by Brett Holland, PT, DPT, CSCS 09/13/2015
Do you have pain just below where my finger is pointing? If yes, then you most likely have a case of tennis elbow.
Background:
-Lateral Epicondylitis is typically an overuse condition involving the lateral forearm musculature near the common tendionous origin (see diagram).(ECRB, ED, EDM, ECU) [1].
-The most commonly affected muscle is the extensor carpi radialis brevis (ECRB) [2].
-It occurs in roughly 1-3% of the general population [3].
Causes:
– Forceful and repetitive use of the arms [4]
– Overuse from weight-training or fitness activities
– Work related activities which may be associated with LE include [4]:
1. Use of tools > 1kg
2. Lifting loads > 20 kg more than 10 X per day
3. Repetitive use > 2 hours
– Racquet sports (poor technique, duration, frequency, racquet handle size, racquet weight) [3]
Author’s Breakdown:
-Lateral Epicondylitis is a nagging type injury that often starts as a very mild discomfort in which most people ignore (don’t).
-It tends to progressively get worse as time goes on until it prevents you from working, lifting, or performing recreational activities.
-In general, the longer you have the symptoms the harder it is to treat.
-Epicondylitis often is a misnomer (itis indicates inflammation) , tendinosis or tendonopathy (indicating a degenerative process) are better suited to describe the pathology of tennis elbow [5].
Signs and symptoms:
•Lateral forearm pain that gets worse with activities and is relieved with rest
•Palpable thickening of the common extensor tendon
•Decreased grip strength
•Pain with lifting and gripping objects
•Positive Cozen’s test
•Positive resisted third digit test
•Positive Mill’s test
Treatment:
Acute vs Chronic Lateral Epicondylitis
Treatment of tennis elbow depends greatly on the duration of symptoms and proper identification of pathological stage. When a tendon undergoes stress, it responds with an increase in collagen deposition and cross linkage (tendon gets thicker). When the amount of stress exceeds the tendons capabilities, it results in a micro-tear. Multiple and repetitive micro-tears results in tendinosis (degeneration) 6. In short, the treatment approach for an acute tendinopathy is vastly different than the treatment approach for a chronic tendinopathy.
Histological Stages of Repetitive Microtrauma to Tendons [6]:
Stage 1: An acute inflammatory response
Stage 2: Increased concentration of fibroblasts, increase in capillaries (vascular hyperplasia), and increased tissue content in a organized and disorganzied manner in relation to muscle fiber orientation (most cases of tennis elbow are in this stage)
Stage 3: Partial or complete rupture of the tendon
Stage 4: Stage 2 or 3 tendinosis plus other associated changes (calcification etc).
Acute Lateral Epicondylitis Conservative Treatment:
The treatment approach for acute lateral epicondylitis typically includes:
1. Controlling and reducing pain and preventing progression
•Ice
•NSAIDS
•Physiotherapy modalities and manual techniques
•Bracing and taping can help to reduce stress on the lateral epicondyle.
•Orthotic bracing- thin braces may be more effective than thick braces (3/4-1 inch diameter) [7]. Place the brace approximately 1 inch distal to the lateral epicondyle [7].
2. Modifying activity
•Avoid exacerbating activities-find ways to train and perform activities around the injury in a pain free manner
3. Correcting posture and maintaining proper biomechanics during daily activities
4. Gradual restoration of function
•Grip Strength
•Flexibility
•Recreational Activities
5. Gentle Blood Flow Techniques
Chronic Lateral Tendinopathy Conservative Treatment:
The treatment for chronic lateral epicondylitis typically includes:
1. Reduce pain and promote a healing environment
•Blood flow exercises
•Aggressive soft tissue mobilization
•Physiotherapy modalities
2. Eccentric based exercises
•Strengthening of the lateral forearm musculature
3. Manual Therapy
• Physiotherapy techniques
4. Restore mobility
•Forearm and shoulder flexibility exercises
5. Improve shoulder performance
•Rotator cuff
6. Correct faulty posture
•Evaluate postural tendencies during daily activities
7. Reduce Mechanical Stress on the Muscular Origin
•Orthotic Bracing (see above)
In summary, the treatment for chronic lateral tendinopathy is generally a more aggressive approach. Some of the treatment techniques and exercises may elicit mild pain during the duration of the event but should subside immediately or shortly thereafter.
Brief Look at the Evidence:
Eccentrics and epicondylitis:
A recently published systematic review* investigated the effectiveness of an eccentric based exercise regime in the treatment of lateral epicondylitis.
* A systematic review combines already published research into a single article, essentially summarizing the evidence. It is a highly respected and powerful form of evidence.
The authors concluded[8], “Eccentric exercise, used in isolation or as an adjunctive therapy, decreases pain and improves function in lateral epicondylitis patients when compared with baseline”.
-“When compared with other treatment therapies, evidence supports the use of multimodal treatment programmes inclusive of eccentric exercise for improving pain and function in lateral epicondylitis patients “.
-“Exercise programmes prescribed by therapists and which can be performed at home [30] are inexpensive and have limited ongoing costs attached to the treatment”.
-“As the study by Stasinopoulos et al.[21] reported, supervision is important to ensure ongoing adherence and the effective implementation (i.e. progressions, frequency, and performance) of a physical therapy treatment programme”.
-Steroid Injection: balancing risks and rewards
-Steroids injections are often used to reduce pain and inflammation associated with tennis elbow
-Below I highlighted the benefits and risks associated with steroid injections
Positives:
-Short term symptomatic relief
-In a systematic review comparing corticosteroid injections vs Physiotherapy Barr et al found,”All of the included studies found that corticosteroid injections were significantly more effective than physiotherapeutic interventions for outcome measurements at short-term follow-up, i.e. between 3 weeks [30], [31] and [33] and 7 weeks”[9].
Negatives:
-Higher recurrence rate
-In the aforementioned review by Barr et al, the authors concluded, “The findings of this review suggest that corticosteroid injections are favourable to physiotherapeutic interventions at short-term follow-up; however, the recurrence rates have been shown to vary from 34% to 72% [30]”[9].
-Possible tendon degeneration
-In a systematic review, Dean et al concluded, “Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections”[10].
-Less effective in the long-term
-Barr et al also concluded when comparing corticosteroid injections vs physiotherapy, “Physiotherapeutic interventions have been shown to be favourable in the intermediate to longer term”[9].
-Bisset et al concluded in the BMJ in 2006: “The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow”[11].
In my opinion, cortisone shots work if the person moderates their activity levels appropriately and exercises in an appropriate manner. It will not be successful if the person simply returns to the aggravating activity.
References
1. Smidt N, van der Windt DA. Tennis elbow in primary care. BMJ 2006;333:927–928. Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/17082522
2. Cyriax JH. The pathology and treatment of tennis elbow. J Bone Joint Surg 1936;18:921–940. Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/19224937
3. Shiri R,Viikari-Juntura E,Varonen H,Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006;164:1065–1074.?Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/16968862
4. van Rijn RM, Huisstede BM, Koes BW, Burdorf A. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford) 2009;48:528–536.Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/19224937
5. Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, Tytherleigh-Strong G, Rushton N. LAteral Epicondylitis: a review of pathology and management. Bone Joint J. 2013 Sep;95-B(9):1158-64. Review.Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/23997125
6. KRAUSHAAR BS,NIRSCHL RP. TENDINOSIS OF THE ELBOW (TENNIS ELBOW): CLINICAL FEATURES AND FINDINGS OF HISTOLOGICAL, IMMUNOHISTOCHEMICAL, AND ELECTRON MICROSCOPY STUDIES. J BONE JOINT SURG [AM] 1999;81-A:259–278. Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/10073590
7. Rothschild B. mechanical solution for a mechanical problem: tennis elbow. World J Orthop. 2013 Jul 18;4(3):103-6. doi: 10.5312/wjo.v4.i3.103. Print 2013 Jul 18.PMID: 23878775 [PubMed] Pubmed. Web. 30 Apr. 2014.
8. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review of the literature Clin Rehabil. 2014 Jan;28(1):3-19. doi: 10.1177/0269215513491974. Epub 2013 Jul 23 .Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/23881334
9. Barr, Steven, Frances L. Cerisola, and Victoria Blanchard. “EFFECTIVENESS OF CORTICOSTEROID INJECTIONS COMPARED WITH PHYSIOTHERAPEUTIC INTERVENTIONS FOR LATERAL EPICONDYLITIS: A SYSTEMATIC REVIEW.” Physiotherapy 95.4 (2009): 251-65. Pubmed. Web. 30 Apr. 2014. http://www.csp.org.uk/physio-journal/96/2/effectiveness-corticosteroid-injections-compared-physiotherapeutic-interventions
10. John Floyd Dean, Benjamin, MCRS, Emilie Lostis, BSc, Thomas Oakley, BM, BSc, Ines Rombach, MSc, Mark E. Morrey, MD, and Andrew J. Carr, FRCS. “THE RISKS AND BENEFITS OF GLUCOCORTICOID TREATMENT FOR TENDINOPATHY: A SYSTEMATIC REVIEW OF THE EFFECTS OF LOCAL GLUCOCORTICOID ON TENDON.”Seminars in Arthritis and Rheumatism 43.4 (2013): 570-76. Pubmed. Web. 30 Apr. 2014. http://www.ncbi.nlm.nih.gov/pubmed/24074644
11.Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ2006;333:939 http://www.ncbi.nlm.nih.gov/pubmed/17012266
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