Assessment of Tennis Elbow

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Introduction

Tennis Elbow, also known as Lateral Epicondylitis, is described as pain over the lateral epicondyle of the humerus. It is a common presentation between 35-45 years of age. Smoking, obesity, manual work requiring repetitive loading of wrist extensors and tennis players are considered to be risk factors of Tennis Elbow.

Tennis Elbow has great effects on the quality of life as well as the participation in work, sports and leisure activities.

Lateral Tendinopathy is seen in 1-3% of the general population

Although up to 90% of the presentations are self-limiting,, not all of them experience full recovery and the pain and discomfort last up to a year. Recurrence is also common in Tennis Elbow and around 5% need surgery.

Work absenteeism is documented in 5% of affected working adults, with a median duration of 29 days in the previous 12-month time period.

Pathophysiology

The structural pathology is not always evident in various clinical presentation. In fact, some studies reported discordance between clinical severity and tendon pathology in patients with tendinopathy. This drives our attention to the multi-factorial nature of many MSK conditions. Psychological factors, central sensitization and/or other CNS-mediated factors may play roles in the onset and prognosis of the condition.

From a histological point of view, Lateral Teninopathy seems to be progressing as any other tendinopathy, increased cellularity, an accumulation of ground substance, collagen disorganization, and neurovascular ingrowth. In the case of Tennis Elbow this process is observed in the deep and anterior fibers of the extensor carpi radialis brevis (ECRB). In sever presentations, the ECRB is often merged with the lateral collateral ligament (LCL), which fuses with the annular ligament of the proximal radioulnar joint.

Understanding tendon changes associated with Tennis Elbow affects the rehabilitation decisions.

Baseline sever pain is predictable of poorer outcomes

Some studies found a link between stress, anxiety and TE while others reported no association.

Tennis Elbow and Central Sensitization

Hightened Withdrawl reflex is evident in Tennis Elbow in addition to mechanical hyperalgesia and cold hyperalgesia. Clinical ice pain test, a simple test allows clinicians to examine pain senstivity. Pain intensity of more than 5/10, after 10 seconds of ice application indicated 90% likelihood of cold hyperalgesia.

Clinical assessment that identifies increased responsiveness to a variety of physical and emotional stimuli, heightened response to neurodynamic testing, or expansion of symptoms to sites outside the injured area may provide the clinician with important clues for central sensitization.

Examination

Pain provoking tests are the most utilized method of dianosing Tennis Elbow. This could be through palpating the lateral epicondyle, resisted extension of the wrist, index finger, or middle finger; and having the patient grip an object.

ROM of elbow, wrist and forearm should also be examined along with the accessory motion of the radioulnar, radiohumeral, and humeroulnar joints to detect any underlying stiffness or restriction. During examination, signs of elbow instability should be noted:

• clicking
• loss of control
• difficulty with pushing up with the forearm supinated

The posterolateral rotary drawer test can be used if instability was suspected which may need to be further examined by imaging.

In the presence of arm pain or neck pain, the cervical and thoracic spines and the radial nerve should all be examined.

Postural analysis and correction to influence the whole kinematic chain.

Individuals with Tennis Elbow commonly grip with the elbow in a more flexed position and display reduced pain-free grip force and weakness of the short wrist extensors (ECRB) but not the finger extensors. the weakness is widespread in the muscles of the affected upper limb. Also, bilateral deficits in reaction time and speed of movement were found in individuals with TE. This may refer to maladaptive cortical organization changes. therefore motor control training, strength and enduarance training should be put into consideration in the rehabilitaiton plan.

Outcome Measures

The pain-free grip test and the Patient Rated Tennis Elbow Evaluation (PRTEE). Although the pain free grip test is a reliable and sensitive measure, the grip strength is not always impaired in Tennis Elbow and it may exacerbate the symptoms.

PRTEE is a good measure for categorizing pain and disability and also to track improvement.Furthermore, patients with severe symptoms (PRTEE scores greater than 54) have been found to display more pronounced sensory disturbances that may be targeted by different pharmacological therapies

The Patient-Specific Functional Scale (PSFS) is another validated and reliable measure that could measure disability in functional activities as a general.

Imaging

A literature review summed the following:

• MRI is sensitive but not specific
• Ultrasonography detected tendopathic changes on 90% affected and 50% unaffected tendons
• The severity of tendon changes is not always reflected by the degree of symptoms. This is general to all tendinopathies and not exclusive to Tennis elbow.
• Negative Ultrasound can be used to rule out Tennis Elbow.
• If clicking or locking are present, MRI,CT or magnetic resonance arthrography can be used to detect other pathologies such as loose bodies, articular cartilage damage, ligament injury, or elbow synovial fold (plica) syndrome

Differential Diagnosis

A research paper suggested a table to differentiate Tennis Elbow from other similar pathologies. This could be challenging for clinicians as the symptoms are often similar.