Angeles University Foundation

College of Allied Medical Professions

Angeles City

TENNIS

ELBOW

SEMINAR 1

Submitted by :

Castro, Maria Fatima H.

Feliciano, Gian Paul P.

Garcia, Miguel Antonn V.

Liwag, Paula Angela P.

Punzalan, Ruffin Stephanelle O.

Rodriguez, Krishna Yves

Serrano, Kin Marcelene B.

BSTP4

TENNIS ELBOW

I. INTRODUCTION

Injuries to the elbow, specifically humeral epicondylitis, occur frequently in daily activities

as a result of the repetitive loads encountered and in athletes from both repetitive and forceful

muscular activations inherent in throwing, hitting, serving and spiking.

Gradual or acute onset of pain over the lateral epicondyle or wrist extensor muscles, which is

worse when gripping, hitting, dragging, hammering, using a screw-driver or carrying a heavy

briefcase with the palm down. The pinch grip to take down books or files off a shelf is a

common cause. The pain is worse on making a fist, lifting a cup or kettle, or sometimes

writing. Resisted wrist and finger extension are painful.

Lateral epicondylitis, the most common tendinopathy of the elbow, affects the extensor wad,

specifically the extensor carpi radialis brevis (ECRB) origin in the region of the lateral

epicondyle. It can be precipitated by a single event such as direct trauma or repetitive

activities including improper lifting of heavy objects.

This condition is also called tennis elbow but symptoms can result from any excessive

forearm use including gardening, gripping a heavy briefcase, and using a screwdriver.

Infrequently, acute onset may be associated with a direct blow to the lateral elbow.

Posterolateral rotary instability may mimic or be associated with lateral epicondylitis. Lateral

epicondylitis occurs most commonly between the ages of 30 and 55 years. If symptoms are

long-standing or the patient has a history of excessive forearm use, the classification should

be lateral epicondylosis. Treatment includes inflammation control, stretching, postural

training, bracing, and strengthening when the acute inflammatory phase has resolved.

Avoidance of painful activities, modification of provoking activities that cannot be avoided,

and environmental adaptations (at work and leisure) are an integral part of successfully

treating lateral epicondylitis. Infrequently, surgical treatment is utilized to treat patients who

have responded to nonoperative intervention.

II. ANATOMY/PHYSIOLOGY/ETIOLOGY

Involves primarily the ECRB and occasionally, the ECRL and ED

Tendinitis is rarely due to acute trauma; rather, it is because of degeneration. It is a

response to fatigue stresses.

The inflammatory response in an attempt to speed the rate of tissue production to

compensate for an increased rate of tissue microdamage (collagen fiber fracturing)

associated with a loss of mucopolysaccharidechondritin sulfate, which makes the tendon

less extensible.

Due to this, more energy from tensile loading must be absorbed as internal strain to

collagen fibers rather than by deformation of the tissue.

ECRB is susceptible to excessive force overload particularly due to hyperpronation.

Tennis elbow is a type of bursitis that affects the elbow area. This bursitis is not always

caused by playing tennis, as its name suggests. Tennis elbow is a repetitive motion injury.

III. EPIDEMIOLOGY

The annual incidence of the disorder is between 1% to 3% in the general population

and commonly affects people aged from 30 to 55 years old due to age-related tissue

changes. Although often referred to as tennis elbow, 95% of reported cases occur in

individuals other than tennis players. It is more frequently seen in occupations

requiring repetitive upper extremity activities and particularly those involving

computer use, heavy lifting, forceful forearm pronation and supination, and repetitive

vibration.

In athletics, racquet sports are most commonly associated with lateral epicondylitis.

Epidemiologic research on adult tennis players reports incidences of humeral

epicondylitis ranging from 35% to 50%. This incidence is actually far greater than

that reported in elite junior player (11% to 12%) .

The injury is also seen in golf, baseball, and swimming. In tennis, the incidence

appears to be between 30% and 40%. In general, tennis players with symptoms are

older, play more frequently, and tend to be more skilled.

IV. PATHOPHYSIOLOGY

The term “tendinitis” and “epicondylitis” imply an inflammatory process; histologic studies

have confirmed that lateral epicondylitis may not be an inflammatory condition. Tissues

studies of damaged tendons from overuse injuries have not contained large numbers of

inflammatory cells at the time of study demonstrated an increased number of fibroblasts,

vascular, hyperplasia, and disorganized collagen, which is consistent with tendinosis.

This constellation of findings led to coin the phrase “angiofibroblastic hyperplasia”. The

term refers to the degenerative changes that occur when a tendon has failed to heal properly

after an injury or after repetitive microtrauma resulting from overuse.

V. CLINICAL MANIFESTATIONS

Patient will present with lateral elbow and forearm pain experienced during activities such as

lifting, grasping, gripping, hitting a backhand in tennis. The pain associated with lateral

epicondylitis is generally localized to the common extensor origin, but patients may report

pain radiating proximally and distally. Pain is usually worse with resisted wrist extension,

especially with the elbow extended, but can be elicited with radial deviation, finger

extension, or forearm supination.

In the mild stages, the symptoms will develop after completion of an activity. As the severity

progresses, the symptoms are noted soon after starting an activity. In severe cases, the

symptoms will occur with minimal activity such as brushing teeth and shaking hands, and

rest pain may be noted.

This presentation is characterized by pain and point tenderness at the lateral epicondyle and

the involved tendon(s), most commonly the extensor carpi radialis brevis. Pain is worse with

the use of the arm. Reproduction of symptoms will occur with resisted wrist extension and

passive wrist flexion with increased symptoms when the elbow is extended.

VI. CLINICAL COURSE

Grade 1 – generalized soreness with activity, which is most often ignored. A vicious

cycle of irritation, inflammation, pain, weakness and inadequate healing is initiated and

gains full expression in subsequent grades of injury.

Grade 2 – working or playing through the soreness may increase pain, which becomes

localized at the lateral epicondyle or radial head that persists after activity. The lateral

aspect of the joint may become swollen or tender to touch. Pain will interfere with work

or athletic activity. As the condition persists, pain may radiate down the forearm to the

wrist and may extend upward into the upper arm and shoulder.

Grade 3 – simple activities of daily living become more painful and difficult. Continued

activity leads to secondary problems like rotator cuff or low back pain as other joints

attempt to compensate. If ignored, arthritic changes in the proximal radial or humeral-

ulnar joint may occur.

VII. PROGNOSIS

Short term prognosis as follows:

90% to 95% improvement of symptoms

1 to 2 treatments give pain relief with deep tissue massage

92% of patients reported improvement at 4 weeks

Increased grip strength at 6 weeks

Slow progression with greatest improvement at 12 weeks and lasting into

week 52

Long term prognosis includes the following:

91% success at 52 weeks

Approximately 10% recurrence of symptoms.

Rehabilitation may take longer to reduce pain, but results are long term.

VIII. DIAGNOSIS AND EVALUATION PROCEDURES

Patients with lateral tennis elbow present with localized tenderness medial and distal to the

lateral epicondyle. Pain and tenderness extend distally along the muscle mass of the extensor

carpi radialis brevis. Symptoms are exacerbated with provocative stress testing such as active

(resisted) wrist and finger extension with elbow extended (and in advanced cases, with elbow

flexed). Passive wrist flexion can also increase symptoms, especially with the elbow

extended. Radiographs are often normal, but may show calcific deposits in the extensor

aponeurosis.

IX. DIFFERENTIAL DIAGNOSIS

Radial Tunnel Syndrome

Posterior Interosseous Syndrome

Elbow Osteoarthritis

Pain

Loss of range of motion

Fractures

Distal Radial Fractures

Radial Head Fracture

Olecranon Fracture

Cervical Radiculopathy

X. TREATMENT

A. Medical

Central to conservative nonoperative management of lateral epicondylitis are patient

education, protection of the elbow, and avoidance of activities that aggravate pain.

Patients should be taught proper techniques for lifting and other sporting activities. In

general, lifting should be performed with the arms close to the body and supinated. A

“wait-and-see” strategy may be viable treatment strategy for lateral epicondylitis.

Referral to physical or occupational therapy may be helpful in the prevention and

treatment of lateral epicondylitis. In general, therapy consists of three phases. The

first phase emphasizes rest to control pain and decrease disability. In addition to

limiting activities, modalities including heat, ice massage, and ultrasound can be

helpful. The second phase, rehabilitation, involves stretching or flexibility exercises

for the extensor wad muscle tendon units, which are started when the pain has

subsided with rest. Stretching exercises of the extensors are initially performed with

the elbow in flexion and progressed to performing the exercises with the elbow in

extension. In the third phase, a gradual strengthening program is instituted with

isometric followed by isotonic exercises. If pain develops during the program, the

exercises are not progressed; the patient returns to the previous phase until the

symptoms resolve. If lateral epicondylitis has developed from a sporting activity,

proper sport specific counseling should be a part of the rehabilitation process. In

particular, tennis players should consider playing on a soft surface, using new tennis

balls frequently, and selecting the appropriate racket with proper grip size and string

tension. Hitting a backhand while leading with the elbow often is a factor in lateral

epicondylitis; therefore, professional stroke instruction is beneficial.

Elbow bands can be used to reduce pain from lateral epicondylitis. A counterforce

brace applies a compressive force over the extensor mechanism of the forearm. This

band essentially prevents full muscular expansion by creating a new functional origin

of the extensor musculature of the forearm. The efficacy of the device has been

disputed. Studies have shown that elbow bands may decrease pain and increase grip

strength, whereas other studies show no difference when compared with sham

bracing.

Corticosteroid injections have been effective in treating lateral epicondylitis. The

injection consists of a combination of local anesthetics and corticosteroid. The most

common is 0.5 ml methylprednisolone and 0.5 ml lidocaine. In randomized study of

164 patients being treated with corticosteroid injections, naproxen, or placebo, 92%

of patients in the injection group had complete resolution or improvement compared

with 57% in the naproxen group and 50% in the placebo group. Risks associated with

steroid injections include elevation of glucose in patients with diabetes, steroid flare,

and skin changes with subcutaneous fat necrosis, discoloration, and atrophy. Multiple

injections are discouraged because of the risk of collagen degeneration, although

commonly used, benefits seen from corticosteroid use are short term and their long

term effects are uncertain.

B. Surgical

Conservative treatment is generally effective or the vast majority (>90%) of patients

with lateral epicondylitis. Surgical treatment is recommended when the patient

experiences persistent debilitating pain despite 6-12 months of nonsurgical

management, and other causes for the pain have been excluded. Three main

categories of operative treatments have been described and studied in the literature:

open, percutaneous, and arthroscopic. Each has advantages and disadvantages, but

studies comparing the different techniques are limited.

The current standard for most open procedure reported in the literature is the Nirschl

procedure and its modifications. The common thread among these procedures is

identification of abnormal diseased tissue, most commonly at the origin of the ECRB,

followed by excision of the lesion and repair.

The technique, as originally described by Nirschl and Pettrone and subsequently

modified by numerous authors, is as follows. A 5-cm gently curved incision is made

centered just distal to the lateral epicondyle. The deep fascia is incised in line with the

incision, and the common extensor origin is then identified. An interval between

ECRL and EDC is created to visualize the underlying ECRB. Once the ECRB is

exposed, the degenerative tissue, which often appears gray and friable, is sharply

excised. Sometimes a portion of the EDC is involved as well and is removed

concurrently. Nirschl and colleagues described a scratch maneuver using the edge of

the scalpel to scrape away abnormal tendinosis tissue while leaving normal tissue

intact. The remaining normal tendon is sutured back to surrounding fascia or

periosteum. The lateral epicondyle is drilled or decorticated with a rongeur,

purportedly to stimulate bleeding and a healing response. However one level 1 study

compared the Nirschl procedure with and without drilling and found that drilling had

no benefit in their series and cause more pain and stiffness postoperatively. Some

authors have advocated repair of the origin of the ECRB back to the epicondyle using

sutures through bone tunnels or suture anchors, although this is not universally

practiced. The interval between the ECRL and the EDC is then repaired, and the skin

is then closed. Postoperatively, the elbow is immobilized for a short period to allow

for soft tissue healing after which range of motion exercises are started.

Complications include iatrogenic posterolateral rotatory instability secondary to

excessive debridement and neuroma of the posterior cutaneous nerve of the forearm.

More recently, there has been interest in using arthroscopic techniques for treatment

of lateral epicondylitis. In addition to the ability to evaluate the joint for intra-articular

pathology, the technique allows for debridement of the undersurface of the ECRB

tendon without division of the common extensor aponeurosis as well as a possibly

shorter recovery time.

For the arthroscopic technique, two portals are used: a proximal medial portal for

viewing and a lateral working portal. Before establishment of the portals, the joint is

injected with 30 mL of saline solution to displace the neurovascular structures

anteriorly. The medial portal is established, taking care to maintain contact of the

trocar with the anterior surface of the humerus. The arthroscope is inserted and the

initial joint inspection is then performed. The superior lateral portal is then

established under the direct visualization, and a motorized shaver or radiofrequency

ablation device is placed in the joint. The lateral capsule is then resected, allowing

visualization of the undersurface of the ECRB. The brevis is then released off of the

lateral epicondyle, removing pathologic tissue in the process. Care must be taken to

limit the distal extent of debridement to the superior half of the radial head. More

aggressive resection risks injuring the origin of the collateral complex and producing

iatrogenic instability. The lateral epicondyle is then decorticated with a burr.

Postoperatively, the patients are placed in soft dressings, and early active range of

motion is begun with return to full activity as tolerated. Complications include nerve

injury from portal placement, the development of heterotopic ossification, and

posterolateral rotatory instability.

Surgery is generally reserved for chronic conditions that are unresponsive to

conservative management and are associated with significant limitation in functional

performance. The approach most commonly involves debridement of degenerative

granulation tissue adjacent to the extensor carpi radialis brevis insertion and partial

release of the common extensor aponeurosis. Postoperative rehabilitation employs the

principles previously discussed and often requires 4 to 6 months resumption of full

activity.

Recently, a study was published comparing the results of all three techniques.

Although nonrandomized and retrospective, it is the largest comparative series to

date. When evaluating groups of patients treated with the open technique,

percutaneous technique, and arthroscopic technique, all three groups improved in

clinical outcomes measures, with no statistical difference between them. In another

retrospective, nonrandomized study comparing the results of open versus arthroscopic

treatment, both groups were similar in both outcome measures and postoperative

function, with no statistical difference. The arthroscopic group did, however, return to

work sooner, at 1.7 months, compared with 2.5 months for the open group.

There is still no consensus on which operative procedure offers the best results.

Therefore the choice of procedure often will be surgeon dependent.

Postoperative Management

The type of surgical technique and the presence of postoperative complications may

affect the timing of referral to therapy. Early postoperative care may include

fabrication of an orthosis to support the wrist and/or elbow, gentle active range of

motion for the elbow and wrist, and physical agents to modulate pain and decrease

edema. Referral may be delayed until the time of suture removal. Therapy includes

active range of motion for the elbow and wrist and progressive functional activity as

tolerated. In addition to physical agents to modulate pain and decrease edema, scar

management, particularly desensitization, is often needed in the short term.

Neuromuscular conditioning, as previously described, is typically initiated at 6-12

weeks after surgery, with emphasis on progressive resistive total arm strengthening

ergonomic counseling and sports modification.

XI. REHABILITATION

A. AREAS AND INSTRUMENTATIONS

ROM and MMT testing:

Wrist Flexion

Wrist Extension

Wrist Radial Deviation

Wrist Ulnar Deviation

Forearm Supination

Forearm Pronation

Special Tests:

Lateral Epicondylitis (Tennis Elbow or Cozen’s) Test (Method 1)

The patient’s elbow is stabilized by the examiner’s thumb, which rests on the

patient’s lateral epicondyle. The patient is then asked to actively make a fist, pronate

the forearm, and radially deviate and extend the wrist while the examiner resists the

motion. A sudden severe pain in the area of the lateral epicondyle of the humerus is a

positive sign. The epicondyle may be palpated to indicate the origin of the pain.

Lateral Epicondylitis (Tennis Elbow or Mill’s) Test (Method 2)

While palpating the lateral epicondyle, the examiner passively pronates the patient’s

forearm, flexes the wrist fully, and extends the elbow. Pain over the lateral epicondyle

of the humerus indicated a positive test. This maneuver also puts stress on the radial

nerve and, in the presence of compression of the radial nerve, causes symptoms

similar to those of tennis elbow.

Lateral Epicondylitis (Tennis Elbow or Maudsley’s) Test (Method 3)

The examiner resists extension of the third digit of the hand distal to the proximal

interphalangeal joint, stressing the extensor digitorum muscle and tendon. A positive

test is indicated by pain over the lateral epicondyle of the humerus.

B. PROBLEMS

Most patients present with localized tenderness over the common forearm extensor

tendon insertion at the lateral epicondyle, often extending into the extensor mass.

Less commonly, there is discomfort over the radiohumeral joint and annular ligament.

Pain is generally reproduced with resisted wrist and middle finger extension and with

gripping activities. Passive wrist flexion with elbow extension often generates

symptoms. Flexibility and strength deficits are often seen in the wrist extensor and

posterior shoulder muscles.

C. TREATMENT AND MANAGEMENT

Treatment is the same as with bursitis. Application of a wide strap just below the

elbow will change and support muscle movement in the forearm, thus reducing some

of the pain.

The treatment of lateral epicondylitis follows the same principles for soft-tissue

rehabilitation: control of inflammation, promotion of healing, reduction of abusive

forces and improvement of soft-tissue flexibility, strength, and endurance. In the

context of acute injuries, resting the involved extremity and avoiding activities that

reproduce symptoms are critical. Occasionally, a wrist cock-up splint may be

necessary. NSAIDs and cryotherapy are useful in the acute phase. Therapeutic

modalities are often administered to relieve pain and inflammation and possibly

promote soft-tissue healing. The most common applications include cryotherapy,

high-voltage galvanic stimulation, transcutaneous electrical nerve stimulation

(TENS), ultrasound, phonophoresis and iontophoresis. Acupuncture has been used

successfully to treat soft-tissue injuries.

1. Rest, Ice, Compression, Elevation

2. Using of NSAIDs, gel or ointment, or iontophoresis during the acute phase.

3. Electrotherapy to settle inflammation such as ultrasound, laser and interferential.

4. Massage techniques to control scar tissue, such as frictions.

5. Stretching of the muscle to stimulate the enthesis and prevent scar contraction.

6. Isometrics of the extensors to organize scar tissue and strengthen the muscles.

7. Dynamic exercises to increase muscle strength.

EPICONDYLITIS REHABILITATION PROGRAM IN SPORTS

PHASE I (acute)

Active rest

Splint when necessary

Modalities to reduce pain, inflammation, and edema and to promote healing

Begin flexibility exercises when tolerated

PHASE II

Continue flexibility exercises

Begin strengthening wrist flexors/forearm pronator

Begin light multi-joint shoulder, scapula and elbow strengthening (avoiding positions of elbow

extension)

Continue modalities as needed

PHASE III

Begin isolated wrist extension, radial deviation and supination strengthening if tolerated (elbow flexion)

Continue strengthening for full upper extremity

Continue flexibility exercises

A. Goals

1. To restore normal, painless use of the involved extremity.

2. To restore normal strength and extensibility of the musculotendinous unit.

3. To encourage proper maturation of scar tissue and collagen formation, and to

allow extensibility and the ability of the tendon to attenuate tensile stress.

B. Objectives

1. Resolution of the chronic inflammatory process

2. Maturation of the scar. The new collagen must be sufficiently stored and

extensible to withstand the tensile stresses imposed by activity. There must be an

appropriate amount of tissue that is oriented to attenuate relief stresses with a

minimum of internal strain.

3. Restoration of strength and extensibility to the muscle-tendon complex.

C. Techniques

1. Acute cases. Tendon injuries of the elbow are by nature, chronic disorders, but

some patients may present with acute symptoms and signs associated with lateral

or medial tennis elbow; pain is referred into the entire forearm and perhaps the

hand, and occasionally, up the back of the arm. There may be some pain at rest

and some degree of muscle spasm is elicited when the tendon is stressed passively

or by restricted movements. In such cases, the immediate goal is to promote

progression to a more chronic state, assisting in the resolution of acute

inflammation.

a) Instruct the patient to apply ice to the site several times a day. The

physical therapy modality of high-voltage galvanic simulation has been

helpful in relieving pain and inflammation.

b) Continued stress to the tendon must be prevented. If the patient present

with acute symptoms and signs as outlined above, this is best achieved by

PHASE IV

Begin wrist and forearm strengthening with elbow in extension if asymptomatic

Continue aggressive upper extremity strengthening exercises

Begin activity-specific function exercises and neuromuscular drills and endurance training

Continue flexibility exercises

PHASE V

Begin sports-specific interval program

Biomechanical or ergonomic assessment and alteration

Maintenance program for strength and flexibility

immobilization of the wrist, hand and fingers (not the elbow) in a resting

splint. In some cases, a simple wrist cock-up splint will suffice because

this obviates the need for the wrist extensors to contract when the finger

flexors are used. Activities involving grasping, pinching and fine finger

movements must be restricted. This is often the most difficult component

of the program to institute but at the same time, the most important at this

stage. The effectiveness of any other treatment measures will be

compromised if the patient continues to engage in activities that stress the

lesion site. For example, a carpenter must take some time off work or

temporarily change duties, a tennis player must abstain from playing for a

while, and persons who enjoy knitting, sewing and gardening must

temporarily alter their activities.

c) A few times a day, the patient should remove the splint and actively move

the wrist into flexion, the forearm into pronation, and the elbow into

extension simultaneously, to minimize the loss of extensibility of the

muscle and tendon. This should be done gently, avoiding significant

discomfort, and slowly to prevent high strain-rate loading of the tissue.

If appropriate instructions are given and the patient faithfully

follows

the outlined program, progression to a more chronic status should

occur during a period of a few (3 to 5) days.

2. Chronic cases (lateral tennis elbow). If the pain is fairly localized over the lateral

elbow region and there is little or no pain at rest, the disorder should be treated as

chronic tendinitis.

a) Advise the patient explicitly as to the appropriate level and type of activity

that may be performed. Strong, repetitive, grasping activities such as

hammering, and activities that particularly stress the tendon, such as

tennis, must be restricted until there is little pain on resisted isometric

wrist extension and little or no pain when the tendon is passively stretched

(such as in wrist flexion, forearm pronation and elbow extension). Such

activities must be resumed gradually, with some protection of the part.

Protection may be provided btht e counterforce bracing with an inelastic

cuff worn firmly around the proximal forearm ( the forearm extensors for

lateral tennis elbow and the forearm flexors for medial tennis elbow).

Also, as normal activities are resumed, certain adaptations may be

implemented to minimize the stresses imposed on the wrist extensors. An

example can be seen in tennis player’s racquet where high string tension

and low racquet flexibility will result in reduced attenuation of forces by

the racquet and, therefore, greater transmission of high-strain rate forces to

the arm.Each patient’s activities should be similarly assessed for ways to

reduce the loads on the wrist extensor group.

b) Two rehabilitation approaches may be taken in treating lateral and medial

tennis elbow. The first approach involves all the normal measure to reduce

inflammation and pain. Treatment may include rest and restriction of

activities, using therapeutic modalities such as cryotherapy,

electrotherapy; iontophoresis and ultrasound. And using non-steroidal

anti-inflammatory drugs. The second approach would be to realize that the

patient has chronic inflammation, which is not going anywhere and is in

effect stuck. The goal of this approach is to “jump start” the inflammatory

process, in effect, using techniques that are likely to increase the

inflammatory response and allowing healing to progress as normal to the

fibroplastic and remodeling phases. To increase the inflammatory

response, deep transverse friction massage may be used. The beneficial

effects of the friction massage in cases of tendinitis are not well

understood but are probably related to the induced hyperemia and the

mechanical influence it may have on tissue maturation. The hyperemic

effects are of greatest importance in cases of tendinitis that may be related

to hypovascularity, for instance, at the shoulder. Hyperemia does not seem

to be a significant factor in the origin of tennis elbow, however, and this

may in part explain why friction massage is effective for a shorter period

of time in rotator cuff tendinitis than it is in cases of tennis elbow. The

mechanical effects of the deep massage may promote orientation of

immature collagen along the lines of stress. This would be an important

factor in pathologic disorders, such as tennis elbow, in which some type of

mechanical stimulus is necessary for adequate tissue maturation. Use of

the deep transverse massage may assist in tissue maturation without

imposing a longitudinal stress to the healing tendon tissue and, therefore,

without continued rupturing of the fibers at the side of the lesion. Thus,

the defect heals with a maximum degree of tissue extensibility and is

likely to be overstressed as use of the part is resumed. This seems to be a

solution to the dilemma mentioned above. If the patient continues to use

the part, he or she perpetuates the problem by producing continued

damage at the lesion site; if the patient completely immobilizes the part,

there is no stimulus for tissue maturation and as soon as the activity is

resumed, the healed tissue begins to break down.

c) Strength and mobility must be restored. As symptoms and signs indicate

signs of improvement, the patient must resume activities gradually.

Excessive internal strain to the tendon can be minimized during stressful

activities by optimizing tissue extensibility. No vigorous activities should

be allowed until it is determined whether the muscle-tendon complex has

sufficient extensibility. To facilitate the mobility, the clinician should

gently and slowly stretch the tissue by holding the elbow extended and

forearm pronated, and wrist ulnarly deviated, while flexing the wrist and

fingers. The patient is instructed to perform this stretch at home,

emphasizing that is must be performed slowly and gently. The patient

should notice a stretching sensation. As vigorous activities such as tennis,

carpentry and gardening are resumed, the patient may be taught to

administer friction massage for a few minutes before engaging in the

activity.Also, before a normal level of activity is resumed it is important to

ensure that good forearm strength has been restored in lateral tennis

elbow, wrist extensor strengthening exercises are always necessary

because the muscles invariably undergo atrophy from disuse and reflex

inhibition. Good reflex strength is necessary to protect the tendon from

high strain-rate passive loading, which may occur with many types of

activities. A convenient method of wrist extensor strengthening is to have

the patient tie a rope 3 feet long to the center of a 1-inch dowel and add a

weight to the end of the rope; the patient grasps both ends of the dowel

and rotates it toward him or her until the entire rope become wrapped

around the dowel. This can be repeated as appropriate; the weight may be

varied as necessary.

Forearm rehabilitative exercises to increase muscle power

flexibility and endurance are important. Continued strengthening of

uninjured areas and protective exercises for the injured areas are

necessary. Isometric, isotonic, isokinetic, and isoflex exercises are all

used. Isoflex exercises consist of muscle strengthening, using both

concentric and eccentric cord. Maximum strengthening of the muscles

must necessarily include eccentric exercise. Plyometric exercises and

functional training activities should progressively incorporate the stresses,

strains and forces that occur during the normal activity, gradually

increasing the frequency, intensity and duration of exercise.

Local anti-inflammatory therapy such as infiltration with a corticosteroid

is commonly used In cases of tendinitis. Although symptomatic

improvement is often dramatic; such treatment has only temporary value.

It has no lasting beneficial effect on the pathologic process and does not

influence etiologic factors. At best, it should be considered an adjunct to

management in the acute state. Too often other important components of

the treatment program are ignored when an apparent “cure” is heralded by

dramatic symptomatic improvement.

In those individuals who have persistent pain that does not resolve after 1

year of conservative treatment, surgery should be considered.

When treating a patient for lateral tennis elbow, it is important to address weaknesses and

biomechanical abnormalities in other parts of the upper extremity, which may be related to this

condition.

Early on, relief of pain and any inflammation that is present is achieved through relative ice, rest

and non- steroidal anti-inflammatory drugs. Ice can be applied multiple times throughout the

day. Other helpful modalities may include ultrasound, electrical stimulation, and other sources of

heat.

Rehabilitative exercises are begun with isometric strengthening of the elbow flexors, wrist

extensors, and pronators and supinators. This is initially is done only within the arcs of pain-free

motion, but later is expanded to include full range of motion. Isotonic weight and resistance

training is added as tolerated, initially with the elbow flexed and later with the elbow extended.

For more competitive athletes, arm cycling and isokinetic exercises may be useful as well.

Stretching is often not tolerated early in the treatment, but as 80% of normal strength is achieved,

a stretching program can be initiated. The stretches included in this program are performed in

flexion and extension; again at first with the elbow flexed, and the later with the elbow extended.

Ice application both before and after stretching can be beneficial.

When the patient is starting to feel better and is ready to return to full activity, a gradual

progression of return to either sport or job is indicated. Proper technique should be taught, and

aggravating activities avoided. As a rule, patients should not lift objects with palm down,

especially heavy objects on repetitive basis. They should avoid prolonged or strong gripping

activities, which cause a contraction of the wrist extensors. They may need to be taught not to

grip a briefcase or suitcase overly tightly, but to let the finger carry the load. Too early a return to

activity often causes a recurrence, which can be difficult to treat.

Surgical management, which includes resection of the pathologic tissue while leaving all normal

tendon origin in place, is considered only if the patient fails to respond to adequate rehabilitation

program ( generally lasting 3-4 months)

D. PRECAUTIONS

Preventive approach is the most practical and prudent way to deal with elbow

injuries.

It includes proper warm-up, Avoidance if sudden excessive overloading or overuse,

optimal technique, and exercises to develop flexibility, strength and endurance.

The most effective stretching exercise to prevent Lateral Epicondylitis is to stretch the

supinators of the elbow and forearm (Supinator Muscle, Biceps Brachii and

Brachioradialis) by grasping a broomstick, golf club, or tennis raquet in a dorsal grip

(back of the hand faces down and thumb grasps under the handle.

This type of stretch can be intensified by hanging from a chin-up bar in a dorsal grip.

XII. REFERRENCES

Brotzman, S.B. and Manske, R.C. (2011) Clinical Orthopaedic Rehabilitation: An

Evidence-Based Approach (3rd Ed.) Philadelphia, PA: Elsevier Mosby

Frontera, W.R. and Delisa, J.A. (2010) Physical Medicine and Rehabilitation:

Principles and Practice (5th Ed.) Philadelphia, PA: Lippincott Williams and Wilkins

Magee, D.J. (2014) Orthopedic Physical Assessment (6th Ed.) Philadelphia, PA:

Elsevier Saunders

Meadows, J.T.S. (1999) Orthopedic Differential Diagnosis in Physical Therapy USA:

McGraw-Hill Companies

Skirven, T.M (2011) Rehabilitation of the Hand and Upper Extremity (6th Ed.)

Philadelphia, PA: Elsevier Mosby

Andrews, J. (2004) Physical Rehabilitation of the Injured Athlete (3rd Ed.)

Philadelphia, PA: Elsevier Saunders

Read, M.T.F (2008) Concise Guide to Sports Injuries (2nd Ed.) Philadelphia, PA:

Churchill Livingstone Elsevier

Buschbacher R.M (2002) Practice Guide to Musculoskeletal Disorders : Diagnosis

and Rehabilitation (2nd Ed.)

Goodman, Snyder (2013) Differential Diagnosis in Physical Therapy (3rd Ed.)

Neighbors M. and Jones R.T (2006) Human Diseases (2nd Ed)

Cyriax, J, (1996) Illustrated Manual of Orthopaedic Medicine (3rd Ed.)

Goodman and Snyder Differential Diagnosis in Physical Therapy (3rd Ed.)

Hertling, D.; Kessler, R. (2005) Management of Common Musculoskeletal Disorders,

Physical Therapy Principles and Methods, Fourth Edition

Suekl, D.; Brechter, J. (2010) Orthopedic Rehabilition Clinical Adviser

Alter, M.J. Science of Flexibility (2nd Ed.)

www.physio-pedia.com

SOAP

Initial Evaluation

GENERAL INFORMATION

Name: L.E

Age: 46 years old

Civil status: Married

Handedness: ®

Sex: Male

Occupation: Butcher

Address: Magalang Road, Pandan, Angeles City

Religion: Roman Catholic

Citizenship: Filipino

Date of Consultation: May 9, 2014

Physiatrist: Dr. Andy Aygenman

Date of Initial evaluation: May 12, 2014

Dx: ® lateral epicondylitis

HPI

3 months PTC (Feb. 9, 2014) the Pt. felt localized, intermittent dull aching pain PS (5/10) on the

® lateral aspect of the elbow while chopping a pork thigh. Pain worsens when Pt. extends his ®

wrist and carries heavy meat PS (7/10) Pt. took Ibuprofen 500 mg which ↓ the pain to PS (3/10)

every time he experienced pain at the ® lateral aspect of the elbow for 2 months.

30 days PTC (April 9, 2014) the Pt. was having difficulty in doing ADL’s like turning door

knobs, chopping ingredients and lifting heavy objects.

1 day PTC (May 8, 2014) while the Pt. is scaling milkfish an ↑ dull aching pain PS (8/10) on his

® lateral elbow. The Pt. rested for an hour and took Ibuprofen 500 mg. The pain did not ↓ even

though he took Ibuprofen. This prompt him to consult Dr. Andy Aygenman the next day. Upon

consultation the doctor noted a grade 3 tenderness on the ® lateral elbow . The doctor peformed

Cozen and Maudsley test and the Pt. was positive of ® lateral epicondylitis. Dr. Aygenman

referred Pt. to a physical therapist for further evaluation and management.

PMHx

(-) Trauma

(-) Hospitalization

(-) Past surgeries

(-) HPN

(-) DM

(-) Arthritis

FMHx

Father Mother

HPN (-) (-)

DM (-) (-)

Asthma (-) (-)

Tumors/CA (-) (-)

Allergies (-) (-)

Arthritis (-) (-)

PSHx

Type B lifestyle

Sedentary lifestyle

(-) smoker

(-) alcohol drinker

Home set-up situation

o Bungalow

o Lives with wife and 3 daughters

Sleeps on firm mattress

Sleeps in fetal position

Work Assessment

Works as a butcher for 25 years

Working hours: 4am-12pm Monday-Saturday at the local public market

Chops meat, scaling and removing internal organs of fishes and lifting heavy meat.

S

C/C: “Kapagnagchop-chop ako ng karne, nagaalis ng kaliskis ng isda at

ginagawaangibakongtrabahosumasakityungkanangsikoko” PS (8/10)

PT Interpretation: “Whenever I chop meat, scaling fish and doing other work, I feel pain on my

® elbow” PS (8/10)

O

Vital Signs:

Before After

BP: 120/80 mm Hg 120/80 mm Hg

RR: 16 cpm 16 cpm

PR: 80 bpm 80 bpm

T: 37 ° C 37 ° C

Findings: all vital signs are WNL

Significance: baseline purposes

OI:

Ambulatory š AD

Alert,coherent,cooperative

Mesomorph

(+) swelling on ® lateral elbow

(-) Ecchymosis

(-) deformity

(-) wounds

(-) scars

(-) postural deviation

(-) gait deviation

Palpation:

Normothermic on all exposed body parts

Normotonic on (B) UE and LE

(+) Grade 3 tenderness on ® lat. elbow

(+) ms. Guarding of wrist extensors

(-) ms. Spasm

(-) edema

(+) swelling

(-) nodules

(-) mass

(-) subluxation/dislocation

(-) crepitus

ROM: All joints of (B) UE and LE are WNL actively and passively done pain free except for the

ffg:

Motions Active Passive N Diff. A Diff. P Endfeel

Wrist

Flexion

0°-70° 0°-75° 0°-80° 10° 5° Firm

Wrist

Extension

0°-50° 0°-55° 0°-70° 20° 15° Firm

Wrist

Pronation

0°-70° 0°-75° 0°-80° 10° 5° Firm

Wrist

Supination

0°-70° 0°-75° 0°-80° 10° 5° Firm

Wrist

Radial

Deviation

0°-5° 0°-10° 0°-20° 15° 10° Firm

Wrist

Ulnar

Deviation

0°-20° 0°25° 0°-30° 10° 5° Firm

Findings: There is LOM in ® forearm and wrist movements.

Significance: LOM 2° to Pain

MMT: All ms of (B) UE and LE are grossly graded 5/5 except for the ffg:

Wrist Flexion: Grade 2-

Wrist Extension: Grade 2-

Wrist Pronation: Grade 2-

Wrist Supination: Grade 2-

Wrist Radial Deviation: Grade 2-

Wrist Ulnar Deviation: Grade 2-

Findings: there are weakness on ® wrist flexion, extension, radial deviation, ulnar deviation,

forearm supination and pronation.

Significance: Muscle weakness 2° to pain

GRIP STRENGTH:

A dynamometer was used.

(L):43 kg

® : 28 kg

Difference: 15 kg

Findings: decreased grip strength of ® hand.

Significance: weakness 2° to pain

Sensory Assessment

STD: pin for pain, brush for light touch, thumb for pressure

Findings: 100% sensory intact as to pain, light touch, and pressure.

Significance: Intact Lateral Spinothalamic Tract

DTRs

Legend:

0 = reflexive

+ = hyporeflexive

++ = normoreflexive

+++ = hyperreflexive

++++ = clonus

Findings: DTRs are normal

SPECIAL TEST:

(+) Cozen Test

(+) Maudsley Test

Findings: Test are (+)

Significance: ® lateral epicondylitis

LGM

Marking (R) elbow (L) elbow

Marking (R) (L) Difference

10 cm above lateral

epicondyle

28 cm 28 cm 0 cm

5 cm above lateral

epicondyle

28 cm 28 cm 0 cm

Lateral epicondyle 30 cm 28 cm 2 cm

5 cm below lateral

epicondyle

27 cm 26 cm 1 cm

10 cm below lateral

epicondyle

25 cm 25 cm 0 cm

Findings: a difference of 2 cm on the ® lateral epicondyle

Significance: (+) swelling on ® elbow.

Gait Analysis

Findings: All parameters of gait are (N)

Functional Analysis

Functional Status Scale

On a typical day during the past two weeks have hand and wrist symptoms caused you to have

any difficulty doing activities listed below? Please circle one number that best describe your

ability to do the activity.

Activity No Difficulty Mild

Difficulty

Moderate

Difficulty

Severe

Difficulty

Cannot Do at

All Due to

Hand or Wrist

Symptoms

Writing 1 2 3 4 5

Buttoning of

clothes 1 2 3 4 5

Holding a

book while

reading

1 2 3 4 5

Gripping of a

telephone

handle

1 2 3 4 5

Opening of

jars

1 2 3 4 5

Household

chores

1 2 3 4 5

Carrying of

grocery bags

1 2 3 4 5

Bathing and

dressing

1 2 3 4 5

Findings: Pt. encounters moderate or severe difficulty when performing ADL’s involving

gripping of telephone handle, opening of jars, household chores, carrying of grocery bags and

mild difficulty in bathing and dressing.

ADLs

Pt. is independent in all aspects of ADL's as to ambulation except with turning door knobs and

work activities such as chopping meat, scaling and removing internal organs of fishes and

carrying heavy meat.

A

Dx: ® lateral epicondylitis

PT Impression: Pt. has a ® lateral epicondylitis manifested by LOM and muscle

weakness of ® wrist flexors, extensors, radial deviators, ulnar deviators, forearm pronators and

supinators,with a grade 3 tenderness and swelling on ® lateral elbow, and has difficulty in

activities involving ®wrist motion such as chopping meat, scaling and removing internal organs

of fishes and carrying heavy meat.

Problem List:

1. Dull aching pain (PS 8/10) on ® lateral elbow

2. Muscle weakness on wrist extensors and flexors, radial and ulnar deviators, forearm supinators

and pronators

3. LOM in wrist flexors and extensors, radial and ulnar deviators, forearm supinators and

pronators

4. Swelling on the ® lateral elbow

5. Decrease in grip strength of the right hand

6. Difficulties in doing ADLs such as gripping of telephone handle, opening of jars, household

chores and carrying of grocery bags

LTG:

1. To restore normal, painless use of the involved extremity.

2. To restore normal strength and extensibility of the musculotendinous unit

3. To encourage proper maturation of scar tissue and collagen formation, and allow

extensibility and the ability of the tendon to attenuate tensile stresses.

STG:

1. To decrease pain from PS (8/10) to PS (4/10)

2. To restore a portion of the original strength of the muscles.

P

PT Management:

1. Ultrasound on ® lat. Elbow using water bag technique (small head – 1MHz)

2. Friction massage to control scar tissue

3. PROM of ® elbow and wrist for 10 reps X 1 set

4. Isometric contraction of wrist extensors 10 reps X 3 sets

5. Stretching with the elbow in extension, forearm in pronation, wrist in flexion and ulnar

deviation 30sh X 3 set

HI

1. Avoid stressful movements that will induce pain on the ® elbow.

2. Instruct the Pt. to apply ice to the site several times a day.

3. AAROM exercises of ® elbow and wrist in pain free range for 10 reps X bid

4. Squeeze ball exercises for 6sh X 10 reps X bid