Lateral Epicondyle Tendinopathy Toolkit: Section B - Clinical Assessment
Original Editor - Kim Jackson uploaded for the BC Tendinopathy Task Force Dr. Joseph Anthony, Paul Blazey, Dr. Allison Ezzat, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates and Alison Hoens
Top Contributors - Nupur Smit Shah, Cindy John-Chu, Kim Jackson, Rishika Babburu and Vidya Acharya
Introduction[edit | edit source]
The purpose of this document is to summarize the clinical assessment of the patient diagnosed with lateral epicondyle tendinopathy. Initially, the assessment consists of history, objective and subjective examination, chief complaints in order to confirm the diagnosis. The toolkit will even include differential diagnosis, the process of identifying causes/risk factors of lateral epicondyle tendinopathy and functional examination.
Risk factors[edit | edit source]
Risk factors are the ones which increase the chances of developing this condition. There are two types of risk factors, modifiable and non modifiable.
Non-modifiable risk factors[edit | edit source]
These are the factors which cannot be changed
Age Typically occurs > 40 years [1]
Gender Weak evidence for female >male[1][2]
Metabolic disorder Generally, metabolic factors are weakly associated with LET compared to mechanical overuse (modifiable) factors.[3]
Familial Disorder Genetics – variants in connective tissue health more likely to be susceptible to LET[5]
Systemic Inflammatory Disease
Spondyloarthropathy (SpA) is generally associated with enthesis disorders, more commonly in the load bearing tendons of lower limbs compared to upper limbs.
SpA (SCREEND’EM)[6] – acronym for a useful screening tool to assist in identifying individuals that would benefit from further medical investigation for SpA.
Modifiable risk factors[edit | edit source]
These are the factors which can be worked on and measures can be taken to change them. They are the exposures /behavior's which lowers or increases the person's risk of lateral elbow epicondylitis.
Lifestyle
- Smoking – current and past history[1]
- Active Group – Overuse from repetitive and forceful recreational and occupational activity
- Sport[1]
- Grip strength weakness
- Equipment (eg improper tennis grip size)
- Technique (eg poor backhand swing)
- Sport[1]
Only 10% of LET are associated with racquet sport.[5]
- Occupation[1]
Repetition, Ergonomics, Tools (forceful grip, vibration)
- Inactive/Sedentary Group
More likely to have overuse response to unaccustomed loads from ADLs, or decline in tendon load capacity (age, activity, or lifestyle factors).
Previous shoulder injury: Rotator cuff weakness ipsilateral side
History[edit | edit source]
- Lateral elbow pain which is related to over use.
Subjective symptoms[edit | edit source]
These symptoms are perceptible only to the patient. Typical subjective symptom is pain.
- Symptoms increases during activity.
- Extensor muscles weakness and reduced grip strength
- Pain is usually localized on the lateral elbow or sometimes referred to extensor or supinator groups of forearm.
Biopsychological factors[edit | edit source]
These factors includes the complex interaction of biological, psychological and social factors to understand health. The biological factors are brain damage/genetics, social factors are life traumas and stress and psychological is how the patient interprets life events.
- Persistent LET pain may involve behavioral and psychosocial factors contributing to nervous system sensitivity (peripheral and central). There is evidence that psychological variables (catastrophization, signs of distress) can increase LET symptoms. In patients with psychosocial drivers, treatment programs should consider providing pain neuroscience education, as well as addressing cognitive and behavioral barriers.[7]
Objective Signs[edit | edit source]
Objective signs are the ones which are examined by the physiotherapist and documented.
| Upper quadrant Screening Exam | Contributing Factors |
|---|---|
| Cervical | Radiculopathy, Neuropathy |
| Shoulder | Rotator cuff weakness MTrP, Neuropathic tender points |
| Elbow , Forearm | Grip weakness MTrP, Neuropathic tender points |
| Abnormal Neural Tension(Neurodynamics) | Peripheral nerve – Radial bias |
| Local Exam | Technique |
| Palpation | Primarily at ECRB tendon insertion at lateral epicondyle. May include ECRL + EDC insertion |
| Mill's test : Passive stretch of extensor group. | Start position : Shoulder neutral, elbow 90 degrees, forearm pronated, wrist fully flexed. Operator gradually passively extends elbow towards zero degrees, maintaining forearm pronation or wrist flexion. Monitor pain over lateral elbow. |
Differential Diagnosis[edit | edit source]
Articular[edit | edit source]
Intra-articular synovial plica of radial-capitular joint[9]
Radio-capitular arthritis[9]
Osteochondritis dessicans[9]
Instability[edit | edit source]
- Posterolateral rotary instability due to laxity of collateral ligaments[9]
Neural[edit | edit source]
- Radial tunnel entrapment of posterior interosseous nerve (Arcade of Froshe)[10]
- Cervical radiculopathy
- Abnormal neural tension neurodynamics (radial nerve bias)[9]
Imaging[edit | edit source]
Imaging (US, MRI) may be useful, particularly for patients whose symptoms are inconsistent with LET and are not responding to conservative interventions, to ascertain whether there are structural changes in tendon consistent with LET. Imaging may also assist to ‘rule out’ the tendon as a source of pathology, and investigate for other intra/extra articular conditions.[1]
Resources[edit | edit source]
- Click to go back to the main page of Lateral Epicondyle Tendinopathy (LET) Toolkit.
- Click to continue to Section C - Outcome Measures
- Click to continue to Section D: Summary of Evidence
- Click to continue to Section E- Exercise prescription
- Click to continue to Section F- Manual therapy
- Click to continue to Section G- Laser dosage
- Click to continue to Section H-Braces , Splints and Taping
- UBC Lateral Epicondyle Tendinopathy (LET) Toolkit
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Watts A, Robinson P. Epicondylitis. BMJ Best Practice. (2021). Available from: https://bestpractice.bmj.com/topics/engb/978. [cited 2022Nov4].
- ↑ Shiri R, et al. Prevalence and determinants of lateral and medial epicondylitis: A population study. Amer Jour Epidemiology. (2006). 164(11):1065-1074.
- ↑ 3.0 3.1 3.2 Park HB, Gwark JY, Im JH, Na JB. Factors associated with lateral epicondylitis of the elbow. Orthopaedic Journal of Sports Medicine. 2021 May 12;9(5):23259671211007734.
- ↑ Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, Shishido H, Fukuhara S, Kikuchi S, Konno S. Chronic hyperglycemia increases the risk of lateral epicondylitis: the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS). Springerplus. 2015 Dec;4(1):1-9.
- ↑ 5.0 5.1 Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
- ↑ Zytoon A, et al. Ultrasound assessment of elbow enthesitis in patients with seronegative arthropathies. Jour Ultrasound. (2014). 17:33-44.
- ↑ Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.
- ↑ 8.0 8.1 8.2 Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. British journal of sports medicine. 2017 May 1;51(9):743-8.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, Tsepis E, Gioftsos G. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)–A systematic review. Journal of Hand Therapy. 2021 Feb 27.
- ↑ Hegmann KT, Thiese MS, Kapellusch J, Merryweather A, Bao S, Silverstein B, Wood EM, Kendall R, Foster J, Drury DL, Garg A. Association between epicondylitis and cardiovascular risk factors in pooled occupational cohorts. BMC musculoskeletal disorders. 2017 Dec;18(1):1-0.
