Lateral epicondylitis (Tennis elbow)

Non-specific inflammation characterized by pain and tenderness at the lateral epicondyle of the humerus (at the origin of extensor muscles of the forearm).

The condition is seen in tennis players due to awkward strokes during the game therefore called tennis elbow but however is an overuse injury in the day to day activities of pulling, lifting, pushing or squeezing clothes etc.

Anatomy-

  • The lateral border of the humerus ends at the lateral epicondyle. 
  • Its lateral and anterior surface show a well-marked impression for the superficial group of the extensor muscles of the forearm which arise from the lateral side of the humeral epiphysis.

Causes-

  • Angiofibroblastic proliferation of extensor carpi radialis brevis
  • Periostitis ( inflammation of periosteum)
  • Inflammation of adventitious bursa between common extensor origin and radio humeral head
  • Calcified deposition in common extensor tendon
  • Painful annular ligament due to hypertrophy of synovial fringe  between the radial head and the capitulum
  • Neurological pain

Pathophysiology-

Stage1- Stage of acute inflammation and pain is felt during activity only.

Stage2- Stage of chronic inflammation with some angioblastic invasion and pain is felt both during activity and at rest.

Stage3- Stage of chronic inflammation with extensive angioblastic invasion and pain is felt at rest, at night and during daily activities.

Etiology-

  • Faulty playing techniques of tennis
  • Non-tennis players
  • Indian house wives
  • IT professionals ( very common in recent scenarios) etc.

Clinical features-

  • Pain and tenderness on the outer aspect of the elbow
  • Difficulty in gripping and lifting objects
  • Difficulty in extending the elbow.

Physical examination-

  • Local tenderness- at the point of common extensor origin in the elbow.
  • Cozen test- Resisted wrist extension with stabilized elbow extension elicits pain at lateral side of elbow.
  • Maudsley’s test- Resisted extension of middle finger elicits pain.
  • Pinch grip test- 
  • Radiograph- In 16% cases a faint calcification along the lateral epicondyle can be detected.

Management-

Conservative treatment-

NSAIDs or injection of hydrocortisone acetate with  local anesthetic solution.

Physiotherapy management-

  • Cryotherapy- Over painful areas for 7 min with an ice cube or 30 minutes with an ice pack.
  • Supportive measurement- Tennis elbow splint for 2-3 weeks.
  • Electrical stimulation, iontophoresis, diapulse and TENS etc. to control pain and inflammation.
  • Mulligan lateral glide reduces pain and improves function.
  • Gentle active movements progressed with progressive resisted exercises after extension range achieved.
  • Kinesio taping

Surgical management-

  • Percutaneous release of epicondylar muscle.
  • Bosworth technique of excision of the proximal portion of annular ligament, release of the origin of the extensor muscle, excision of the bursa and excision of synovial fringes.

Post operative physiotherapy management-

  • Immobilization for 1 week with limb elevation
  • Measures to reduce pain and inflammation.
  • Mobilization- Begin with slow, relaxed passive full range of motion and progress to functional movement patterns and resisted exercises to PREs.

Reference-

  • Mark Dutton ( Dutton’s orthopedic )
  • Mohit Bhandari ( Evidence based orthopedics)
  • David J. Magee and Robert C. Manske ( Orthopedic physical assessment)
  • Jayant Joshi and Prakash Kotwal ( Orthopedics and applied physiotherapy)
  • J. Maheshwari and Vikram A. Mhaskar ( Essential orthopedics)