Known as tennis elbow, it is caused by contractile overloading of the wrist extensor muscles, leading to tendinosis and if pain is persistent pain system changes/central sensitisation.
Extensor carpi radialis brevis (ECRB) most frequently involved, given its small attachment site onto the humerus.
Most commonly presents on the dominant arm, between 35-54 yoa. Risk factors include office work, older age, being female, previous tobacco use and concurrent rotator cuff pathology / cervical spine pain.
Treatment and management: Eccentric exercise + Manual Therapy / Acupuncture / Orthoses. Multi modal treatment more effective than single interventions.
Exclude red flags: such as swelling and dislocation following trauma, a tender swollen joint suggestive of septic arthritis, bilateral joint involvement suggesting inflammatory arthritis or a rapidly increasing mass suggestive of malignancy.
Radial nerve involvement: Posterior Interosseous Syndrome (entrapment between two heads of supinator) or Radial Tunnel Syndrome.
Lateral Collateral Ligament injury
Insidious onset, often history of altered loading and overuse with no obvious trauma (e.g. gardening, lifting, decorating etc).
Pain can radiate into posterior forearm.
Pain worsens with activity and improves with rest.
Tennis players less affected than general population.
Elbow: Pain is aggravated by palpation (up to 2cm distal to ECRB insertion), gripping and resisted wrist and/or second or third finger extension. Passive ROM of elbow can evaluate presence of radiohumeral bursitis, PIN entrapment and articular pathologies.
Neurodynamic testing of Radial nerve for checking neurological symptoms. Gentle shoulder girdle depression, elbow extension, shoulder internal rotation, forearm pronation, wrist and finger flexion, shoulder abduction.
Cervical/Thoracic spine and shoulder examinations: neck pain is more common in people with LE compared with their healthy counterparts. Those with neck/shoulder pain may also have a poorer prognosis.
The C6 and C7 radiculopathy also may cause weakness of multiple wrist and finger extensor muscles, resulting in an imbalance of the wrist and finger extensor and flexor muscles during any functional use. This weakness and imbalance might trigger injury to the ECRB tendon and initiate lateral epicondylitis.
Expectation management – LE is often not self limiting and associated with ongoing pain / disability with slow recovery. Manual workers most at risk of LE, have poorer prognosis and more resistant to treatment. Recurrence is common and average prognosis is around 6 – 18 months. Those with higher pain and disability at initial presentation are more likely to have ongoing pain at 12 months.
Degenerative overuse of the ERCB and common extensor tendons which results in microtearing in the tendon with subsequent degeneration, immature repair, and tendinosis.
Scar tissue forms, vulnerable to repetitive trauma, which leads to further micro-tearing. Continuation of this cycle of injury and immature repair (fibroblast proliferation, angiogenesis etc) results in alteration and failure of musculotendinous biomechanics and worsening of symptoms.
Persistent symptoms can lead to pain sensitisation changes, leading to reduced pain threshold and greater temporal summation. People with LE exhibit widespread hyperalgesia (enhanced pain response to various non-noxious stimuli) e.g. increased sensitivity to cold/ice. In individuals with LET, there is evidence of heightened nociceptive withdrawal reflex and widespread mechanical hyperalgesia. A subgroup of patients reporting severe levels of pain and disability displayed cold hyperalgesia (mean, 13.7°C), while cold pain threshold was an independent predictor of short- and long-term prognosis in untreated individuals with LET.
Treatment and Management
Exercise and stretching: combination of eccentric loading for tendon remodelling and isometric contractions for symptom modification. Plus acupuncture, manual therapy etc. Orthoses can be useful for symptom modification.
Advice on load management. Reduce amount of load but maintain activity to tolerable level if possible.
Shoulder and Cervical spine.
If tennis player – check if racket string tension has been adjusted recently.
Steroid Injection: reduce short-term pain but increase the risk of recurrence and overall duration of the condition (presumed due to impaired tendon healing).
If evidence for central sensitisation: cervical spine manual therapy reduces mechanical. hyperalgesia at remote sites in people with and without musculoskeletal pain, suggesting a potential effect on central sensitization. Neural mobilization exercises might also be suitable for addressing central sensitization processes, including enhanced sensory hypersensitivity in response to repeated stimuli. Motor control and isometric exercises may be appropriate, as well as exercise of nonpainful regions.72
Bisset, L.M. and Vicenzino, B., 2015. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy, 61(4), pp.174-181.
Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy: one size does not fit all. journal of orthopaedic & sports physical therapy, 45(11), 938-949.
NICE Clinical Knowledge Summary, Tennis elbow. cks.nice.org.uk/tennis-elbow#!scenario Javed, M., Mustafa, S., Boyle, S. and Scott, F., 2015. Elbow pain: a guide to assessment and management in primary care. Br J Gen Pract, 65(640), pp.610-612.