Lateral Epicondylitis

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Definition/Description

Lateral epicondylitis is the most common overuse syndrome in the elbow. Lateral epicondylitis or tennis elbow is an injury involving the extensor muscles of the forearm. These muscles originate on the lateral epicondylar region of the distal of the humerus.http://emedicine.medscape.com/article/1231903-overview (accessed 17 Nov 2010) In a lot of cases, the insertion of the extensor carpi radialis brevis is involved.

Lateral epicondylitis is also known as tennis elbow but it should be remembered that only 5% of people suffering from tennis elbow relate the injury to tennis. This group is characterized by a high activity level and they often play tennis 3 times a week, for at least 30 minutes per session.

Contractile overloads that chronically tension or stress the tendon near the attachment on the humerus are the primary cause of epicondylitis. It occurs often in repetitive upper extremity activities such as computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration. Despite the name you will also commonly see this chronic condition in other sports such as squash, badminton, baseball, swimming and field throwing events. People whit one-sides movements in their jobs such as electricians, carpenters, gardener and women who practice needlework. [35][41][42][43][49]

Clinically Relevant Anatomy

The elbow joint is made up of three bones: the humerus (upper arm bone), the radius and ulna (two bones in the forearm). At the distal end of the humerus there are two epicondyles, one lateral (on the outside) and one medial (on the inside). 

The area of maximal tenderness is usually an area just distal to the origin of the extensor muscles of the forearm at the lateral epicondyle. Most commonly, the extensor carpi radialis brevis (ECRB) is involved, but others may include the extensor digitorum, extensor carpi radialis longus (ECRL), and extensor carpi ulnaris. [41][44]

The radial nerve is also in close proximity to this region, and divides into the superficial radial nerve and the posterior interosseous nerve.

<img src="/images/7/73/Bone_ElbowAnatomy.jpg" _fck_mw_filename="Bone ElbowAnatomy.jpg" _fck_mw_location="center" alt="" class="fck_mw_center" />

Epidemiology /Etiology

Lateral epicondylitis is classified as an overuse injury that may result in hyaline degeneration of the origin of the extensor tendon. Overuse of the muscles and tendons of the forearm and elbow together with repetitive contractions or manual tasks can put too much strain on the elbow tendons. These contractions or manual tasks require manipulation of the hand that causes maladaptions in tendon structure that lead to pain over the lateral epicondyle. Mostly, the pain is located anterior and distal from the lateral epicondyle. [42]

Epicondylitis occurs at least five times more often and predominantly occurs on the lateral rather than on the medial aspect of the joint, with a 4:1 to 7:1 ratio.

This injury is often work-related, any activity involving wrist extension, pronation or supination during manual labour, housework and hobbies are considered as important causal factors.Van Rijn RM, Huisstede BM, Koes BW, Burdorf A. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford). May 2009;48(5):528-36. A1 http://rheumatology.oxfordjournals.org/content/48/5/528.full.pdf (accessed 17 Nov 2010) Lateral epicondylitis is equally common in both sexes. Between the ages of 30-50 years the disease is most prevalent. Obtaining of the condition at the both lateral epicondyle is rare, the dominant arm has the greatest chance of the occurrence of lateral epicondylitis. Twenty percent of cases persist for more than a year. [41][50]

A systematic review identified 3 risk factors: handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times per day, and repetitive movements for more than 2 hours per day. Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors. [5]

There are several opinions concerning the cause of lateral epicondylitis:

Inflammation

Although the term epicondylitis implies the presence of an inflammatory condition, inflammation is present only in the earliest stages of the disease process. Baker CL, Plancher KD. Operative treatment of elbow injuries. New York: Springer, 2002.

Microscopic tearing

• Nirschl and Pettrone attributed the cause to microscopic tearing with formation of reparative tissue (angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle. This micro-tearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle.
• That microscopic or macroscopic tears of the common extensor origin were involved in the disease process, was postulated by Cyriax in 1936.
• The first to describe macroscopic tearing in association with the histological findings were Coonrad and Hooper.
• Histology of tissue samples shows "collagen disorientation, disorganization, and fibre separation by increased proteoglycan content, increased cellularity, neovascularization, with local necrosis." Nirschl termed these histological findings bangiofibroblastic hyperplasia. The term has since been modified to bangiofibroblastic tendinosis. He noted that the tissue was characterized by disorganized, immature collagen formation with immature fibroblastic and vascular elements. This grey, friable tissue is found in association with varying degrees of tearing involving the extensor carpi radialis brevis.

Degenerative process

The histopathological features of 11 patients who had lateral epicondylitis were examined by Regan et al. They determined that the cause of lateral epicondylitis was more indicative of a degenerative process than an inflammatory process. The condition is degenerative with increased fibroblasts, vascular hyperplasia, proteoglycans and glycosaminoglycans, and disorganized and immature collagen. Repetitive eccentric or concentric overloading of the extensor muscle mass is thought to be the cause of this angiofibroblastic tendinosis of the ECRB.

Epicondylitis is a degenerative condition in which increased fibrolastic activity and granulation tissue formation occur within the tendon. [41][42]

Hypovascularity

Because this tendinous region contains areas that are relatively hypovascular, the tendinous unit is unable to respond adequately to repetitive forces transmitted through the muscle, resulting in declining functional tolerance. Davenport TE, Kulig K, Matharu Y, Blanco CE. The EdUReP Model for Nonsurgical Management of Tendinopathy. Phys Ther. 2005;85(10):1093-103. http://ptjournal.apta.org/content/85/10/1093.long

Characteristics/Clinical Presentation

Lateral epicondylitis has an annual incidence of 1-3% within the general population. Wright JG. Evidence-based orthopaedics: the best answers to clinical questions. Philadelphia: Saunders Elsevier, 2008.
The difference between men and women on lateral epicondylitis is still controversial.
Patients with lateral epicondylitis are typically 35 to 54 years. It’s less common in people under 30 years. Symptoms last, on average, from 6 months to 2 years. 89% of the patients recover within 1 year without any treatment except perhaps avoidance of the painful movements. Cyriax JH. The pathology and treatment of tennis elbow. J Bone Joint Surg 1936; 18: 921–40. http://www.ejbjs.org/cgi/reprint/18/4/921.pdf (accessed 30 Dec 2010)Smidt N, van der Windt D, Assendelft W, Devillé W, Korthals-de Bos I, Bouter L. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359: 657–62. A2 http://www.physio-pedia.com/images/9/9e/Smidt_et_al_RCT_lateral_elbow.pdf (accessed 30 Dec 2010)

Patients often report weakness in their grip strength or difficulty carrying objects in their hand, especially with the elbow extended. They have complaints of pain just distal to and localized tenderness over the lateral epicondyle. Patients will commonly have pain with palpation of the lateral epicondyle, resisted wrist, or second or third finger extension (Cozen's sign). Bisset L, Beller E, Jull E, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;doi:10.1136/bmj.38961.584653. B https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633771/ (accessed 20 Nov 2010)

Differential Diagnosis

• Radial Tunnel Syndrome Roles NC, Maudsley RH. Radial tunnel syndrome: Resistant tennis elbow as nerve entrapment. J Bone Joint Surg Br 54:499-508, 1972. http://web.jbjs.org.uk/cgi/reprint/54-B/3/499 (accessed 20 Nov 2010)
• <a _fcknotitle="true" href="Posterior Interosseus Syndrome">Posterior Interosseus Syndrome</a>
• Elbow <a href="Osteoarthritis">osteoarthritis</a>
  • Pain
  • Loss of range of motion
• Fractures]
  • <a _fcknotitle="true" href="Distal Radial Fractures">Distal Radial Fractures</a>
  • <a _fcknotitle="true" href="Radial Head Fracture">Radial Head Fracture</a>
  • <a _fcknotitle="true" href="Olecranon Fracture">Olecranon Fracture</a>
• <a _fcknotitle="true" href="Cervical Radiculopathy">Cervical Radiculopathy</a>
  • Radiating arm pain corresponding to the dermatomes 
  • Neck pain
  • Parasthesia
  • Muscle weakness in myotome
  • Reflex impairment/loss
  • Headaches
  • Scapular pain
  • Sensory and motor dysfunction in upper extremities and neck

Diagnostic Procedures

The diagnosis of lateral epicondylitis is substantiated by tenderness over the ECRB or common extensor origin. By the following methods, the therapist or physiotherapist should be able to reproduce the typical pain:
1. Digital palpation on the facet of the lateral epicondyle
2. Resisted wrist extension or resisted middle-finger extension with the elbow in extension
3. Having the patient grip an object

Outcome Measures

• mASES
• QuickDASH (reliability= .90, MCID not reported)
• <a href="DASH Outcome Measure">DASH_Outcome_Measure</a>
• PSFS (reliability= .82-.92, MCID=2.0)
• PrTEEQ - Patient-Rated Tennis Elbow Evaluation Questionnaire (Pain ICC = 0.89-0.99, Function ICC = 0.83-0.99, Total ICC = 0.89-0.99)Leung HB, Yen CH, Tse PYT. Reliability of Hong Kong Chinese version of the Patient ratedfckLRForearm Evaluation Questionnaire for lateral epicondylitis. Hong Kong Med J 2004;10:172-7.Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, Gay RE, Arendt KW. Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis. J Hand Ther 2005;18:400-6.Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis. J Hand Ther 1999;12:31-7.

Examination

The diagnosis of lateral epicondylitis is substantiated by tenderness over the ECRB or common extensor origin. By the following methods, the therapist or physiotherapist should be able to reproduce the typical pain:

• To examine the sincerity of the tennis elbow, there is a dynamometer and a Patient-rated Tennis Elbow Evaluation Questionnaire (PrTEEQ).[16][17] The dynamometer measures grip strength.[18][19] The PrTEEQ is a 15-item questionnaire, it’s designed to measure forearm pain and disability in patients with lateral epicondylitis. The patients have to rate their levels of tennis elbow pain and disability from 0 to 10, and consists of 2 subscales. There is the pain subscale (0 = no pain, 10 = worst imaginable) en the function subscale (0 = no difficulty, 10 = unable to do).
• Cozen’s test:
  Cozen’s test is also known as the resisted wrist extension test. The elbow is stabilized in 90° flexion. The therapist palpates the lateral epicondyle and the other hand positions the patient’s hand into radial deviation and forarm pronation. Then the patient is asked to resist wrist extension. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle.[20][21][38]
• Chair test: The patient grasps the back of the chair while standing behind it and attempts to lift the chair by using a three finger pinch (thumb, index long fingers) and the elbow fully extended. The test is positive when pain occurs at the lateral epicondyle. [38]
• Mill's Test: The patient is seated with the upper extremity relaxed at side and the elbow extended. The examiner passively stretches the wrist in flexion and pronation. Pain at the lateral epicondyle or proximal musculotendinous junction of wrist extensors is positive for lateral epicondylitis. [38] [39][42]
• Maudsley’s test: The examiner resist extension of the third digit of the hand, while palpating the lateral epicondyle. A positive test is indicated by pain over the lateral epicondyle. [39][42]
• The coffee cup test (by Coonrad and Hooper): While doing a specific activity such as picking up a full cup of coffee or a milk bottle. The patient is asked to rate their pain on a scale of zero to ten. [39][42]
  
  

Medical Management

Medical management of lateral epicondylalgia has historically included NSAIDs, advice regarding rest, use of an elbow counterforce brace, and corticosteroid injection(s). Histologic research and the discovery of the true nature of this condition has led to more appropriate diagnosis and treatment in regard to the degeneration that is occurring at the site. Current medical treatment and research involves the use of interventions like prolotherapy, autologous blood injections, and even surgery (usually after failed conservative treatment for >6 mos). Low level laser therapy has also been found to be an ineffective treatment modality for lateral epicondylalgia. Bjordal JM, Rodrigo AB Lopes-Martins, Joensen J, Couppe C, Ljunggren AE, Stegioulas A, Johnson MI. A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musc Dis. 2008;9:75,1471-2474 http://www.biomedcentral.com/1471-2474/9/75

Tennis elbow, or LE, is a common yet challenging condition to treat. Various non-surgical modalities have been described, the selection of which depends on experience of the management team, availability of the equipment, available expertise, and patient choice/response. In general, treatment can begin with patient education, application of commonly available treatments (physiotherapy, manual therapy, tennis elbow brace, as well as oral or topical NSAIDs). NSAIDs, or non steroidal anti-inflammatory medications, are currently the medication of choice although it has not been proved that they have a specific effect on fibroblast function or tendon healing (11,12). It has been suggested that although NSAIDs reduce inflammation by inhibiting the secretion of prostaglandin E2, they also inhibit the synthesis of DNA, which is detrimental to the repair of damaged tendon. (13)Steroid injection is not recommended as it lacks long-term benefit and is associated with a high relapse rate. When usual treatments fail to resolve symptoms, injection of PRP (Platelet-rich Plasma) may be an option, but its efficacy and cost-effectiveness are not yet established. Injection of hyaluronate may also be tried before resorting to surgery. Surgery is usually indicated for resistant patients not responsive to non-surgical therapy. More research is needed to evaluate the best treatment modalities and protocols for LE sufferers. [36]

Then there is accupunture, a consensus statement from the National Institutes of Health states that study results are promising enough to consider acupuncture as an appropriate option for the treatment of lateral epicondylitis.41 However, conflicting evidence exists, and recommendations for or against this therapy cannot be made. Two systematic reviews and one meta-analysis found that acupuncture leads to short-term (three days to two months) pain reduction.42,43 Two additional systematic reviews acknowledge that acupuncture might provide short-term benefit, but they conclude that there is insufficient evidence on the use of acupuncture for the treatment of lateral epicondylitis.(44,45)

Physical Therapy Management

There are different types of therapies to treat lateral epicondylitis, all with the same aim: reduce <a href="http://www.physio-pedia.com/Pain_Course">pain</a> and improve function.

The study of Nagrale et al. demonstrate that Cyriax physiotherapy is a better treatment compared to phonophoresis and exercise for treating lateral epicondylalgia. The cyriax physiotherapy group had significantly better scores for all measurements at follow up (p<0.05). mit V. Nagrale; Christ opher R. Herd; Shyam Ganvir; Gopichand Ramteke,Cyriax Physiotherapy Versus Phonophoresis with Supervised Exercise in Subjects with LateralEpicondylalgia: A Randomized Clinical Trial, J Man Manip Ther. 2009; 17(3): 171-178 Level of evidence:1B Rajadurai et al demonstrate that supervised exercise program may be the first treatment in managing tennis elbow in comparison to Cyriax physiotherapy. Much more studies should be done to prove the evidence of using manual treatment like Cyriax physiotherapy.Rajadurai Viswas, Rejeeshkumar Ramachandran, and Payal Korde Anantkumar, “Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow Lateral Epicondylitis): A Randomized Clinical Trial”, The ScientificWorld Journal Volume 2012, Article ID 939645, 8 pages doi:10.1100/2012/939645 Level of evidence: 1B

Physical therapy interventions including elbow joint mobilization with movement combined with exercise has been shown to have better results than <a href="Therapeutic Corticosteroid Injection">corticosteroid injection</a> at 6 weeks and to wait and see at 6 weeks but not 52 weeks. Recent research regarding cervicothoracic joint mobilization in conjunction with local treatment for lateral epicondylalgia has shown improvements in strength, pain, and tolerance to activity compared to local treatment alone. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. J Man and Manip Ther. 2005;13(3):143-151.

Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.[35]

Physical therapy management including only the use of <a href="Therapeutic Ultrasound for Lateral Epicondylitis">ultrasound</a>, massage, and exercise has been shown to be no better than a "wait and see" treatment method. Smidt N, Van der Windt DAWM, Assendelft WJJ, Deville WLFM, Korthals-de Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. LANCET. 2002;359:657-662. Activity modification, when possible, can help prevent recurrent episodes of lateral epicondylalgia, as well as use of a counterforce brace as needed.

Extracorporeal Shockwave therapy
Shockwave Therapy is a method of treatment for multiple tendonopathies that can be used for the treatment of lateral epicondylitis.
ESTW is a treatment technique in which patients are exposed to a strong mechanical wave impulses which can be used on a fairly accurate position.
There are several studies [51][52][53][54][55] that examine the effects of extracorporeal shockwave on lateral epicondylitis. Statistical analysis of visual analogue scale (VAS), disabilities of the arm, shoulder, and hand (DASH) questionnaire and pain-free grip strength test scores has shown, both after treatment and to the follow-up at 6 months, significant difference comparing study group versus control group (P <0.001) [49]. The use of RSWT allowed a decrease of pain, and functional impairment, and an increase of the pain-free grip strength test, in patients with tennis elbow. [49]
Although the technique is widely reported to be safe, there is a potential for haemorrhage and local soft tissue damage through cavitation and this appears to be more likely with high doses [50] Studies has shown that Extracorporeal shockwave therapy offers a significant placebo effect with a moderate dos of ESWT in subjects with lateral epicondylitis. However there is no evidence of added benefit of treatment when compared to sham (placebo) therapy. This may be the reason why there are significant improvements noted by other studies. [52][53][54][55]

Cyriax Physiotherapy

It’s a very common intervention that combines the use of deep transverse friction(DTF) with manipulations, which was used with success by Cyriax and Cyriax for treating lateral epicondylitis. 

Cyriax and Cyriax claimed substantial success in treating tennis elbow using deep transverse friction (DTF) in combination with Mill’s manipulation, which is performed immediately after DTF. For it to be considered a Cyriax intervention, the two components must be used together in the order mentioned.  Patients must follow the protocol three times a week for four weeks. [46][47]
There are studies in which Cyriax physiotherapy for tennis elbow has been used. Conclusion of studies: Although Cyriax physiotherapy is commonly used in the treatment of tennis elbow, more research is needed to assess firstly its effectiveness and secondly the effects of both its components. [47]

Contraindications: active infections, <a href="http://www.physio-pedia.com/Bursitis">bursitis</a>, disorders of the nerve structures, ossification and calcification of the soft tissues, active <a href="http://www.physio-pedia.com/Rheumatoid_Arthritis">rheumatoid arthritis</a>, anticoagulant.

Deep Transverse Frictions

<img src="/images/thumb/0/05/Dtf.png/116px-Dtf.png" _fck_mw_filename="Dtf.png" _fck_mw_location="right" _fck_mw_width="116" _fck_mw_height="100" _fck_mw_type="thumb" alt="" class="fck_mw_frame fck_mw_right" />

The therapist must try to reach an analgesic effect applying the DTF at the point of the lesion for 10 min till a numbing effect has been reached, that all for preparing the tendon for the manipulations. Pain during the friction massage is considered as a wrong indication. An interval of 48 hours between two sessions is necessary.

The purpose of the <a href="http://www.physio-pedia.com/index.php/Friction_Massage">deep friction massage</a> is to maintain the mobility within the soft tissue structures.GAIL J. CHAMBERLAIN, MA, PT*, Cyriax's Friction Massage: A Review, 0196-601 1 /82/0401-0016$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTSP HYSICALT HERAPY Copyright O 1982 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Level of evidence:2 A It seems to have a pain relief function, due to modulation of the nociceptive impulses (gate control theory), a better alignment of connective tissue fibrils, softens the scar tissue, and blood flow increases, but further studies are needed.

”Seated with arm fully supinated in 90° of elbow flexion, identify the area of tenderness on the lateral epicondyle and apply pressure(DTF) ,with the tip of the thumb on the lateral epicondyle, in a posterior direction on the teno-osseous junction. The other hand stabilized the patient’s wrist.”

Mills Mobilisation

<img src="/images/thumb/0/03/Mills.png/135px-Mills.png" _fck_mw_filename="Mills.png" _fck_mw_location="right" _fck_mw_width="135" _fck_mw_height="199" _fck_mw_type="thumb" alt="" class="fck_mw_frame fck_mw_right" />

The commonly used Mill's manipulation, is a small-amplitude high-velocity thrust performed at the end of elbow extension while the wrist and hand are held flexed.Bill Vicenzino, PT, PhD, Joshua A. Cleland, PT, PhD, OCS, FAAOMPT, and Leanne Bisset, PT, MPhty (Sports), Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary, J Man Manip Ther. 2007; 15(1): 50–56 Level of evidende:2A “ It’s used to pull apart the two edges of the tear and relieve tension on the painful scar lying between the edges, imitating the mechanism of spontaneous recovery. This motion allows the self-perpetrating post-traumatic inflammation to subside with permanent lengthening of the tendon. This approach was described by Mills.”

Mill’s intention was to shift the annular ligament and replace it. Cyriax found out that the annular ligament applies the greatest possible stretching tension to the extensor carpi radialis muscles, that’s why the manipulative procedure should be carried out with a sharp jerk, in order to open the tear in the tendon and relieve tension on the tendon scar by converting a tear.

This manipulation must only be performed if a fully pain-free elbow extension can be achieved, and with a properly technique. To prevent symptoms worsening, full wrist flexion must be achieved during the procedure.

Patient seated with the affected extremity in 90° abduction and internal rotation (olecranon faced up).Therapist stands behind the patient , stabilized the patient’s wrist in full pronation and flexion, while the other hand is placed on the olecranon. The high-velocity low amplitude (HVLA) thrust at the end range of elbow extension, is a quick movement in the direction illustrated.

This manipulation may produce mild discomfort at the instant of its performance.
The clinician applies this procedure a 2-3 times a week until cure, with a range of 4-12 sessions. SHIRLEY KUSHNER, BScPT, BPE,* DAVID C. REID, MD, MCh(Orth), FRCS(C)t, Manipulation in the Treatment of Tennis Elbow, 01 96-601 1 /86/0705-0264$02.00/0THE J OURNAOFL O RTHOPAEOA~NC0 SPORTPSH YSICATLH ERAPY Copyright O 1986 by The Orthopaedic and Sports Physical Therapy Sections of th American Physical Therapy Association Level of evidence:2A

Exercise Therapy

StretchingWaseem M., et al, Lateral epicondylitis: A review of the Literature, 2012, J Back Musculoskelet Rehabil (Level of Evidence 2A)Viswas R., et al. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A Randomized Clinical Trial, 2012, Scientific World Journal (Level of Evidence 1B)

The literature on the treatment of a Lateral Epicondylitis suggests that strengthening and stretching exercises are the most important components of exercise programmes, for the reason that tendons should not only be strong but also flexible. The stretching exercises are intended to improve the flexibility of the extensor group of the wrist. These exercises ought to be instituted and continued until the range of motion of the wrist is the same as that of the uninvolved side. These programmes should occur early in the treatment, to facilitate correct tissue remodelling. Early strength training should focus on low load and high-repetition training programmes, to prevent symptom aggravation.  The best stretching position for the Extensor Carpi Radialis Brevis tendon, is reached with the elbow in extension, forearm in pronation, wrist in flexion and with ulnar deviation of the wrist, according to the patient’s tolerance. This stretching should be held for 30- 45 s and 3 times before and after the eccentric exercises, during each treatment session with a 30 s rest interval.                                                                                                                                                                         

Eccentric exercises

There are three principles of eccentric exercises. These are load ( resistance), speed (velocity) and frequency of contractions.

Load ( resistance)

Increasing the load ensures the tendon is subjected to greater stress and forms the fundamental basis of the progression of the exercise programme. The basis of all physical training programmes is formed by this principle of progressive overloading. According to the patient’s symptoms, it is important that the load of these eccentric exercises should be increased. If it’s not increased then the possibility of re-injury will be high.

Speed ( velocity)

The speed (velocity) of contractions is also a fundamental principle of successful eccentric exercises. In each treatment session the speed of the eccentric training should be increased. Hence the load on the tendon increases to stimulate the mechanism of the injury.
However the therapists must ensure that the patients perform the eccentric exercises slowly to avoid pain.

Frequency of contractions

The frequency of contractions is the third principle of eccentric exercises. There can be variations of sets and repetitions in the literature.
According to the therapists 3 sets of 10 repetitions can normally be performed without overloading the injured tendon, as determined by the tolerance of the patient. The elbow is in full extension, forearm in pronation and the arm is supported. The greatest strengthening result for the extensor tendons of the wrist is reached in this position. This is a recommendation and the frequency must be patient specific.

Exercise:
Theraband exercises (or exercises with a small weight) are performed each day for 3 sets of 10. You fix one side of the theraband under you feet or another place and you take the other side in your hand or you have a small weight in your hand.
The patient starts the exercise in wrist flexion, then he/she does a wrist extension and comes back to the start position very slowly. [33] This exercise is an concentric en eccentric exercise for the wrist extensors. They concluded that supervised exercise consisting of static stretching and eccentric strengthening produced the largest effect in reducing pain, strenght and improving function. [56] Once the patients can do this, they can progress to another colour of theraband or you increase the weight. [33]
In this study the subjects were assigned to group A or group B. Group A received supervised therapeutic exercise program which included static stretching of the Extensor Carpi Radialis Brevis followed by eccentric strengthening of the wrist extensors. Group B was treated with Cyriax physiotherapy. The groups that performed supervised exercise program (group A) for 4 weeks showed significantly greater improvement in reduction of pain and functional status than the Cyriax physiotherapy treatment. (33)

Flexbar® exercisePhil Page, et al, A new exercise for tennis elbow that works, 2010, North American Journal of Sports Physical Therapy. (Level of Evidence 2C)

The Flexbar® is an effective and beneficial eccentric exercise for patients with lateral epicondylitis.  This resistance device is easy to use at home and is an excellent example of true “evidence-based practice” in physical therapy. Instructions for the 5 Steps of the Exercise:

1. Hold FlexBar® in the affected (right) hand. Make sure it's in full wrist extension..
2. The other end of the device must be held with your unaffected (left) hand.
3. Twist FlexBar® with unaffected wrist while holding. <a href="http://www.youtube.com/watch?v=gsKGbqA9aNo#http://www.youtube.com/watch?v=gsKGbqA9aNo">Demonstration of the exercise</a>

The FlexBar® exercise is performed each day for 3 sets of 15. It takes 4 seconds to complete each repetition and between each set of 15 repetitions there is 30 seconds of rest. Once the patients can perform 3 sets of 15, they progress to another colour FlexBar® with a higher intensity of eccentric resistance. After an average of 7 weeks (with 10 clinic visits) the patient will have a resolution of symptoms. The treatment should be continued until this resolution occurs.

Resources

fckLRImage:AchTendToolkit Algorithm.png|140px|border|left|fckLRrect 0 0 220 126 Lateral Epicondyle Tendinopathy (Tennis Elbow) ToolkitfckLRdesc nonefckLR

<a _fcknotitle="true" href="Lateral Epicondyle Tendinopathy (Tennis Elbow) Toolkit">Lateral Epicondyle Tendinopathy (Tennis Elbow) Toolkit</a> The Lateral Epicondyle Tendinopathy Toolkit is a comprehensive evidence based resource to assist practitioners in clinical decision making for Lateral Epicondylar Tendinopathy. <a href="Achilles Tendinopathy Toolkit">View the Toolkit</a>

Presentations

fckLRImage:Lateral_Epicondylagia_Presentation.png|200px|border|left|fckLRrect 0 0 830 452 [1]fckLRdesc nonefckLR

<a href="https://connect.regis.edu/p41113266/">Lateral Epicondylagia</a>  This presentation, brought to you by Dominic Severino, Christian Little and Geoffrey Klein as part of the Regis University OMPT Fellowship in 2011, discusses the current best evidence for interventions for Lateral Epicondylagia.  <a href="https://connect.regis.edu/p19057977/">View the presentation</a>

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1xE-KhlNQ_RGiLC4OxHPPmN269WAIWqL_pzNNaX1a5cgaDrQyY%7Ccharset=UTF-8%7Cshort%7Cmax=10

References

33) Vicenzino B. et al.;Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold; Journal of Orthopaedic & Sports Physical Therapy; 2003 (2B)
34) Olaussen M et al, Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review, British Medical Journal , 2013 (1A)
35) James KH Luk et al, Lateral epicondylalgia: midlife crisis of a tendon, Hong Kong Medical Journal, 2014
36) James KH Luk et al., Lateral epicondylalgia: midlife crisis of a tendon, Hong Kong Medical Journal, 2014; 145-151
37) Nirschl RP: Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med. 1988;7:289–308. [PubMed]

38) Teitz CC, Garrett WE, Jr, Miniaci A, et al. Tendon problems in athletic individuals. J Bone Joint Surg Am. 1997;79:138–152.

39) Almekinders LC, Baynes AJ, Bracey LW. An in vitro investigation into the effects of repetitive motion and nonsteroidal antiinflammatory medication on human tendon fibroblasts. Am J Sports Med. 1995;23:119–123. [PubMed]

40) Shyam Kumar, David Stanley et al. Tennis elbow; ANNALS; 2011; 432-435

41) National Institutes of Health Consensus Conference. Acupuncture. JAMA. 1998;280:1518–24. (5)

42) Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411–22. (1A)

43) Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004;17:243–66. (2A)

44) Assendelft W, Green S, Buchbinder R, Struijs P, Smidt N. Tennis elbow. Clin Evid. 2004;(11):1633–44. (1A)

45) Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002;(1):CD003527. (1A)
46) Cyriax HJ, Cyriax JP. Cyriax’s illustrated manual of orthopaedic medicine. Oxford: Butterworth-Heinemann, 1983.
47) D Stasinopoulos1, M I Johnson2 ; Cyriax physiotherapy for tennis elbow/lateral epicondylitis Br J Sports Med 2004; (1A)
48) Haake M1, König IR, Decker T, Riedel C, Buch M, Müller HH; Extracorporeal Shock Wave Therapy Clinical Trial Group;Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. ; J Bone Joint Surg Am. 2002 Nov;84-A(11):1982-91 (1B)
49) Spacca G1, Necozione S, Cacchio A.;Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. ; Eura Medicophys. 2005 Mar;41(1):17-25. (1B)
50) C.A. Speed , D. Nichols , Richards Humphreys J.T. Wies ; S. Burnet B.L. Hazleman; Extracorporeal shock wave therapy for lateral epicondylitis––a double blind randomised controlled trial (1B)
51) Ilieva EM1, Minchev RM, Petrova NS.;Radial shock wave therapy in patients with lateral epicondylitis. ; Folia Med (Plovdiv). 2012 Jul-Sep;54(3):35-41. (2A)
52) Hammer DS, Rupp S, Ensslin S, et al. Extracorporeal shock wave therapy in patients with tennis elbow and painful heel. Arch Orthop Trauma Surg 2000;120:304–7
53) Ko JY, Chen HS, Chen LM. Treatment of lateral epicondylitis of the elbow with shock waves. Clin Orthop 2001;(387):60–7. (1B)
54) Rompe JD, Hopf C, Kullmer K, et al. Low energy extracorporeal shock wave therapy for persistent tennis elbow. Int Orthop 1996;20:23–7. (1B)
55) Rompe JD, Kullmer K, Riehle HM, et al. Effectiveness of low- energy extracorporeal shockwaves for chronic plantar fasciitis. Foot Ankle Surg 1996;2:215–21.(1B)
56) Tyler F, Thomas GC, Nicholas SJ, McHugh MP.; Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial.; J Shoulder Elbow Surg. 2010 Sep;19 (1B)
57) http://www.physio-pedia.com/Maudsley%27s_test (accessed 23 mei 2014)

<a _fcknotitle="true" href="Category:Elbow">Elbow</a> <a _fcknotitle="true" href="Category:Tendons">Tendons</a> <a _fcknotitle="true" href="Category:Musculoskeletal/Orthopaedics">Musculoskeletal/Orthopaedics</a> <a _fcknotitle="true" href="Category:Neurodynamics">Neurodynamics</a> <a href="Category:Vrije_Universiteit_Brussel_Project">Template:VUB</a> <a _fcknotitle="true" href="Category:EIM_Residency_Project">EIM_Residency_Project</a>