Lateral Epicondylitis: Difference between revisions
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== Epidemiology /Etiology == | == Epidemiology /Etiology == | ||
Lateral | Lateral epicondylitis is classified as an overuse injury. Overuse of the muscles and tendons of the forearm and elbow together with repetitive gripping or manual tasks can put too much strain on the elbow tendons. These gripping 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. | ||
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. <br>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. <ref>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)</ref> | |||
Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors.<br>There are several opinions concerning the cause of lateral epicondylitis: | |||
<u>Inflammation:<br></u>• Although the term epicondylitis implies the presence of an inflammatory condition, inflammation is present only in the earliest stages of the disease process. <ref>Baker CL, Plancher KD. Operative treatment of elbow injuries. New York: Springer, 2002.</ref> | |||
<u>Microscopic tearing:<br></u>• 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.<br>• That microscopic or macroscopic tears of the common extensor origin were involved in the disease process, was postulated by Cyriax in 1936.<br>• The first to describe macroscopic tearing in association with the histological findings were Coonrad and Hooper.<br>• 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. | |||
<u>Degenerative process:<br></u>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. | |||
<u>Hypovascularity:<br></u>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. <ref>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</ref> | |||
== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
Revision as of 13:00, 3 January 2011
Original Editor - Hannah Norton, Elien Vanderlinden
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Search Strategy[edit | edit source]
MeSH terms: Lateral Epicondylitis, Tennis Elbow.
Key words: Lateral Epicondylitis, Tennis Elbow, Elbow.
The university’s library and sites: Pubmed, Web of Knowledge and Google.
Definition/Description[edit | edit source]
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.[1]
Clinically Relevant Anatomy[edit | edit source]
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).
Musculature involved is most commonly the extensor carpi radialis brevis (ECRB), but this injury can also involve the extensor carpi radialis longus (ECRL), extensor digitorum, and extensor carpi ulnaris.
The radial nerve is also in close proximity to this region, and divides into the superficial radial nerve and the posterior interosseous nerve.
Epidemiology /Etiology[edit | edit source]
Lateral epicondylitis is classified as an overuse injury. Overuse of the muscles and tendons of the forearm and elbow together with repetitive gripping or manual tasks can put too much strain on the elbow tendons. These gripping 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.
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.
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. [2]
Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors.
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. [3]
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.
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. [4]
Characteristics/Clinical Presentation[edit | edit source]
Patients presenting with lateral epicondylalgia are typically in their 3rd to 5th decade of life, and have complaints of pain just distal to the lateral epicondyle, usually with gripping activities. Patients will commonly have pain with palpation of the lateral epicondyle, resisted wrist, or second or third finger extension (Cozen's sign). [5] Grip strength will typically be weakened, especially with the elbow extended.
Differential Diagnosis
[edit | edit source]
• Elbow osteoarthritis
• Fracture
• Radial tunnel syndrome
• Cervical Radiculopathy
Diagnostic Procedures[edit | edit source]
add text here related to medical diagnostic procedures
Plain film radiologic evaluation may be indicated if there is lack of elbow joint movement or if the patient's symptoms persist despite adequate treatment (eMedicine)
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
mASES
QuickDASH (reliability= .90, MCID not reported)
PSFS (reliability= .82-.92, MCID=2.0)
Examination[edit | edit source]
• (+) tenderness to palpation at the anterior epicondyle
• Cozen's sign- The patient is positioned with the UE relaxed, elbow extended. The examiner resists supination and wrist extension OR resists middle finger extension; pain is positive for lateral epicondylalgia
• Chair test- patient grasps the back of the chair while standing behind it and attempts to lift it. Pain reproduction at the lateral epicondyle is a positive test
• Mill's Test- The patient is positioned in standing with the UE relaxed at side, 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 epicondylalgia
Medical Management
[edit | edit source]
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)(Emedicine). Low level laser therapy has also been found to be an ineffective treatment modality for lateral epicondylalgia. [6]
Physical Therapy Management
[edit | edit source]
Physical therapy interventions including elbow joint mobilization with movement combined with exercise has been shown to have better results than corticosteroid injection at 6 weeks and to wait and see at 6 weeks but not 52 weeks.[5] 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. [7]
Physical therapy management including only the use of ultrasound, massage, and exercise has been shown to be no better than a "wait and see" treatment method. [8] Activity modification, when possible, can help prevent recurrent episodes of lateral epicondylalgia, as well as use of a counterforce brace as needed.
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Resources
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Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
References will automatically be added here, see adding references tutorial.
- ↑ http://emedicine.medscape.com/article/1231903-overview (accessed 17 Nov 2010)
- ↑ 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)
- ↑ Baker CL, Plancher KD. Operative treatment of elbow injuries. New York: Springer, 2002.
- ↑ 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
- ↑ 5.0 5.1 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 2006;doi:10.1136/bmj.38961.584653.AE (accessed 01 December 2009)
- ↑ 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
- ↑ 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.
- ↑ 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.
