Tennis Elbow definition, Causes, pathophysiology and clinical features, test, treatment

 Painful elbow syndromes encompass(to contain) lateral, medial and posterior elbow syndromes. The one commonly encountered is the lateral tennis elbow which is known as the classical tennis elbow and is the pain and tenderness on the lateral side of the elbow, some well defined and some vague that results from repetitive stress. It is a lesion affecting the tendinous origin of common wrist extensors from the lateral epicondyle 

Causes:-

• Epicondylitis this is due to single or multiple tears in the common extensor origin, periosteitis, angiofibroblastic proliferation of extensor carpi radialis brevis(ECRB). Etc. 

• Inflammation of adventitious bursa Between the common extensor origin and radio humeral joint. 

• Calcified deposits Within the common extensor tendon.  

• Painful annular ligament is due to hypertrophy of synovial fringe between the radial head and the capitulum's.

• Pain of neurological origin, for example, cervical spine affection, radial nerve  entrapment, etc. 

• Causes in tennis players More than one-third tennis players all over the would are affected with this problem over 35 years of age. 

• Household activities causing tennis elbow Different types of Indian household women suffering from tennis elbow

Pathophysiology and Related Symptoms

Stage 1-- There is acute inflammation but no angioblastic invasion. Patient complains of pain during activity. 

Stage 2-- This is the stage of chronic inflammation. There is some angioblastic invasion. Patient complains of pain both during activity and at rest. 

Stage 3-- Chronic inflammation with extension angioblastic invasion. Patient complains pain at rest, night pains, and pain during daily activities. 

Clinical tests

• Local tenderness on the outside of the elbow at the common extensor origin with aching pain in the baack of the forearm

• Painful resisted extension of the wrist with elbow in full extension elicits pain at the lateral elbow (Cozen's test). 

• Elbow held in extension, passive wrist flexion and pronation produces pain. 

Treatment

Conservative management:- it consists of rest and pain killers. In tennis players exercises, light racket, smaller grip, elbow strap, etc.  are helpful. Injection of local anesthetic and steroid are useful in 40 percent of cases

Physiotherapy Management for Tennis Elbow

The following measures are used to counter the pain:

During the Acute Phase

• Rest:- An above elbow pop split with elbow in 90° flexion and supination and the wrist in slight dorsiflexion is recommended. 

• Thermotherapy:- Heat modalities like, ultrasound and SWD help a great deal in reducing pain. 

• Cryotherapy:- Ice cold packs on the tender area for a period of 15-20 mts are very effective in reducing the pain. 

• Electrical Stimulation:- If this is done for 15-20 mts with the arm elevated, it reduces pain and inflammation. 

• Massaging gentle massaging for the first 10days followed by friction massages for the next 15 days greatly helps. 

• Exercises:- Active exercises for the Shoulder, elbow, wrist and hands are indicated. Isometric also helps.  

• Progressive resistive exercises for wrist extension, lateral deviatiom, forearm supination and finger flexion using the normal contra lateral hand distinctly improves the condition (Dumbbells of 0.5 to 2 kg are used). 

• Manipulation This is practiced in certain situations and is not commonly done. 

• Injection treatment Local infiltration of hydrocortisone is an effective method in certain resistant cases. 

Postacute phase 

• patient is instructed to avoid repeated wrist extension and supination movements. 

•Strengthening exercises to the extensor carpi radialis longus and brevis muscle, supinator muscle and common extensor group of muscles after adequate period of rest and support during the acute phase. 

•Exercises:-

---- passive exercises In the supine position, relaxed passive movements of the elbow flexion and forearm supination are carried out in its complete range

---- Resistive exercises When a painless range of movements are achieved by the passive exercises, progressive resistive exercises are adviced

-----Strenthening exercises Strong isometric exercises to the triceps, active ROM, exercises to the wrist and fingers are also adviced

Surgical Management

Indications

•Severe pain for 6 weeks at least

• Marked and localized tenderness over lateral epicondyle. 

• Failure to respond to restricted activity or immobilization for at least 2weeks

Surgical methods

• Percutaneous release of epicondylar muscles. 

• Bosworth technique of excision of the proximal portion of the annular ligament, release of the origin of the extensor muscle, excision of the bursa and excision of synovial fingers. 

• Arthroscopic release of the common extensor muscles origin from the lateral epicondyle is the surgical method of choice due to its minimal exposure and effectiveness

Physiotherapy after surgery

• measure to control pain as mentioned earlier

• Active ROM exercises to the shoulder

• passive ROM exercises to shoulder, elbow, forearm and wrist

• Progressive RE as mentioned earlier

• Thermotherapy helps to reduce pain. 



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