Lateral Epicondylitis (Tennis Elbow) - Part II

History and Physical Examination

Evaluation of the patient who has lateral epicondylitis should begin with examination of the cervical spine, proceeding then to the shoulder. A thorough examination of the shoulder should be done, because some patients have posterior capsules that contribute to their elbow pain.

In the elbow, the lateral epicondyle is tenderer to palpation than the muscular mass. These patients have reproducible pain in the region of the lateral epicondyle as the physical therapist tests resisted wrist extension with the elbow fully extended. This maneuver will test the extensor (ECRB) carpi radialis brevis strength. Also patients with lateral epicondyle have reproducible pain at maximal wrist flexion, which will place the ECRB on maximal stretch. The common extensor tendon can also be compromised in up to 35% of the patients (Nirschl, R.P., 1992). Grip strength should be tested to determine if it is decreased, compared to the non-affected side, or if it causes discomfort. (Whaley, A.L., Baker, C.L., 2004). It is important to palpate the radiocapitellar joint to evaluate for a possible plica (Antuna, S.A., O’Driscoll, S.W., 2001). Testing for a plica involves passively flexing the elbow with the forearm pronated and supinated. If the cause of the pain is from the plica, the point of maximal tenderness is slightly more distal over the radiocapitellar joint than it is in lateral epicondyle. Included in the differential diagnosis of lateral epicondylitis is also the radial tunnel syndrome and posterior interosseous nerve syndrome. According to Gabel and Morrey, this occurs in up to 5% of the patients, simultaneously with lateral epicondylitis. Pain on resisted supination can indicate nerve entrapment in the supinator muscle, and pain with resisted long-finger extension can indicate nerve entrapment in the ERCB. In these last two cases, the treatment is release of compression along the path of the nerve (Whaley, A.L., Baker, C.L., 2004).

Treatment

Physical therapy for the lateral epicondylitis can include deep tissue massage of the ECRB tendon in the lateral epicondyle, stretching and strengthening of the ECRB muscle, and ice. Rest for all the activities that causes pain should also be done. According to Martine-Silvestrini et al, eccentric strengthening loads the musculotendinous unit to induce hypertrophy and increased tensile strength, reducing the strain on the tendon during the movement. An eccentric contraction may provide a greater stimulus for the tendon cells to produce collagen and trains the tendon to withstand a greater force. It is believed that eccentric strengthening decreases the neovascularization believed to be a causative factor in painful tendinopathies. According to various studies, six weeks is the minimum time required to treat the condition.

In case of radial entrapment both in the supinator muscle as in the ECRB, physical therapy also is able to help. The treatment can be done through massage and stretching of the involved muscles, and, if needed, with neural tension tests for the radial nerve, to stretch the radial nerve.