Tennis Elbow

Tennis elbow or lateral epicondylitis, as it is known, is defined as a local inflammation or tendinitis at the musculotendenous junction of the common wrist extensors at their attachment lateral epicondyle of the elbow. It is commonly known as tennis elbow due to the high incidence in the sport.(1)

It is estimated that the incidence rate is approximately 1.3% of the general population. People who play tennis up to 2 hours daily are 4 times more likely to suffer lateral epicondylitis.

Rates are also increased in a smoking population and population that undergoes forceful activity like manual labourious jobs. It has no preference for male or female and is most common in  people aged between 45-54 yrs of age.(1, 2)

Clinical Signs & Symptoms

• The typical age of those affected is 40 to 50 years.
• Patients most typically report an insidious onset, but they will often relate a history of overuse without specific trauma.
• Symptom onset generally occurs 24-72 hours after repeated wrist extension activity.
• Delayed symptoms are probably due to microscopic tears in the tendon.
• Complaints of pain over the lateral elbow that worsens with activity and improves with rest. The patient will also often describe aggravating conditions such as a backhand stroke in tennis or the overuse of a screwdriver.
• Pain may radiate down the posterior aspect of the forearm.
• The patient can often pinpoint pain 1.5 cm distal to the origin of the ECRB muscle.
• Pain can vary from being mild (eg, with aggravating activities like tennis or the repeated use of a hand tool), or it can be such severe pain that simple activities like picking up and holding a coffee cup (ie, “coffee cup sign”) will act as a trigger for the pain.

Lab Tests and Imaging

• No specific lab tests for Lateral epicondylitis however if any rheumatic conditions are suspected it would pay to do the appropriate bloods to either rule them in or out.
• Plain radiography is useful to evaluate osteoarthritis, osteochodrosis dissecans, or other bony abnormalities.
• Musculoskeletal (MSK) ultrasonography is not very sensitive; epicondylitis appears as a thickening or thinning of the tendon, as well as decreased echogenecity and poor definition of tendon.
• Magnetic resonance imaging (MRI) is the gold standard in detecting epicondylitis. MRI is the most sensitive test, showing tendon thickening and high T2 signal intensity.

Review of Evidence for Management

Following an evidence based approach towards the treatment of lateral epicondylitis medical practitioners will find little quality evidence toward the best treatment approach.

Currently, initial treatment involves modifying the affecting causative activates to allow time for the tissue to heal appropriately. This is enhanced by the use of anti-inflammatory medication and the use of  osteopathy and counter force bracing(3).

Symptoms of lateral epicondylitis can persist as long as six months to two years. Rest alone may not be enough for the tissue to heal properly and is therefore recommended that some sort of conservative management is undertaken(4).

A  single blind randomised control trial that included 98 participants aged 18 to 65 years with a clinical diagnosis of lateral epicondylitis for a minimum six weeks’ duration, who had not received any other active treatment by a health practitioner in the previous six months, has concluded that manual therapy which combines elbow manipulation is a far better option than doing nothing in the first six week period and far superior to corticosteroid injections after a six week period.(5)

Common physical therapy interventions include education on pathology and ergonomics, stretching and strengthening exercises, and progressive work-hardening protocols(6).

As an osteopath, it is important to look as the other associated structures and also treat them appropriately common dysfunctions seen in lateral epicondylitis include the ipsilateral upper thoracic spine and ribs, the radial head and ulnohumeraljoint, the lower cervical spine, and the pronator teres muscle.

Applying osteopathic techniques to these areas will allow tension to be relieved in the area of the lateral epicondyle allowing greater pain relief and tissue healing capability. It should also be noted that the patient with lateral epicondyle pain may not in fact have true lateral epicondylitis but radial head dysfunction or ulnar deviation.(7)

Sources:

1. Ferri FF. Ferri’s Clinical Advisor. Philadelphia: Elsevier; 2013. p. 374-75.
2. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. American journal of epidemiology. 2006;164(11):1065-74.
3. Jayanthi N. Epicondylitis (tennis and golf elbow) 2014 [cited 2014 26th August]. Available from: https://www.uptodate.com/contents/epicondylitis-tennis-and-golf-elbow?source=search_result&search=lateral+epicondylitis&selectedTitle=1~15.
4. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial. The American journal of sports medicine. 2004;32(2):462-9.
5. 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. BMJ (Clinical research ed). 2006;333(7575):939.
6. Barr S, Cerisola FL, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. Physiotherapy. 2009;95(4):251-65.
7. Chila AG, American Osteopathic Association. Foundations of osteopathic medicine. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011. p. p.658