Tendinopathy

Tennis elbow

Tennis elbow (also known as lateral epicondylitis / epicondylalgia/ tendinopathy/ tendonosis) can occur as a result of repetitive strain and trauma on the attachment of the wrist extensors at the lateral epicondyle (age of tendon can be a factor also) (Barr et al, 2009).

Symptom are tenderness and/or pain over the lateral epicondyle which may radiate into the forearm muscles. The pain is reproduced with resisted wrist extension and muscle tension in the associated wrist extensor. This area is usually tender to touch and aggravated by movements which extend the wrist such as lifting, gripping, computer use or playing tennis.

The incidence of tennis elbow is 1-3% in the adult population (Barr et al, 2009) high as 15% in manual workers. It accounts for 4-7 consultations in General Practice per 1000 in the UK (Croisier et al, 2007).

Differential Diagnosis

Cervical spine referral, elbow joint capsulitis, upper limb neural tension or ulnar nerve entrapment.

Golfers elbow

Golfers elbow (also known as medial epicondylitis/ epicondylalgia/ tendinopathy/ tendonosis/ climbers elbow) can occur as a result of repetitive strain and trauma on the attachment of the wrist flexors at the medial epicondyle (age of tendon can be a factor also). This is felt as tenderness or pain over the medial epicondyle which may radiate into the forearm muscles. Pain is reproduced with resisted wrist flexion & pronation, and muscle tension in the associated wrist flexors. This area is usually tender to touch and aggravated by movements which flex the wrist such as lifting, gripping, shaking hands or playing golf. Pain when using affected muscles i.e. opening a jar.

The incidence of golfers elbow is, about one fifth less than tennis elbow (1-3% adult population) (Croisier et al 2007).

Differential Diagnosis

Cervical spine referral, elbow joint capsulitis, medial ligament strain, upper limb neural tension or ulna nerve entrapment.

Tennis elbow

Palpation

Tenderness over lateral epicondyle

Pain on stretching the wrist extensors

The patient is positioned in sitting or standing with their shoulder in 90° flexion, elbow in full extension and forearm pronated.  The therapist passively flexes the wrist.  A positive test reproduces the patients pain

Pain on resisting wrist extension

The patient is positioned in sitting or standing with their shoulder in 90° flexion, elbow in full extension, forearm pronated and wrist in neutral.  The therapist resists wrist extension.  A positive test reproduces the patients pain

Pain on resisting middle finger extension

The patient is positioned in sitting or standing with their shoulder in 90° flexion, elbow in full extension, forearm pronated and wrist in neutral.  The therapist resists middle finger extension.  A positive test reproduces the patients’ pain (www.youtube.com/watch?v=TsF-wsqVw0I)

Other Tests

On occasion EMG may be considered to rule out radial nerve entrapment. Can ask GP for this (Roles et al,1972).

Golfers elbow

Palpation

Tenderness over medial epicondyle

Pain on stretching the wrist flexors

The patient is positioned in sitting or standing with their shoulder flexed at 90°.  The elbow is in full extension and the wrist in full passive extension and supination.  The clinician applies a passive stretch to the wrist flexors (by extending the wrist).  The test is positive if the patients’ symptoms are reproduced.  

Pain on resisting wrist flexors

The patient is positioned in sitting or standing with their shoulder flexed at 90°.  The elbow is in full extension and the wrist in neutral. The physiotherapist resists wrist flexion. The test is positive if the patients’ symptoms are reproduced.   

Tennis elbow

Not indicated from an MSK point of view.

Golfer's elbow

Not indicated for MSK.

Overview

• Optimise pain management
• Prophylactic advice / activity modification
• Stretches of extensor / flexor mechanism
• Eccentric loading
• Consider orthotic / CSI as felt appropriate

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Tennis elbow

Rehabilitation

Conservative management – no specific evidence on guidance of exercises (therefore aim to restore ROM/strength etc)

• NSAID’s & analgesia
• Maintain correct elbow posture. Ergonomics for key boards/manual tasks
• Stretches to wrist extensors (Bisset and Vincenzino, 2015), Croisier et al, 2007, Finestone and Rabinovitch, 2008 and Kaux et al, 2007)
• Advice/education as to returning to normal activity levels.
• Eccentric  loading Programme (Croisier et al, 2007 and Finestone and Rabinovitch, 2008) https://www.shoulderdoc.co.uk/article/1268

Surgical Cases – as per surgeon/protocol. Not always successful.

Golfers elbow

Rehabilitation

Conservative management – no specific evidence on guidance of exercises (therefore aim to restore ROM/strength etc)

• NSAID’s & analgesia
• Maintain correct elbow posture. Ergonomics for key boards/manual tasks
• Stretches to wrist flexors (Bisset  and Vincenzino, 2015, Croisier et al, 2007, Finestone and  Rabinovitch, 2008  and Kaux et al, 2007)
• Advice/education as to returning to normal activity levels.
• Eccentric flexion/loading Programme (Croisier et al, 2007 and Finestone and  Rabinovitch, 2008)                       

Surgical Cases – as per surgeon/protocol. Not always successful

Non-evidence based strategies

Tennis elbow

Electrotherapy –insufficient evidence to support use from recent literature  (Bisset and Vincenzino, 2015).

Acupuncture – insufficient evidence to support use from recent literature search (Though may gain short term relief from needling attachment!) (Bisset and Vincenzino, 2015).

Orthosis/Clasp

No trials to support this; however anecdotal evidence may suggest it can help in some cases (Kaux et al, 2007 and Stuijs et al, 2009).

CSI

No actual evidence to support (Barr et al, 2009, Bisset, et al, 2006, Cardone and Tallia, 2002 and Vicenzino et al 2013).

CSI on occasion, for symptomatic relief only.  Discuss with injection therapist.

Manual Therapy
Insufficient evidence to support use from recent literature search.

Golfers elbow

Electrotherapy –insufficient evidence to support use from recent literature search (Bisset  and Vincenzino, 2015).

Acupuncture – insufficient evidence to support use from recent literature search (Though may gain short term relief from needling attachment!) ( Bisset  and Vincenzino, 2015).

Orthosis/Clasp

No trials to support use of clasp/splint. However anecdotal evidence may suggest it can help in some cases (Kaux et al, 2007 and Stuijs et al, 2002).

CSI

No actual evidence to support (Barr et al, 2009, Bisset et al, 2006, Cardone and Tallia, 2002 and Vicenzino et al, 2014).

CSI on occasion, for symptomatic relief only. Discuss with injection therapist.

Manual Therapy
Insufficient evidence to support use from recent literature.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

Tennis elbow

Referral to orthopaedics can be considered for orthopaedic opinion if the patient is not progressing and would consider orthopaedic intervention. Research suggests symptoms can last up to 2 years and beyond.

However orthopaedic intervention is not usually considered until symptoms persist over 6 months or longer with appropriate conservative management.

Golfers elbow

Referral to orthopaedics can be considered for orthopaedic opinion if the patient is not progressing and would consider orthopaedic intervention.

Research suggests symptoms can last up to 2 yrs and beyond.

Orthopaedic intervention is not usually considered unless symptoms persist 6 months or longer with appropriate conservative management.

Barr, S., Cerisola, F.,L., Blanchard, V. 2009. Effectiveness of Corticosteroind Injections compared with Physiotherapeutic Intervention for Lateral Epicondylitis: A Systematic Review. Physiotherapy 95, 251-265. Link Here (link correct as of 16/08/19).

Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., and Vincenzino, B. 2006. Mobilisation with Movement and Exercise, Corticosteroid Injection or Wait and See for Tennis Elbow: Randomised Control Trial.  British Medical Journal, 333:939.  Link Here (link correct as of 16/08/19).

Bisset, L. and Vincenzino, B. 2015. Physiotherapy Management of Lateral Epicondlagia.  Journal of Physiotherapy (Australia) 178 -186.  Link Here (link correct as of 16/08/19).

Cardone, D.A.  and Tallia, A.F. 2002. Diagnostic and Therapeutic Injection of the Elbow  Region” American Family Physician   66.11

Croisier, J.L., Foidart-Dessalle, M., Tinant, F., Crielaard, J.M. and Forthhomme, B. 2007.  An Isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy.  British Journal of Sports Medicine 41:4 269-275. Link Here (link correct as of 16/08/19).

Finestone, H.M. and Rabinovitch, D.L. 2008.  Tennis Elbow No More: Practical eccentric and concentric exercises to heal the pain.  Canadian Family Physician 54(8). Link Here (link correct as of 16/08/19).

Kaux, J.F., Forthomme, B., Le Golf, C., Crielaard, J.M. and Croisier, J.L.  2011.  Current Options in Tendinopathy.  Journal of Sports Science and Medicine 10(2) 238-53. Link Here (link correct as of 16/08/19).

Roles, R.H. and Maudsley, R.H. 1972.  Radial tunnel syndrome: resistant tennis elbow as a nerve entrapment.  Journal of Bone and Joint Surgery 54(3):499-508. Link Here (link correct as of 16/08/19).

Stuijs, P.A.A., Smidt, N., Arola, H., van Dijk, C.N., Buchbinder, R. and Assendelft, W.J.J.  2002. Orthotic devices for the treatment of tennis elbow (Review) The Cochrane Collaboration. Link Here (link correct as of 16/08/19).

Vicenzino, B., Coombes, B.K., Bisset, L., Brooks, P. and Khan, A.B. (2013) Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia - A Randomised Controlled Trial. Journal of American Medical Association 309(5) 461 – 469. Link Here  (link correct as of 16/08/19.

NHS GGC Physiotherapy Service - Elbow

National Patient Information Sheet - Tennis elbow

National Patient Information Sheet - Golfers elbow

NHS Inform - Elbow Problems