MSK Viva Voce Preparation Sheet

Topic: Lateral Epicondylitis (Tennis Elbow) _________________________________________________________

Pathomechanics (including pathology, MOI & aetiology) Pathomechanics Lateral epicondylitis is one of the most common upper extremity disorders. It typically presents with lateral elbow pain on resisted wrist extension activities. It primarily involves extensor carpi radialisbrevis (ECRB) and longus. (it can on rare occasion involve extensor carpi ulnaris). ECRB susceptible to excessive force overload particularly with hyperpronation. This could be due to the added tensile load permitted by the radial head when the tendon is stretch in wrist flexion, elbow extension and pronation of the forearm. Degeneration of cells in the matrix.

Lateral epicondylitis is a painful condition which affects the tendionous tissue of the extensor muscles of the wrist at the lateral epicondyle of the humerus. This can result in a loss of function of wrist and forearm and can have a major impact on a patients professional and social life. This painful condition can result from over-use of extensor carpi radialisbrevis (ECRB) by repeated movements causing microtrauma which results in a primary tendinosis

Can progress to affect the ECU ED and EDM whole ext origin. Pain could be a tear between the tedon and periosteum between the bone. No swelling. Gradual 1-2 years. Combination of treatments used. Not inflammatory later on in the condition presence of firboblasts.

MOI No specific but could be age related. Overuse injury to ECRB. Can be a truma.Can be refered pain from cervical C5, C6 and C7.

Aetiology Tennis elbow is thought to result from overuse ofthe extensor carpi radialisbrevis (ECRB) muscleby repetitive microtrauma resulting in a primarytendinosis of the ECRB.

Clinical features / examination findings (including epidemiology) Pain when gripping, hammering, screw driving, pushing doorhandle, closing a tap and knocking the elbow. Positive tennis elbow test (resistance against extension in extension position of the wrist with close fist), palpable swelling in ECRB. Localised tenderness/pain. Pain over lateral epicondyle Gradual onset 30-50yrs age group Incidence 3-15% (general population to sport population)

Special question

Grade I Generalised elbow soreness with activity often ignored. Cycle of irritation, inflammation, pain, weakness and inadequate healing is initiated.

Grade II Working or playing through soreness may increase pain which becomes localised to lateral condyle or radial head often persists after activity. This can become swollen, warm or tender to touch.Pain starts to interfere with work or athletic activity. Progression of the condition may see pain radiating down the forearm to the wrist. It can also radiate upwards towards the shoulder.

Grade III ADL become painful and difficult to carry out. If activity is continued it can lead to secondary problems such as rotator cuff injury or lower back pain as other joint tend to compensate. If this becomes ignored arthritic changes in the proximal radial or humeral ulnar joint occur.

Swelling and soreness due to repeated and sustained wrist extension causes the tendon sheaths of ECRB to become inflamed and irritated.

Referred pain over C7 segment down dorsum of the hand and possibly into the ring and long fingers.

Onset of pain is gradual and can be related to wrist extension activities. Pain on rest can be a dull ache to completely absent. On activity it presents as sharp twinge or a strained sensation. Pain with active wrist flexion.

Test Full passive wrist flexion with ulna deviation, forearm pronation and elbow extension. Passive elbow movements alone are painless.

Test Resisted wrist extension with elbow extended (isometric movement). Resisted movement of mcp joint.

Reduce grip strength. Joint play movements should be full and painless. Tender over epicondlyes when palpating, extending into belly of muscle. Tenderness can sometimes be found at the insertion of ECRL.

Poor elbow proprioception due to degeneration of tissues. Pain interrupts the sensory information.

Altered motor pattern throught lack of use due to plastic changes. Pivvum and pavumClearance tests to cervical spine

Epidemiology 1 in 3 % of the population.

accounts for 7% of all sports injuries mostly occurring in45-54 adults, with no difference between mean and women.

Tobacco use can increase the risk of developing the condition healing rates? Repetitive movements and forceful activities were also positively correlated with lateral epicondylitis.

Tennis only make up 10% of the population. 90% cervical spine C6 & 7 The natural course of the condition seems to befavourable, with spontaneous recovery within 12 years in 8090% of the patients.

Clinical reasoning / differential diagnosis Clearance tests to cervical spine A pain that is dermatonal in pattern, e.g. Radiculopathy (C6C7) Extensor carpi ulnaris tendinitis (at wrist) similar MOI and epi, however pain present in wrist, does not tend to refer. Pronator syndrome Entrapment of the posterior interosseus nerve Arthrosis of the radiohumeral joint: Pain seen around the joint. Due to over use however has a much later presentation normally seen in men 55+. Osteochondritisdissecans, Osteonecrosis (Panner) present with pain and swelling however normally happened in children. Radial tunnel Medial epi nerve entrapment C8 and T1. Common flexor tendon. Location of pain.

Likely problem list (prioritised & specific) 1. Lack of understanding and awareness of the condition & Likely prognosis.

2. NocioceptorLocal pain in/around lateral area and immediate surrounding tissue with high VAS e.g. mild but highly irritable. Muscle belly ECRB. 3. A reduced AROM and PROM due to pain when grping 4. Motor patter and proprioception affected.

Management/ treatment (including contribution by others where applicable) Patient position and procedure: Sitting with the elbow flexed, forearm pronated and resting on a table, and the wrist in extension. Begin with gentle isometric contraction with the wrist extension in the shorter position. Resist wrist extension, hold the contraction to the count of 6, relax, and repeat the isometric resistance sequence to the wrist extensors in the position of elbow extension and wrist flexion. Reduce the pain (ice, local modalities, acu), strapping bracing to unload the tissue MWM pain relief Eccentric programmes to retain supinator and ECRB

1. Make patient aware of Aggs and eases factors. Pain medication. Time scale of condition 1-2 years can heal on its own. Rest can be essential to deal with pain but can have a detrimental effect on the tissues healing. Talk about rehab plan 2. Pain medication this will aid physio treatment. Short term corico steroid injection initial inflammation.Muscles brace two theories how it works: One theory involves the

constriction and limitation of full forearm musculature contraction which decreases the tension at the musculotendinous unit below the brace. Another theory explains how the brace provides compression directly over the ECRB muscle belly which creates a secondary origin and theoretically unloads the tension at the true muscle origin at the lateral epicondyle. 3. Ice pack reduce swelling. Can be used at home will also have an analgesic effect. 4. To restore strength and full AROM continue use of arm as this is encourage the correct healing formation. Strengthening exercises - Eccentric strengthening places a load at the musculotendinous unit to cause hypertrophy and an increased tensile strength which reduces the tendon strain during movement. Mills manipulations. Deep transvers frictions massage encourages new fibres of collage fibres to mature. Break down adhesions that are present. Stretch for range of movement. Pronation and supination in cardinal movements. Tapping the elbow proprioception.

Local friction or gentle massage, and gentle stretching can help to improve local blood supply and tightness. In addition, ultrasound treatment of swelling and pain, addressing the cause of the problems requires:

a. Adherence to alternative or modified duties at work. b. The use of properly designed equipment c. Adequate manual handling techniques d. Counterforce bracing to minimise the risk of overloading e. Avoid tight gripping f. Avoid high load repetitive activities, such as hammering

g. Using ergonomically designed tool, non-clip grip, and the use of power tools and longer levers.