Tennis Elbow Management: Difference between revisions

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== Framework For Rehabilitation ==
== Framework For Rehabilitation ==


Management of tennis elbow (Lateral Epicondyle Tendinopathy) is similar in concept and approach to tendon rehabilitation. For the benefit of achieving long term goals, rehabilitation should be a multi-modal perspective and also to meet individual needs. We explored the different causes and associations of Tennis Elbow in the assessment course including, central sensitization, muscle and tendon structural changes and mechanical abnormalities. Hence, there is a need to examine all these aspects in the history taking and objective examination and consider them when designing a rehabilitation programme.
The management approach of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy, adapts the general principals of  [[Tendinopathy Rehabilitation|tendinopathy rehabilitation]]. For the benefit of achieving long term goals, rehabilitation should be a multi-modal perspective and also to meet individual's needs. We explored the different causes and effects of Tennis Elbow in the [https://members.physio-pedia.com/learn/tennis-elbow-assessment/ assessment course] including central sensitization, muscle and tendon structural changes and mechanical abnormalities. Hence, there is a need to examine all these aspects in the history taking and objective examination and consider them when designing a rehabilitation programme.


The use of multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy<ref>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;333(7575):939. doi:10.1136/bmj.38961.584653.AE</ref>. This includes education, exercises, tissue loading management, manual therapy and steroid injection. All of thhese management strategies can be used and tailored depending on the patient's needs, the clinician's clinical reasoning and a shared decision between patient and clinician. It should be centred around exercise based programme- best ,managememnt we have at the moment.
The use of multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy<ref>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;333(7575):939. doi:10.1136/bmj.38961.584653.AE</ref>. This includes education, exercises, tissue loading management, manual therapy and steroid injection. All of these management strategies can be used and tailored depending on the patient's needs, clinician's clinical reasoning and a shared decision between patient and clinician. Since exercises are the best management option available to us at the moment, TE management should be centred around exercises<ref name=":1">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482821/</ref>.  


== Patient Education ==
== Patient Education ==
Educating patiens on their condition, prognosis, management options and self-management may not be effective on the short term and cannot be used as a stand alone measure. However, it has a good long-term effect if used in cobination with other measures for the management of Tennis Elbow<ref>Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. ''J Can Chiropr Assoc''. 2015;59(4):349–362.</ref>.   
Educating patiens on their condition, prognosis, management options and self-management may not be effective on the short term and cannot be used as a stand alone measure. However, it has good long-term effects if used in combination with other measures for the management of Tennis Elbow<ref>Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. ''J Can Chiropr Assoc''. 2015;59(4):349–362.</ref>.   


Patient education is defined as <nowiki>''a planned learning experience using a combination of methods such as teaching, counselling, and behaviour modification techniques which influence patients’ knowledge and health behaviour''</nowiki><ref>training physiotherapy students to educate patients: a randamized controlled trial</ref>. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improving self-efficacy<ref>Ndosi M, Johnson D, Young T, et al. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. ''Ann Rheum Dis''. 2016;75(6):1126–1132. doi:10.1136/annrheumdis-2014-207171</ref>.  
Patient education is defined as <nowiki>''a planned learning experience using a combination of methods such as teaching, counselling, and behaviour modification techniques which influence patients’ knowledge and health behaviour''</nowiki><ref>training physiotherapy students to educate patients: a randamized controlled trial</ref>. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improves self-efficacy<ref>Ndosi M, Johnson D, Young T, et al. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. ''Ann Rheum Dis''. 2016;75(6):1126–1132. doi:10.1136/annrheumdis-2014-207171</ref>.  


Tendon structure is strong, made up of type I collagen.
Since tendinopathy is a degenerative disease and the first stages are condidered inflammatory, recovery and treatemnt will depend on the general health of the body. Smoking, obesity, high consumption of processed and fatty food and obesity can delay the recovery. These factors should be discussed with the patients to ensure optimum engagement with treatment. 
 
Health of tendon- thinking in a wide prespective, smoking, food and inactivity, diabetes, obesity- they all determine health in general and also recovery of tendonitis.  


== Load Management ==
== Load Management ==
Lateral Epicondyle Tendinopathy is a degenerative condition characterised by increased thickness and tearing in the common extensor tendon<ref>Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. ''J Musculoskelet Neuronal Interact''. 2018;18(3):323–332.</ref>, and the presence of neuromotor dysfunction- particularly of extensor carpi radialis brevis (ECRB)<ref name=":0">Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case-control study. Scand J Med Sci Sports. 2016;26(12):1382–1390.  
TE is a degenerative condition characterised by increased thickness in the common extensor tendon<ref>Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. ''J Musculoskelet Neuronal Interact''. 2018;18(3):323–332.</ref>, and the presence of different neuromuscular strategies with wrist function particularily when gripping<ref name=":0">Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case-control study. Scand J Med Sci Sports. 2016;26(12):1382–1390.  
</ref>. Pain with hand grip is the most common presentation with TE. Powerful grip in healthy individuals in observed when the wrist is at 35 degrees extension. The same power is observed they grip with 11 degrees less wrist extension. The muscle activity of the wrist exhibit less reaction time in people with TE<ref>Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.</ref>. And use different nueromuscular strategies when gripping<ref name=":0" />.  
</ref>. Pain with hand grip is the most common presentation with TE and as a result people with TE demonestrated their most powerful grip at a reduced wrist extension angle when cpompared with healthy individuals. angle of wrist extension when gripping<ref name=":0" /> and less reaction time in wrist muscle activity <ref>Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.</ref>, particularily ECRB muscle<ref>Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.</ref>.  


Reduction of load on the tendon is an effective pain management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to target load by retraining the mechanical properties of the tendon. A good way of altering the load is to ask patient to work under pain threashold on a numerical scale from 1-10 and loading the tendon under the level of exaggerated pain<ref>Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy</ref>.   
Reduction of load on the tendon is an effective management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to target load by retraining the mechanical properties of the tendon. A good way of altering the load is to ask patient to work under their pain threashold and engage them in exercises that load the tendon below the level of exaggerated pain<ref>Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy</ref>.   


Pain and swelling will occur in response to increased load- this phase is known as [[Tendinopathy|<nowiki>''reactive tendinopathy''</nowiki>]]. Reducing pain is essential in this phase by pain management measures and de-loading.  Identifying the contributing factors to pain and tendinopathy can help in modifying the loads on the tendon. These factors include sudden increase in load or it can mean applying changes to the way a player holds a tennis raquet or a person lifting an object. Lifting objects with flexed elbow and supinated forearm is a way of de-loading the extensors at the elbow, particularily ECRB, which is the main. It is a static stabilizer of the wrist. in slight extension when holding your phone for example.  Lifting with elbow extended and forearm supinated.    
Pain and swelling will occur in response to increased load which is known as [[Tendinopathy|<nowiki>''reactive tendinopathy''</nowiki>]]. Reducing pain is essential in this phase by pain management measures and de-loading.  Identifying the contributing factors to pain and tendinopathy can help in modifying the loads on the tendon. A sudden increase in load by movements involving repetitive wrist extension from pronated forearm and extended elbow can trigger pain and inflammation on the common extensor origin. To de-load the inflammed tendon, educate your pateint on lifting objects with flexed elbow and supinated forearm.      


== Exercises ==
== Exercises ==
progresing exercises gradually- to build tendon strength, tolerance adn resilience.  
The classical model for exercises in [https://members.physio-pedia.com/learn/tendinopathy/ tenidnoopathy rehabilitation] is eccentric contraction as a standard protocol, especially with Achilis and Patellar Tendinopathies<ref name=":1" />. Eccentric exercises are considered to be an effective measure for tendon overuse injuries and prevention of re-injuries<ref>Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. J Biomech. 2010 Dec 1;43(16):3073-9 </ref>.  They are also better in preparing patients/athletes for return to function or athletic activities when compared to concentric exercises<ref>Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986 Jul;(208):65-8</ref>. Tendons response to eccentric exercises in Achillis tendinopathy were observed after twelve weeks of trainig<ref>Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004 Feb;38(1):8-11, discussion :11</ref>. However, other studies found no difference on tendon response between concentric and eccentric exercises<ref name=":2">Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology (Oxford). 2008 Oct;47(10):1493-7, doi:10.1093/rheumatology/ken262</ref>. The evidence on load, speed of movement, number of repetition, duration of contraction and type of exercise remain inconclusive<ref name=":2" />.  
 
The default was to think about eccentric exercises. This was the standard protocol particularily in Achilis and Patellar Tendinopathyies.  
 
Exercise types, load and programme design are still inconclusive regarding TE exercise management. Loading for a minimum of 12 weeks- studies point to 
 
Role of Isometrics as an option- ECRB as a main tendon involved in TE- the role is static stabilizer of the wrist. makes sense.tasks.   
 
Isomteric exercises for wrist. one of the measures. 
 
To progressively load the tendons, start with elbow flexed and forearm supinated, isometric in this position. then gradually increase elbow extension angle- weight/theraband to add more load. 
 
Bilateral movement- bearing in mind the central effects of TE<ref>Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.</ref>  
 
task oriented exercise- functional to include shoulder
 
weight bearing through arm  
 
The aim is to exapnd the view beyind the typical exercises
 
dominance of long wrist extensors over short extensors- when doing isometrics keep a fist, or avoid pushing fingers into extension/   


Should exercises painfree pr painful is debated in litrature-  exercising into pain in MSK disorders 
Considering the fact that ECRB is the main tendon affected in TE and the role of the muscle in stabilizing the wrist statically support the use of isometric exercies in TE management. Isometric exercises were found to have hypoalgesic effect both locally and in remote sites from exercised part during and after contraction<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578581/</ref>.


Pain free exercises are most common. Exercise helps, loading is good and ex is the best treatemtn available. weighting in the long term benefits to the current pain. education of patient- exercises are damaging your joint- tackling myths. To build efficacy they have to go through pain sometimes.   
Coombes et al<ref>Isometric Exercise Above but not Below an Individual’s Pain Threshold Influences Pain Perception in People With Lateral Epicondylalgia
</ref> compared the immediate effects of isometric exercises performed with different intensities (above and below the pain threshold) on pain perception in patients with chronic TE. Their findings support the use of exercises above pain threshold in incerasing resting pain intensity immediately after exercises compared to the other group. Another intersting finding of this study was that greater fear of movement resulted in greater pain intensity during exercises above pain threshold.   


If atient is not responding- 
Gradual progression of exercises is essential to increase tendon tolerance to loads. The following are different ways to progress your exercises: 


c  
* Elbow and forearm position: begin with flexed elbow and forearm in supination, then progress by increase elbow extension angle.
* Fingers flexion vs extension: begining with fingers in flexion then progressing to extension to load the long extensors.
* Adding weights: wither by an exercise band or dumbells
* Bilateral movement. Many people report  bilateral symptoms , supporting the evidence of the association of central senstization with TE<ref>Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.</ref><ref>Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.</ref>.
* Functional training exercises and targeting the whole upper limb.
* Weight bearing exercises 


Isometric exercises were found to have hypoalgesic effect both locally and away from exercised part during and after contraction<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578581/</ref>.  
Exercising in the pain-free range and refraining from exercises that aggravate the pain are the common advice given in any MSK management. However, weighing in and explaining the long term benefits of exercises on loading the tendon properly and building tissue tolerance may require some pain initially<ref>https://bjsm.bmj.com/content/53/14/907</ref>.          


== MWM ==
== MWM ==

Revision as of 14:22, 11 August 2019

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Tarina van der Stockt, Robin Tacchetti, Tony Lowe and Jorge Rodríguez Palomino


Assessment of Tennis Elbow

Framework For Rehabilitation[edit | edit source]

The management approach of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy, adapts the general principals of tendinopathy rehabilitation. For the benefit of achieving long term goals, rehabilitation should be a multi-modal perspective and also to meet individual's needs. We explored the different causes and effects of Tennis Elbow in the assessment course including central sensitization, muscle and tendon structural changes and mechanical abnormalities. Hence, there is a need to examine all these aspects in the history taking and objective examination and consider them when designing a rehabilitation programme.

The use of multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy[1]. This includes education, exercises, tissue loading management, manual therapy and steroid injection. All of these management strategies can be used and tailored depending on the patient's needs, clinician's clinical reasoning and a shared decision between patient and clinician. Since exercises are the best management option available to us at the moment, TE management should be centred around exercises[2].

Patient Education[edit | edit source]

Educating patiens on their condition, prognosis, management options and self-management may not be effective on the short term and cannot be used as a stand alone measure. However, it has good long-term effects if used in combination with other measures for the management of Tennis Elbow[3].

Patient education is defined as ''a planned learning experience using a combination of methods such as teaching, counselling, and behaviour modification techniques which influence patients’ knowledge and health behaviour''[4]. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improves self-efficacy[5].

Since tendinopathy is a degenerative disease and the first stages are condidered inflammatory, recovery and treatemnt will depend on the general health of the body. Smoking, obesity, high consumption of processed and fatty food and obesity can delay the recovery. These factors should be discussed with the patients to ensure optimum engagement with treatment.

Load Management[edit | edit source]

TE is a degenerative condition characterised by increased thickness in the common extensor tendon[6], and the presence of different neuromuscular strategies with wrist function particularily when gripping[7]. Pain with hand grip is the most common presentation with TE and as a result people with TE demonestrated their most powerful grip at a reduced wrist extension angle when cpompared with healthy individuals. angle of wrist extension when gripping[7] and less reaction time in wrist muscle activity [8], particularily ECRB muscle[9].

Reduction of load on the tendon is an effective management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to target load by retraining the mechanical properties of the tendon. A good way of altering the load is to ask patient to work under their pain threashold and engage them in exercises that load the tendon below the level of exaggerated pain[10].

Pain and swelling will occur in response to increased load which is known as ''reactive tendinopathy''. Reducing pain is essential in this phase by pain management measures and de-loading. Identifying the contributing factors to pain and tendinopathy can help in modifying the loads on the tendon. A sudden increase in load by movements involving repetitive wrist extension from pronated forearm and extended elbow can trigger pain and inflammation on the common extensor origin. To de-load the inflammed tendon, educate your pateint on lifting objects with flexed elbow and supinated forearm.

Exercises[edit | edit source]

The classical model for exercises in tenidnoopathy rehabilitation is eccentric contraction as a standard protocol, especially with Achilis and Patellar Tendinopathies[2]. Eccentric exercises are considered to be an effective measure for tendon overuse injuries and prevention of re-injuries[11]. They are also better in preparing patients/athletes for return to function or athletic activities when compared to concentric exercises[12]. Tendons response to eccentric exercises in Achillis tendinopathy were observed after twelve weeks of trainig[13]. However, other studies found no difference on tendon response between concentric and eccentric exercises[14]. The evidence on load, speed of movement, number of repetition, duration of contraction and type of exercise remain inconclusive[14].

Considering the fact that ECRB is the main tendon affected in TE and the role of the muscle in stabilizing the wrist statically support the use of isometric exercies in TE management. Isometric exercises were found to have hypoalgesic effect both locally and in remote sites from exercised part during and after contraction[15].

Coombes et al[16] compared the immediate effects of isometric exercises performed with different intensities (above and below the pain threshold) on pain perception in patients with chronic TE. Their findings support the use of exercises above pain threshold in incerasing resting pain intensity immediately after exercises compared to the other group. Another intersting finding of this study was that greater fear of movement resulted in greater pain intensity during exercises above pain threshold.

Gradual progression of exercises is essential to increase tendon tolerance to loads. The following are different ways to progress your exercises:

  • Elbow and forearm position: begin with flexed elbow and forearm in supination, then progress by increase elbow extension angle.
  • Fingers flexion vs extension: begining with fingers in flexion then progressing to extension to load the long extensors.
  • Adding weights: wither by an exercise band or dumbells
  • Bilateral movement. Many people report bilateral symptoms , supporting the evidence of the association of central senstization with TE[17][18].
  • Functional training exercises and targeting the whole upper limb.
  • Weight bearing exercises

Exercising in the pain-free range and refraining from exercises that aggravate the pain are the common advice given in any MSK management. However, weighing in and explaining the long term benefits of exercises on loading the tendon properly and building tissue tolerance may require some pain initially[19].

MWM[edit | edit source]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633771/

Steroid injection[edit | edit source]

long term outcomes are poor-

98% get better with physio

worse prognosis, high recurence rate and development of chronicity. there is a big move away.

Clinical reasoning skills- weight out the benefit and the current symptoms.

Discussion- shared decision

If there is a need to reduce pain- this might be a good way to engage patients into exercises by reducing their pain.

Taping[edit | edit source]

References[edit | edit source]

  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;333(7575):939. doi:10.1136/bmj.38961.584653.AE
  2. ↑ 2.0 2.1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482821/
  3. ↑ Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Can Chiropr Assoc. 2015;59(4):349–362.
  4. ↑ training physiotherapy students to educate patients: a randamized controlled trial
  5. ↑ Ndosi M, Johnson D, Young T, et al. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Ann Rheum Dis. 2016;75(6):1126–1132. doi:10.1136/annrheumdis-2014-207171
  6. ↑ Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. J Musculoskelet Neuronal Interact. 2018;18(3):323–332.
  7. ↑ 7.0 7.1 Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case-control study. Scand J Med Sci Sports. 2016;26(12):1382–1390.
  8. ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.
  9. ↑ Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
  10. ↑ Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy
  11. ↑ Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. J Biomech. 2010 Dec 1;43(16):3073-9
  12. ↑ Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986 Jul;(208):65-8
  13. ↑ Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004 Feb;38(1):8-11, discussion :11
  14. ↑ 14.0 14.1 Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology (Oxford). 2008 Oct;47(10):1493-7, doi:10.1093/rheumatology/ken262
  15. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578581/
  16. ↑ Isometric Exercise Above but not Below an Individual’s Pain Threshold Influences Pain Perception in People With Lateral Epicondylalgia
  17. ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.
  18. ↑ Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.
  19. ↑ https://bjsm.bmj.com/content/53/14/907
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