Assessment of Tennis Elbow

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Tony Lowe, Tarina van der Stockt, Jess Bell, Nupur Smit Shah, Rachael Lowe, Simisola Ajeyalemi, Lucinda hampton, Olajumoke Ogunleye and Robin Tacchetti  

Page is under work:

This page is currently undergoing work, but please come back later to check out new information!!

Introduction

Tennis Elbow, also known as Lateral Epicondylitis, is described as pain over the lateral epicondyle of the humerus. Tennis Elbow It is a common MSK presentation (4-7 out of 1000 MSK conditions annually , about 1-3% of the general population), often seen between 35-45 years of age in the dominant arm.

Smoking, obesity, manual work requiring repetitive loading of wrist extensors and being a tennis player 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. Work absenteeism is documented in 5% of affected working adults, with a median duration of 29 days

Despite the fact that tennis players represent 5-10% of the represented cases, the term Tennis Elbow is widely recognized among physiotherapists, general practitioners and patients more than Lateral Epicondylitis.

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, about 72% after receiving a corticosteriod injection compared to 9% with a ''wait and see'' approach, and around 5% need surgery.

Pathophysiology

Research has proven that structural pathology is not always present in many clinical presentations. This could be true particularly if we considered Tennis Elbow to be related to tendon pathology. A multifactorial model has been proposed by researchers to contribute to the development of pain and disability. Psychological factors, central sensitization and/or other CNS-mediated factors may play roles in the onset and prognosis of the condition.

Coombes et al proposed a pathophysiological integrative model explaining the development of Tennis Elbow. The model hypothesizes an integration of local tendon pathology, changes in the pain system and impairment in the motor system are the factors behind TE. This could reflect on the clinical decisions and research field to understand the nature of the condition and facilitate patients' sub-grouping.

From a histological point of view, increased cellularity, an accumulation of ground substance, collagen disorganization, and neurovascular ingrowth are similar to those observed in any other tendinopahty. In the case of Tennis Elbow this was 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. These structural changes could be the result of overuse, underuse or a combination of different forces across the tendon insertion. Both very high strain and low strain levels predispose the tendon to structural changes.

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

The presence of neurochemical pain mediators is evident in TE which is believed to be one of the contributing factors to the reduced pain threshold in TE.

Muscle weakness is also found in Tennis Elbow. Pain free gripping was reduced by about 60% compared to non affected side, another study found bilateral weakness and another reported weakness in the whole upper limb except for the metacarpophalengeal joint muscles. The last finding suggests Tennis Elbow patients may maintain or increase strength of the finger extensors to compensate for weakness in the wrist extensors. Tennis players with Tennis Elbow had significantly less ECRB activities during the early acceleration phase, while greater at ball impact compared with uninjured players. ECRB also produced less activity in isometric wrist extension and gripping tasks which was reversed with the relief of symptoms suggesting a link between neuromuscular activity and symptoms.

Tennis Elbow and Central Sensitization

Mechanical hyperalgesia and cold hyperalgesia are evident in Tennis Elbow. Clinical ice pain test, a simple test that allows clinicians to examine pain sensitivity. Pain intensity of more than 5/10, after 10 seconds of ice application indicates 90% likelihood of cold hyperalgesia.

Central sensitization (CS) could be detected clinically starting with a thorough history taking. There are some information obtained in history relates to the presence of CS such as: hypersensitivity to : bright light, touch, noise, mechanical pressure, medication, temperature. sometimes the patient report being uncomfortable to partner hug or wearing sunglasses in buildings can be valuable in detecting CS. Fatigue, sleep disturbances, unrefreshing sleep, concentration difficulties, swollen feeling (e.g. in limbs), tingling and numbness. may be clue for CS, if non present CS is excluded. If any of these symptoms are present, the clinicians may take it further to examine pain thresholds, sensitivity to touch during manual palpation, sensitivity to vibration, sensitivity to heat and sensitivity to cold at sites remote from the symptomatic area. Also, assessment of pressure pain thresholds during and following exercise, assessment of joint end feel and Brachial plexus provocation test.

Examination

Pain provoking tests are the most utilized method of diagnosing 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, such as clicking, loss of control and 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.

Also , examination of posture and motor control should be considered to understand the kinematic influence and tackle any abnormalities in the rehabilitation.

Outcome Measures

The pain-free grip test. It is is a reliable in monitoring recovery and sensitive measure, however, it should be noted that grip strength is not always impaired in Tennis Elbow and the test may exacerbate the symptoms.

Patient Rated Tennis Elbow Evaluation is also a good measure for categorizing pain and disability and also to track improvement.

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

Imaging

A literature review summarized the following:

• MRI is sensitive but not specific
• Ultrasonography detected tendopathic changes on 90% affected and 50% unaffected tendons. It also detects tendon tears, calcification and bony irregularity.
• 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
• Tendon neovascularisation in LE has been detected with Doppler ultrasound and correlated with degenerative tissue on biopsy. The absence of both tendon neovascularity and grey-scale changes was shown to rule out Lateral Tennis Elbow as a diagnosis and should prompt further investigation. Neovascualrity wasn't associated with pain severity or function.

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.