. The interval between the ECRL and the EDC is then repaired, and the skin
is then closed. Postoperatively, the elbow is immobilized for a short period to allow
for soft tissue healing after which range of motion exercises are started.
Complications include iatrogenic posterolateral rotatory instability secondary to
excessive debridement and neuroma of the posterior cutaneous nerve of the forearm.
More recently, there has been interest in using arthroscopic techniques for treatment
of lateral epicondylitis. In addition to the ability to evaluate the joint for intra-articular
pathology, the technique allows for debridement of the undersurface of the ECRB
tendon without division of the common extensor aponeurosis as well as a possibly
shorter recovery time.
For the arthroscopic technique, two portals are used: a proximal medial portal for
viewing and a lateral working portal. Before establishment of the portals, the joint is
injected with 30 mL of saline solution to displace the neurovascular structures
anteriorly. The medial portal is established, taking care to maintain contact of the
trocar with the anterior surface of the humerus. The arthroscope is inserted and the
initial joint inspection is then performed. The superior lateral portal is then
established under the direct visualization, and a motorized shaver or radiofrequency
ablation device is placed in the joint. The lateral capsule is then resected, allowing
visualization of the undersurface of the ECRB. The brevis is then released off of the
lateral epicondyle, removing pathologic tissue in the process. Care must be taken to
limit the distal extent of debridement to the superior half of the radial head. More
aggressive resection risks injuring the origin of the collateral complex and producing
iatrogenic instability. The lateral epicondyle is then decorticated with a burr.
Postoperatively, the patients are placed in soft dressings, and early active range of
motion is begun with return to full activity as tolerated. Complications include nerve
injury from portal placement, the development of heterotopic ossification, and
posterolateral rotatory instability.
Surgery is generally reserved for chronic conditions that are unresponsive to
conservative management and are associated with significant limitation in functional
performance. The approach most commonly involves debridement of degenerative
granulation tissue adjacent to the extensor carpi radialis brevis insertion and partial
release of the common extensor aponeurosis. Postoperative rehabilitation employs the
principles previously discussed and often requires 4 to 6 months resumption of full
activity.
Recently, a study was published comparing the results of all three techniques.
Although nonrandomized and retrospective, it is the largest comparative series to
date. When evaluating groups of patients treated with the open technique,
percutaneous technique, and arthroscopic technique, all three groups improved in
clinical outcomes measures, with no statistical difference between them. In another
retrospective, nonrandomized study comparing the results of open versus arthroscopic
treatment, both groups were similar in both outcome measures and postoperative
function, with no statistical difference. The arthroscopic group did, however, return to
work sooner, at 1.7 months, compared with 2.5 months for the open group.
There is still no consensus on which operative procedure offers the best results.
Therefore the choice of procedure often will be surgeon dependent.
Postoperative Management
The type of surgical technique and the presence of postoperative complications may
affect the timing of referral to therapy. Early postoperative care may include
fabrication of an orthosis to support the wrist and/or elbow, gentle active range of
motion for the elbow and wrist, and physical agents to modulate pain and decrease
edema. Referral may be delayed until the time of suture removal. Therapy includes
active range of motion for the elbow and wrist and progressive functional activity as
tolerated. In addition to physical agents to modulate pain and decrease edema, scar
management, particularly desensitization, is often needed in the short term.
Neuromuscular conditioning, as previously described, is typically initiated at 6-12
weeks after surgery, with emphasis on progressive resistive total arm strengthening
ergonomic counseling and sports modification.
XI. REHABILITATION
A. AREAS AND INSTRUMENTATIONS
ROM and MMT testing:
Wrist Flexion
Wrist Extension
Wrist Radial Deviation
Wrist Ulnar Deviation
Forearm Supination
Forearm Pronation
Special Tests:
Lateral Epicondylitis (Tennis Elbow or Cozen’s) Test (Method 1)
The patient’s elbow is stabilized by the examiner’s thumb, which rests on the
patient’s lateral epicondyle. The patient is then asked to actively make a fist, pronate
the forearm, and radially deviate and extend the wrist while the examiner resists the
motion. A sudden severe pain in the area of the lateral epicondyle of the humerus is a
positive sign. The epicondyle may be palpated to indicate the origin of the pain.
Lateral Epicondylitis (Tennis Elbow or Mill’s) Test (Method 2)
While palpating the lateral epicondyle, the examiner passively pronates the patient’s
forearm, flexes the wrist fully, and extends the elbow. Pain over the lateral epicondyle
of the humerus indicated a positive test. This maneuver also puts stress on the radial
nerve and, in the presence of compression of the radial nerve, causes symptoms
similar to those of tennis elbow.
Lateral Epicondylitis (Tennis Elbow or Maudsley’s) Test (Method 3)
The examiner resists extension of the third digit of the hand distal to the proximal
interphalangeal joint, stressing the extensor digitorum muscle and tendon. A positive
test is indicated by pain over the lateral epicondyle of the humerus.
B. PROBLEMS
Most patients present with localized tenderness over the common forearm extensor
tendon insertion at the lateral epicondyle, often extending into the extensor mass.
Less commonly, there is discomfort over the radiohumeral joint and annular ligament.
Pain is generally reproduced with resisted wrist and middle finger extension and with
gripping activities. Passive wrist flexion with elbow extension often generates
symptoms. Flexibility and strength deficits are often seen in the wrist extensor and
posterior shoulder muscles.
C. TREATMENT AND MANAGEMENT
Treatment is the same as with bursitis. Application of a wide strap just below the
elbow will change and support muscle movement in the forearm, thus reducing some
of the pain.
The treatment of lateral epicondylitis follows the same principles for soft-tissue
rehabilitation: control of inflammation, promotion of healing, reduction of abusive
forces and improvement of soft-tissue flexibility, strength, and endurance. In the
context of acute injuries, resting the involved extremity and avoiding activities that
reproduce symptoms are critical. Occasionally, a wrist cock-up splint may be
necessary. NSAIDs and cryotherapy are useful in the acute phase. Therapeutic
modalities are often administered to relieve pain and inflammation and possibly
promote soft-tissue healing. The most common applications include cryotherapy,
high-voltage galvanic stimulation, transcutaneous electrical nerve stimulation
(TENS), ultrasound, phonophoresis and iontophoresis. Acupuncture has been used
successfully to treat soft-tissue injuries.
1. Rest, Ice, Compression, Elevation
2. Using of NSAIDs, gel or ointment, or iontophoresis during the acute phase.
3. Electrotherapy to settle inflammation such as ultrasound, laser and interferential.
4. Massage techniques to control scar tissue, such as frictions.
5. Stretching of the muscle to stimulate the enthesis and prevent scar contraction.
6. Isometrics of the extensors to organize scar tissue and strengthen the muscles.
7. Dynamic exercises to increase muscle strength.
EPICONDYLITIS REHABILITATION PROGRAM IN SPORTS
PHASE I (acute)
Active rest
Splint when necessary
Modalities to reduce pain, inflammation, and edema and to promote healing
Begin flexibility exercises when tolerated
PHASE II
Continue flexibility exercises
Begin strengthening wrist flexors/forearm pronator
Begin light multi-joint shoulder, scapula and elbow strengthening (avoiding positions of elbow
extension)
Continue modalities as needed
PHASE III
Begin isolated wrist extension, radial deviation and supination strengthening if tolerated (elbow flexion)
Continue strengthening for full upper extremity
Continue flexibility exercises
A. Goals
1. To restore normal, painless use of the involved extremity.
2. To restore normal strength and extensibility of the musculotendinous unit.
3. To encourage proper maturation of scar tissue and collagen formation, and to
allow extensibility and the ability of the tendon to attenuate tensile stress.
B. Objectives
1. Resolution of the chronic inflammatory process
2. Maturation of the scar. The new collagen must be sufficiently stored and
extensible to withstand the tensile stresses imposed by activity. There must be an
appropriate amount of tissue that is oriented to attenuate relief stresses with a
minimum of internal strain.
3. Restoration of strength and extensibility to the muscle-tendon complex.
C. Techniques
1. Acute cases. Tendon injuries of the elbow are by nature, chronic disorders, but
some patients may present with acute symptoms and signs associated with lateral
or medial tennis elbow; pain is referred into the entire forearm and perhaps the
hand, and occasionally, up the back of the arm. There may be some pain at rest
and some degree of muscle spasm is elicited when the tendon is stressed passively
or by restricted movements. In such cases, the immediate goal is to promote
progression to a more chronic state, assisting in the resolution of acute
inflammation.
a) Instruct the patient to apply ice to the site several times a day. The
physical therapy modality of high-voltage galvanic simulation has been
helpful in relieving pain and inflammation.
b) Continued stress to the tendon must be prevented. If the patient present
with acute symptoms and signs as outlined above, this is best achieved by
PHASE IV
Begin wrist and forearm strengthening with elbow in extension if asymptomatic
Continue aggressive upper extremity strengthening exercises
Begin activity-specific function exercises and neuromuscular drills and endurance training
Continue flexibility exercises
PHASE V
Begin sports-specific interval program
Biomechanical or ergonomic assessment and alteration
Maintenance program for strength and flexibility
immobilization of the wrist, hand and fingers (not the elbow) in a resting
splint. In some cases, a simple wrist cock-up splint will suffice because
this obviates the need for the wrist extensors to contract when the finger
flexors are used. Activities involving grasping, pinching and fine finger
movements must be restricted. This is often the most difficult component
of the program to institute but at the same time, the most important at this
stage. The effectiveness of any other treatment measures will be
compromised if the patient continues to engage in activities that stress the
lesion site. For example, a carpenter must take some time off work or
temporarily change duties, a tennis player must abstain from playing for a
while, and persons who enjoy knitting, sewing and gardening must
temporarily alter their activities.
c) A few times a day, the patient should remove the splint and actively move
the wrist into flexion, the forearm into pronation, and the elbow into
extension simultaneously, to minimize the loss of extensibility of the
muscle and tendon. This should be done gently, avoiding significant
discomfort, and slowly to prevent high strain-rate loading of the tissue.
If appropriate instructions are given and the patient faithfully
follows
the outlined program, progression to a more chronic status should
occur during a period of a few (3 to 5) days.
2. Chronic cases (lateral tennis elbow). If the pain is fairly localized over the lateral
elbow region and there is little or no pain at rest, the disorder should be treated as
chronic tendinitis.
a) Advise the patient explicitly as to the appropriate level and type of activity
that may be performed. Strong, repetitive, grasping activities such as
hammering, and activities that particularly stress the tendon, such as
tennis, must be restricted until there is little pain on resisted isometric
wrist extension and little or no pain when the tendon is passively stretched
(such as in wrist flexion, forearm pronation and elbow extension). Such
activities must be resumed gradually, with some protection of the part.
Protection may be provided btht e counterforce bracing with an inelastic
cuff worn firmly around the proximal forearm ( the forearm extensors for
lateral tennis elbow and the forearm flexors for medial tennis elbow).
Also, as normal activities are resumed, certain adaptations may be
implemented to minimize the stresses imposed on the wrist extensors. An
example can be seen in tennis player’s racquet where high string tension
and low racquet flexibility will result in reduced attenuation of forces by
the racquet and, therefore, greater transmission of high-strain rate forces to
the arm.Each patient’s activities should be similarly assessed for ways to
reduce the loads on the wrist extensor group.
b) Two rehabilitation approaches may be taken in treating lateral and medial
tennis elbow. The first approach involves all the normal measure to reduce
inflammation and pain. Treatment may include rest and restriction of
activities, using therapeutic modalities such as cryotherapy,
electrotherapy; iontophoresis and ultrasound. And using non-steroidal
anti-inflammatory drugs. The second approach would be to realize that the
patient has chronic inflammation, which is not going anywhere and is in
effect stuck. The goal of this approach is to “jump start” the inflammatory
process, in effect, using techniques that are likely to increase the
inflammatory response and allowing healing to progress as normal to the
fibroplastic and remodeling phases. To increase the inflammatory
response, deep transverse friction massage may be used. The beneficial
effects of the friction massage in cases of tendinitis are not well
understood but are probably related to the induced hyperemia and the
mechanical influence it may have on tissue maturation. The hyperemic
effects are of greatest importance in cases of tendinitis that may be related
to hypovascularity, for instance, at the shoulder. Hyperemia does not seem
to be a significant factor in the origin of tennis elbow, however, and this
may in part explain why friction massage is effective for a shorter period
of time in rotator cuff tendinitis than it is in cases of tennis elbow. The
mechanical effects of the deep massage may promote orientation of
immature collagen along the lines of stress. This would be an important
factor in pathologic disorders, such as tennis elbow, in which some type of
mechanical stimulus is necessary for adequate tissue maturation. Use of
the deep transverse massage may assist in tissue maturation without
imposing a longitudinal stress to the healing tendon tissue and, therefore,
without continued rupturing of the fibers at the side of the lesion. Thus,
the defect heals with a maximum degree of tissue extensibility and is
likely to be overstressed as use of the part is resumed. This seems to be a
solution to the dilemma mentioned above. If the patient continues to use
the part, he or she perpetuates the problem by producing continued
damage at the lesion site; if the patient completely immobilizes the part,
there is no stimulus for tissue maturation and as soon as the activity is
resumed, the healed tissue begins to break down.
c) Strength and mobility must be restored. As symptoms and signs indicate
signs of improvement, the patient must resume activities gradually.
Excessive internal strain to the tendon can be minimized during stressful
activities by optimizing tissue extensibility. No vigorous activities should
be allowed until it is determined whether the muscle-tendon complex has
sufficient extensibility. To facilitate the mobility, the clinician should
gently and slowly stretch the tissue by holding the elbow extended and
forearm pronated, and wrist ulnarly deviated, while flexing the wrist and
fingers. The patient is instructed to perform this stretch at home,
emphasizing that is must be performed slowly and gently. The patient
should notice a stretching sensation. As vigorous activities such as tennis,
carpentry and gardening are resumed, the patient may be taught to
administer friction massage for a few minutes before engaging in the
activity.Also, before a normal level of activity is resumed it is important to
ensure that good forearm strength has been restored in lateral tennis
elbow, wrist extensor strengthening exercises are always necessary
because the muscles invariably undergo atrophy from disuse and reflex
inhibition. Good reflex strength is necessary to protect the tendon from
high strain-rate passive loading, which may occur with many types of
activities. A convenient method of wrist extensor strengthening is to have
the patient tie a rope 3 feet long to the center of a 1-inch dowel and add a
weight to the end of the rope; the patient grasps both ends of the dowel
and rotates it toward him or her until the entire rope become wrapped
around the dowel. This can be repeated as appropriate; the weight may be
varied as necessary.
Forearm rehabilitative exercises to increase muscle power
flexibility and endurance are important. Continued strengthening of
uninjured areas and protective exercises for the injured areas are
necessary. Isometric, isotonic, isokinetic, and isoflex exercises are all
used. Isoflex exercises consist of muscle strengthening, using both
concentric and eccentric cord. Maximum strengthening of the muscles
must necessarily include eccentric exercise. Plyometric exercises and
functional training activities should progressively incorporate the stresses,
strains and forces that occur during the normal activity, gradually
increasing the frequency, intensity and duration of exercise.
Local anti-inflammatory therapy such as infiltration with a corticosteroid
is commonly used In cases of tendinitis. Although symptomatic
improvement is often dramatic; such treatment has only temporary value.
It has no lasting beneficial effect on the pathologic process and does not
influence etiologic factors. At best, it should be considered an adjunct to
management in the acute state. Too often other important components of
the treatment program are ignored when an apparent “cure” is heralded by
dramatic symptomatic improvement.
In those individuals who have persistent pain that does not resolve after 1
year of conservative treatment, surgery should be considered.
When treating a patient for lateral tennis elbow, it is important to address weaknesses and
biomechanical abnormalities in other parts of the upper extremity, which may be related to this
condition.
Early on, relief of pain and any inflammation that is present is achieved through relative ice, rest
and non- steroidal anti-inflammatory drugs. Ice can be applied multiple times throughout the
day. Other helpful modalities may include ultrasound, electrical stimulation, and other sources of
heat.
Rehabilitative exercises are begun with isometric strengthening of the elbow flexors, wrist
extensors, and pronators and supinators. This is initially is done only within the arcs of pain-free
motion, but later is expanded to include full range of motion. Isotonic weight and resistance
training is added as tolerated, initially with the elbow flexed and later with the elbow extended.
For more competitive athletes, arm cycling and isokinetic exercises may be useful as well.
Stretching is often not tolerated early in the treatment, but as 80% of normal strength is achieved,
a stretching program can be initiated. The stretches included in this program are performed in
flexion and extension; again at first with the elbow flexed, and the later with the elbow extended.
Ice application both before and after stretching can be beneficial.
When the patient is starting to feel better and is ready to return to full activity, a gradual
progression of return to either sport or job is indicated. Proper technique should be taught, and
aggravating activities avoided. As a rule, patients should not lift objects with palm down,
especially heavy objects on repetitive basis. They should avoid prolonged or strong gripping
activities, which cause a contraction of the wrist extensors. They may need to be taught not to
grip a briefcase or suitcase overly tightly, but to let the finger carry the load. Too early a return to
activity often causes a recurrence, which can be difficult to treat.
Surgical management, which includes resection of the pathologic tissue while leaving all normal
tendon origin in place, is considered only if the patient fails to respond to adequate rehabilitation
program ( generally lasting 3-4 months)
D. PRECAUTIONS
Preventive approach is the most practical and prudent way to deal with elbow
injuries.
It includes proper warm-up, Avoidance if sudden excessive overloading or overuse,
optimal technique, and exercises to develop flexibility, strength and endurance.
The most effective stretching exercise to prevent Lateral Epicondylitis is to stretch the
supinators of the elbow and forearm (Supinator Muscle, Biceps Brachii and
Brachioradialis) by grasping a broomstick, golf club, or tennis raquet in a dorsal grip
(back of the hand faces down and thumb grasps under the handle.
This type of stretch can be intensified by hanging from a chin-up bar in a dorsal grip.
XII. REFERRENCES
Brotzman, S.B. and Manske, R.C. (2011) Clinical Orthopaedic Rehabilitation: An
Evidence-Based Approach (3rd Ed.) Philadelphia, PA: Elsevier Mosby
Frontera, W.R. and Delisa, J.A. (2010) Physical Medicine and Rehabilitation:
Principles and Practice (5th Ed.) Philadelphia, PA: Lippincott Williams and Wilkins
Magee, D.J. (2014) Orthopedic Physical Assessment (6th Ed.) Philadelphia, PA:
Elsevier Saunders
Meadows, J.T.S. (1999) Orthopedic Differential Diagnosis in Physical Therapy USA:
McGraw-Hill Companies
Skirven, T.M (2011) Rehabilitation of the Hand and Upper Extremity (6th Ed.)
Philadelphia, PA: Elsevier Mosby
Andrews, J. (2004) Physical Rehabilitation of the Injured Athlete (3rd Ed.)
Philadelphia, PA: Elsevier Saunders
Read, M.T.F (2008) Concise Guide to Sports Injuries (2nd Ed.) Philadelphia, PA:
Churchill Livingstone Elsevier
Buschbacher R.M (2002) Practice Guide to Musculoskeletal Disorders : Diagnosis
and Rehabilitation (2nd Ed.)
Goodman, Snyder (2013) Differential Diagnosis in Physical Therapy (3rd Ed.)
Neighbors M. and Jones R.T (2006) Human Diseases (2nd Ed)
Cyriax, J, (1996) Illustrated Manual of Orthopaedic Medicine (3rd Ed.)
Goodman and Snyder Differential Diagnosis in Physical Therapy (3rd Ed.)
Hertling, D.; Kessler, R. (2005) Management of Common Musculoskeletal Disorders,
Physical Therapy Principles and Methods, Fourth Edition
Suekl, D.; Brechter, J. (2010) Orthopedic Rehabilition Clinical Adviser
Alter, M.J. Science of Flexibility (2nd Ed.)
www.physio-pedia.com
SOAP
Initial Evaluation
GENERAL INFORMATION
Name: L.E
Age: 46 years old
Civil status: Married
Handedness: ®
Sex: Male
Occupation: Butcher
Address: Magalang Road, Pandan, Angeles City
Religion: Roman Catholic
Citizenship: Filipino
Date of Consultation: May 9, 2014
Physiatrist: Dr. Andy Aygenman
Date of Initial evaluation: May 12, 2014
Dx: ® lateral epicondylitis
HPI
3 months PTC (Feb. 9, 2014) the Pt. felt localized, intermittent dull aching pain PS (5/10) on the
® lateral aspect of the elbow while chopping a pork thigh. Pain worsens when Pt. extends his ®
wrist and carries heavy meat PS (7/10) Pt. took Ibuprofen 500 mg which ↓ the pain to PS (3/10)
every time he experienced pain at the ® lateral aspect of the elbow for 2 months.
30 days PTC (April 9, 2014) the Pt. was having difficulty in doing ADL’s like turning door
knobs, chopping ingredients and lifting heavy objects.
1 day PTC (May 8, 2014) while the Pt. is scaling milkfish an ↑ dull aching pain PS (8/10) on his
® lateral elbow. The Pt. rested for an hour and took Ibuprofen 500 mg. The pain did not ↓ even
though he took Ibuprofen. This prompt him to consult Dr. Andy Aygenman the next day. Upon
consultation the doctor noted a grade 3 tenderness on the ® lateral elbow . The doctor peformed
Cozen and Maudsley test and the Pt. was positive of ® lateral epicondylitis. Dr. Aygenman
referred Pt. to a physical therapist for further evaluation and management.
PMHx
(-) Trauma
(-) Hospitalization
(-) Past surgeries
(-) HPN
(-) DM
(-) Arthritis
FMHx
Father Mother
HPN (-) (-)
DM (-) (-)
Asthma (-) (-)
Tumors/CA (-) (-)
Allergies (-) (-)
Arthritis (-) (-)
PSHx
Type B lifestyle
Sedentary lifestyle
(-) smoker
(-) alcohol drinker
Home set-up situation
o Bungalow
o Lives with wife and 3 daughters
Sleeps on firm mattress
Sleeps in fetal position
Work Assessment
Works as a butcher for 25 years
Working hours: 4am-12pm Monday-Saturday at the local public market
Chops meat, scaling and removing internal organs of fishes and lifting heavy meat.
S
C/C: “Kapagnagchop-chop ako ng karne, nagaalis ng kaliskis ng isda at
ginagawaangibakongtrabahosumasakityungkanangsikoko” PS (8/10)
PT Interpretation: “Whenever I chop meat, scaling fish and doing other work, I feel pain on my
® elbow” PS (8/10)
O
Vital Signs:
Before After
BP: 120/80 mm Hg 120/80 mm Hg
RR: 16 cpm 16 cpm
PR: 80 bpm 80 bpm
T: 37 ° C 37 ° C
Findings: all vital signs are WNL
Significance: baseline purposes
OI:
Ambulatory š AD
Alert,coherent,cooperative
Mesomorph
(+) swelling on ® lateral elbow
(-) Ecchymosis
(-) deformity
(-) wounds
(-) scars
(-) postural deviation
(-) gait deviation
Palpation:
Normothermic on all exposed body parts
Normotonic on (B) UE and LE
(+) Grade 3 tenderness on ® lat. elbow
(+) ms. Guarding of wrist extensors
(-) ms. Spasm
(-) edema
(+) swelling
(-) nodules
(-) mass
(-) subluxation/dislocation
(-) crepitus
ROM: All joints of (B) UE and LE are WNL actively and passively done pain free except for the
ffg:
Motions Active Passive N Diff. A Diff. P Endfeel
Wrist
Flexion
0°-70° 0°-75° 0°-80° 10° 5° Firm
Wrist
Extension
0°-50° 0°-55° 0°-70° 20° 15° Firm
Wrist
Pronation
0°-70° 0°-75° 0°-80° 10° 5° Firm
Wrist
Supination
0°-70° 0°-75° 0°-80° 10° 5° Firm
Wrist
Radial
Deviation
0°-5° 0°-10° 0°-20° 15° 10° Firm
Wrist
Ulnar
Deviation
0°-20° 0°25° 0°-30° 10° 5° Firm
Findings: There is LOM in ® forearm and wrist movements.
Significance: LOM 2° to Pain
MMT: All ms of (B) UE and LE are grossly graded 5/5 except for the ffg:
Wrist Flexion: Grade 2-
Wrist Extension: Grade 2-
Wrist Pronation: Grade 2-
Wrist Supination: Grade 2-
Wrist Radial Deviation: Grade 2-
Wrist Ulnar Deviation: Grade 2-
Findings: there are weakness on ® wrist flexion, extension, radial deviation, ulnar deviation,
forearm supination and pronation.
Significance: Muscle weakness 2° to pain
GRIP STRENGTH:
A dynamometer was used.
(L):43 kg
® : 28 kg
Difference: 15 kg
Findings: decreased grip strength of ® hand.
Significance: weakness 2° to pain
Sensory Assessment
STD: pin for pain, brush for light touch, thumb for pressure
Findings: 100% sensory intact as to pain, light touch, and pressure.
Significance: Intact Lateral Spinothalamic Tract
DTRs
Legend:
0 = reflexive
+ = hyporeflexive
++ = normoreflexive
+++ = hyperreflexive
++++ = clonus
Findings: DTRs are normal
SPECIAL TEST:
(+) Cozen Test
(+) Maudsley Test
Findings: Test are (+)
Significance: ® lateral epicondylitis
LGM
Marking (R) elbow (L) elbow
Marking (R) (L) Difference
10 cm above lateral
epicondyle
28 cm 28 cm 0 cm
5 cm above lateral
epicondyle
28 cm 28 cm 0 cm
Lateral epicondyle 30 cm 28 cm 2 cm
5 cm below lateral
epicondyle
27 cm 26 cm 1 cm
10 cm below lateral
epicondyle
25 cm 25 cm 0 cm
Findings: a difference of 2 cm on the ® lateral epicondyle
Significance: (+) swelling on ® elbow.
Gait Analysis
Findings: All parameters of gait are (N)
Functional Analysis
Functional Status Scale
On a typical day during the past two weeks have hand and wrist symptoms caused you to have
any difficulty doing activities listed below? Please circle one number that best describe your
ability to do the activity.
Activity No Difficulty Mild
Difficulty
Moderate
Difficulty
Severe
Difficulty
Cannot Do at
All Due to
Hand or Wrist
Symptoms
Writing 1 2 3 4 5
Buttoning of
clothes 1 2 3 4 5
Holding a
book while
reading
1 2 3 4 5
Gripping of a
telephone
handle
1 2 3 4 5
Opening of
jars
1 2 3 4 5
Household
chores
1 2 3 4 5
Carrying of
grocery bags
1 2 3 4 5
Bathing and
dressing
1 2 3 4 5
Findings: Pt. encounters moderate or severe difficulty when performing ADL’s involving
gripping of telephone handle, opening of jars, household chores, carrying of grocery bags and
mild difficulty in bathing and dressing.
ADLs
Pt. is independent in all aspects of ADL's as to ambulation except with turning door knobs and
work activities such as chopping meat, scaling and removing internal organs of fishes and
carrying heavy meat.
A
Dx: ® lateral epicondylitis
PT Impression: Pt. has a ® lateral epicondylitis manifested by LOM and muscle
weakness of ® wrist flexors, extensors, radial deviators, ulnar deviators, forearm pronators and
supinators,with a grade 3 tenderness and swelling on ® lateral elbow, and has difficulty in
activities involving ®wrist motion such as chopping meat, scaling and removing internal organs
of fishes and carrying heavy meat.
Problem List:
1. Dull aching pain (PS 8/10) on ® lateral elbow
2. Muscle weakness on wrist extensors and flexors, radial and ulnar deviators, forearm supinators
and pronators
3. LOM in wrist flexors and extensors, radial and ulnar deviators, forearm supinators and
pronators
4. Swelling on the ® lateral elbow
5. Decrease in grip strength of the right hand
6. Difficulties in doing ADLs such as gripping of telephone handle, opening of jars, household
chores and carrying of grocery bags
LTG:
1. To restore normal, painless use of the involved extremity.
2. To restore normal strength and extensibility of the musculotendinous unit
3. To encourage proper maturation of scar tissue and collagen formation, and allow
extensibility and the ability of the tendon to attenuate tensile stresses.
STG:
1. To decrease pain from PS (8/10) to PS (4/10)
2. To restore a portion of the original strength of the muscles.
P
PT Management:
1. Ultrasound on ® lat. Elbow using water bag technique (small head – 1MHz)
2. Friction massage to control scar tissue
3. PROM of ® elbow and wrist for 10 reps X 1 set
4. Isometric contraction of wrist extensors 10 reps X 3 sets
5. Stretching with the elbow in extension, forearm in pronation, wrist in flexion and ulnar
deviation 30sh X 3 set
HI
1. Avoid stressful movements that will induce pain on the ® elbow.
2. Instruct the Pt. to apply ice to the site several times a day.
3. AAROM exercises of ® elbow and wrist in pain free range for 10 reps X bid
4. Squeeze ball exercises for 6sh X 10 reps X bid