LATERAL EPICONDYLITIS (TENNIS ELBOW)

By :Ida Yuanita, MD

Pathophysiology
Inflammation at the muscular origin of the Extensor Carpi Radialis Brevis (ECRB) microtears of the tendon subsequent fibrosis tissue failure Less commonly the attachment of the Extensor Carpi Radialis Longus (ECRL), Extensor Digitorum Communis (EDC), or Extensor Carpi Ulnaris (ECU) are involved
Rene Calliet, Soft Tissue Pain and Disability, 2nd ed

Sex
men and women with equal frequency

Age
most often occurs between 3rd and 5th decades of life

Clinical
History The patient usually describes a gradual onset of lateral elbow pain, which is characterized as follows: The aching pain generally increases with activity Symptoms are typically unilateral

Physical
Most commonly, the examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle. Other symptoms include the following: Pain increases with resisted wrist extension, especially with the elbow in extension

 The patient may have a weakened grip on the affected side Elbow range of motion (ROM) is typically normal

Causes
Lateral epicondylitis is an overuse syndrome generally caused by repetitive use of the wrist extensors or sustained power gripping

Workup Laboratory Studies Not needed Imaging Studies usually are not necessary, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with ultrasonography

 Other Tests Electrodiagnostic studies may help to determine whether other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy, are present

Treatment

Rehabilitation Program Physical Therapy Acute stage goal of treatment to reduce pain and inflammation. A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction

Sub acute stage emphasize the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group. ROM for wrist flexion/extension and pronation/supination Strength and grip training

Chronic stage scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.

Occupational Therapy Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required
Medical Treatment NSAIDs, steroid injection

Surgical Intervention For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.

Data Base Identity

Name Age Address Occupation Status Religion : Mr. M : 38 yo : Ngagel Baru, Surabaya : laborer at wire factory : married : Moslem

Patient was referred from internal oupatient clinic with pain on the right elbow

Chief Complain
Nyeri siku kanan

History of Present Illness

Pain of the right elbow has been felt since 2 months ago Pain as a sharp pain, increase with such an activity as lifting or taking a bath and was relieved by taking analgesic drugs. There was no numbness, tingling sensation and weakness on his hand

 He was still able to do his daily activities but feeling pain. He has worked in the wire factory for 14 years, lifting and pulling the wire (80kg); 9 hours/day with 1 hour break History of Past Illness No history of trauma, DM He went to clinic and he was given Na diklofenac , but he still feels pain

Physical Examination
General Examination (12/10/09) CM, ambulatory independent, gait N, right handed BP : 120/70 mmHg, HR : 88 x/minute Weight : 65 kg ; BH : 170 cm, BMI=22,4

 Head & Neck : no anemia, icterus, cyanosis & dyspneu Thorax : Cor : S1S2 sound, murmur Pulmo : vesiculer, wheezing -/, ronchi -/ Abdomen : Meteorismus -, Hepar / Lien : unpalpable Extremities : warm acral

Physiatric Examination
Cervical Flexion Extension Lateral Flexion Rotation Trunk Flexion Extension Lateral Flexion Rotation ROM F (0-450) F (0-450) F/F (0-450) F/F (0-600) ROM F(0-450 ) F (0-300) F/F (0-350) F/F (0-450) MMT 5 5 5/5 5/5 MMT 5 5 5/5 5/5

Shoulder Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation Elbow Flexion Extension Forearm supination

ROM F/F (0-1800) F/F (0-800) F/F (0-1800) F/F (0-450) F/F (0-450) F/F (0-550) ROM F/F (0-1500) F/F (1500-0) F/F (0-800)
0

MMT 5/5 5/5 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5-/5

Wrist Flexion Extension Radial deviation Ulnar deviation Fingers Flexion MCP PIP DIP Extension

ROM F/F (0-800) F/F (0-700) F/F (0-200) F/F (0-300) ROM F/F (0-900) F/F (0-1000) F/F (0-900) F/F (0-450)
0

MMT 5/5 5-/5 5-/5 5-/5 MMT 5/5 5/5 5/5 5-/5

Thumb Flexion MCP IP Extension Abduction Adduction Opposition

ROM F/F (0-500) F/F (0-900) F/F (0-900) F/F (0-500) F/F (500-0)

MMT 5/5 5/5 5/5 5/5 5/5 5-/5

Hip Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation Knee Flexion Extension

ROM F/F (0-1250) F/F (0-300) F/F (0-450) F/F (0-200) F/F (0-800) F/F (0-800) ROM F/F (0-1350) F/F (1350-0)

MMT 5/5 5/5 5/5 5/5 5/5 5/5 MMT 5/5 5/5

Ankle Plantar Flexion Dorsi Flexion Inversion Eversion Toes Flexion MTP IP Extension

ROM F/F (0-450) F/F (0-300) F/F (0-350) F/F (0-250) ROM F/F (0-300) F/F (0-500) F/F (0-800)

MMT 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5/5

Big Toe Flexion MTP IP Extension

ROM F/F (0-250) F/F (0-250) F/F (0-800)

MMT 5/5 5/5 5/5

Neurological Examination Cranial nerve I-XII : normal Physiological Reflex: BPR +2/+2 KPR +2/+2 TPR +2/+2 APR +2/+2 Pathological Reflex : Babinski -/- HT -/ Sensory deficit :-

Localize status : Right elbow I : swelling -, redness -, deformity P : tender point at right lateral epicondyle

Special test : Yergason test Tinnel sign Thomson test

: -/: -/: +/-

Supporting Examination
X-ray elbow D/S : no abnormality

Diagnosis

: Lateral epicondylitis dextra

Functional diagnosis : Impairment : Lateral epicondylitis dextra Disability : difficult to lift objects and take a bath handicapped : Problem List : Surgical : Medical : Lateral epicondylitis dextra

 Rehabilitation medicine R1 (Ambulation) : R2 (ADL) : difficult to lift objects and take a bath R3 (Communication) : R4 (Social) : R5 (Psychological) : R6 (Vocational) : R7 (Others) : Lateral epicondylitis D Pain (VAS 6)

Planning
Surgical : Medical : continue renadinac from internal outpatient clinic Rehabilitation medicine : PDx : PTx : USD at area of right elbow (origin of ECRB), Freq. 3MHz, contonuous mode, intensity 1,5 W/cm2, duration 8 min. PMx : Clinically PEX : HE / HEP

Summary Reporting a patient, 38 y.o man was referred from internal outpatient clinic with pain on the right elbow. Chief Complain : Nyeri siku kanan Pain of the right elbow has been felt since 2 months ago. Pain as a sharp pain, increase with such an activity as lifting or taking a bath and was relieved by taking analgesic drugs. There was no numbness, tingling sensation and weakness on her hand

He was still able to do his daily activities but feeling pain. He has worked in the wire factory for 14 years, lifting and pulling the wire (80kg); 9 hours/day with 1 hour break From physical examination was found tender point at right lateral epicondyle and Thomson test + at the right elbow We plan to treat it by giving USD at area of the right elbow (origin of ECRB), Health education and Home Exercise Program

THANK YOU

New Treatment for Lateral Epicondylitis

Recent research at NISMAT presented at the 2009 American Orthopaedic Society for Sports Medicine Meeting suggests an effective treatment for tennis elbow using wrist exercises with an inexpensive rubber bar (the TheraBand FlexBar).