Physiotherapy & Sports Injury Clinic

Case Study on Tennis Elbow

Introduction

Tennis elbow or lateral epicondylitis has been identified as one of the most common lesions of the upper limb (Greenfield et al, 2002).

It is a term usually applied to a strain of the wrist extensor muscles at the point of their common origin from the anterolateral aspect at the lateral epicondyle of the humerus. (Cyriax, 1998).

It generally is a work related or sports related pain disorder, usually caused by repetitive movements of the wrist and forearm. Other lesions such as cervical root irritation, shoulder problems or adverse neural tension may also contribute to epicondylar pain. With both a gradual or sudden onset the condition commonly occurs in middle age, with an average episode lasting six months to two years. (Cyriax, 1998).

A brief review of the literature has offered various approaches to the treatment of tennis elbow.

This case study will outline the assessment and treatment using the Cyriax approach to tennis elbow and discuss the results with regard to known pathology.

Aetiology:

Strain of the common extensor muscles is the most commonly seen lesion of the elbow(Greenfield et al,2002).Four specific sites can be affected: The teno-osseus junction, supracondylar ridge, body of extensor tendon or the muscle bellies(Cyriax,1998)This muscle with its small origin transmits huge through its tendon during repetitive grasping and pinching. The result maybe inflammation and microtraumatic tears at the origin, which are the precursors to the formation of scar tissue.

In the chronic stages of lateral epicondylitis there is histological evidence to suggest that degenerative changes occur in the common wrist extensor origins (Greenfield, 2002).Typical pathological changes in extensor tendons with chronic lateral epicondylitis include fibrosis, altered blood vessel changes and calcification.

Palpation generally determines the site of the lesion. Of the cases of tennis elbow encountered, 90% involve the teno-osseous junction of the common extensor tendon. (Cyriax 1998).The remaining 10% involve the body of the tendon, the extensor carpi radialis longus attachment.

Lateral epicondylitis is still poorly understood, despite being one of the most common musculoskeletal lesions of the upper limb. The exact relationship between the above theories and clinical symptoms remains undefined.

History of presenting Complaint:

Prior to assessment it is necessary to obtain a detailed history of the onset and duration of the current and any previous symptoms. Obtaining information relating to the onset, duration, severity and irritability of the condition is important in planning an appropriate treatment program. Details of occupation, sporting activities and hand dominance are important as these may have an effect on the onset and behaviour of symptoms.

The patient chosen for this study was a 23 year old right handed female who complained of a gradual onset of pain in her right elbow over the previous six months. There was no history of injury, but the patient felt it was related to her job as a typist, which she had been doing for the previous four and a half years. Initially she had not sought treatment, but as the pain intensified she attended her GP who diagnosed a tennis elbow and prescribed non steroidal anti inflammatory tablets. No improvement was found after 2 weeks. At this point she returned to her GP who in turn referred her for physiotherapy.

Subjective Examination:

On attending the physiotherapy department a subjective examination was carried out to determine the site and nature of the symptoms, the level of pain experienced, the aggravating and easing factors and the irritability of the condition. Information obtained was then recorded on the appropriate assessment form with the inclusion of the body chart.

The patient complained of pain localised to the lateral aspect of the elbow. (P1)There was no radiation of pain and no numbness or parasthesia

P1 was intermittent and the patient described it as a nagging pain exacerbated by prolonged typing or lifting. E.g. carrying shopping bag. Accidentally hitting the elbow caused pain as did touching a particular point on the elbow.

Objective examination:

The objective examination began with the patient standing suitably undressed to the waist in a well lit cubicle. The arms were positioned in the anatomical position.

Nothing abnormal was detected in terms of overall head neck and shoulder posture.

The carrying angle of the elbow appeared normal and was equal to the contralateral arm. No abnormal colour changes or swelling was noted. There was slight wasting of the extensor muscles of the forearm.

As the elbow is a peripheral joint, the area was palpated. No heat or thickening was noted, but pain was elicited along the supracondylar ridge.

Finally it was established that there was no other relevant medical conditions that may affect treatment choice. The patients drug history consisted of difene gel applied twice daily over the painful site.

Before commencing the patient reported not to be experiencing pain at rest.

Pathology of the cervical spine can have a major influence on elbow pain therefore cervical spine movements were assessed using six active movements as recommended by Cyriax. Full range of motion was found in all directions with no provocation of pain.

The affected elbow was taken through a group of four passive movements, and four resisted tests to determine which structure was at fault.

Passive movements are used to test the inert structures around the joint and determine the pain, range and end feel.

Passive elbow flexion and extension and pronation was found to be full range, pain free and with a normal end feel. Passive supination provoked pain at the end of range.

Four resisted tests were applied to examine pain and power of the contractile structures around the joint. Resisted elbow flexion, extension and pronation were pain free. Resisted supination provoked pain at the lateral aspect of the elbow.

Two further provocative tests specific for the diagnosis of tennis elbow were applied to the joint. Resisted wrist extension test was positive as this caused the patients pain to be felt. Based on Cyriax, this indicated the presence of tennis elbow.

Resisted wrist flexion, used to test for golfers elbow was found to be negative.

Furthermore passive wrist flexion also provoked the patient’s pain.

Palpation revealed a point of maximum tenderness over the supracondylar ridge over the lateral epicondyle.

Clinical Diagnosis:

From the assessment it was evident that the soft tissue signs were positive. The pattern of tennis elbow as reported by Cyriax is:

By applying the information of the objective examination it was concluded that the patient presented with lateral epicondylitis and this was confirmed on palpation.

Treatment Plan

The aims of treatment are taken from the examination and ideally should be agreed upon with the patient:

1. To reduce pain.P1

2. To increase the extensibility of the wrist extensors.

3. To increase the strength of the wrist extensors

4. To provide ergonomic advice to facilitate the patient at work.

Treatment consisted of deep transverse friction massage to the origin of extensor carpi radialis longus at the supracondylar ridge. The patient was positioned with the forearm resting on a pillow, the elbow flexed to approximately 90 degrees, with the forearm in supination. The pad of the thumb is placed against the lower third of the lateral supracondylar ridge, and the transverse friction is applied in a superoinferior direction. (Cyriax 1998).A few superficial sweeps were used initially to allow the therapist to feel for the tissues and induce a degree of numbing.

Ultrasound was also used in the treatment of the lesion, as well as stretches for the neural tissues, strengthening exercises for the wrist extensors and ergonomic advice.

Reassessment:

Cyriax 1983 emphasises the importance of reassessment and this was carried out at the start of each treatment session. The following were selected as the parameters for reassessment:

Subjective        Localised pain on touching the lesion

                Experience with ADL and work.

Objective          Pain on resisted wrist extension

                          Pain on passive wrist flexion

                          Pain on palpation.

Progress was steady. She reported a gradual reduction in her pain levels while typing at work and during activities of daily living, such as gripping and lifting.

Objectively there was no pain elicited on resisted wrist extension or passive wrist flexion. There was only a minor tenderness at the site of the lesion.

The patient at this point was reporting satisfaction with the progress made. It was decided to discharge her with advice and instructions to contact the department if further treatment was required.

Discussion

Initially this patient presented with

Pain P1 at the lateral aspect of the elbow

Pain while typing and activities such as gripping and lifting.

After assessment and treatment the results of this case study were

In the literature many theories have been put forward regarding the cause of this lesion (see aetiology).In this study, the patients occupation was quite probably a precipitating factor for the development of lateral epicondylitis. The patient is a typist and the repetitive nature of this work may have compromised the extensor tendon leading to inflammation.

The positive results obtained can be explained by understanding the anatomy, physiology and repair process which exist. The best treatment for a lesion of this sort is the use of deep transverse frictions (Cyriax 1998). At the beginning of each session a few superficial sweeps were made. The aims of these were:

1. To allow the therapist to gain a feel for the tissue being treated.

2. To achieve some degree of hyperaemia.

Due to the chronic self perpetuating nature of this condition superficial sweeps were followed by deep frictions. These resulted in movement of the chronic inflammatory tissue. This technique stimulates:

1. Proteoglycan synthesis orientating the laying down of new collagen fibres and preventing intermolecular cross links from occurring (Kesson et al 1998).

2. The production of traumatic hyperaemia which enhances blood supply to the area. The hyperaemia diminishes pain by decreasing the speed of destruction of Lewis P substance which is an irritative metabolite produced due to histamine release (Cyriax 1980)

The inclusion of ultrasound post friction acted to speed up the reduction of pain and help on the healing process due its biological effects principally a thermal effect and intracellular.

The knowledge gained in the Orthopaedic medicine Course played an integral part in the handling of this patient. The logical approach to assessment gave a quick and definite diagnosis. This allowed for formulation of a treatment plan.

References

Cyriax J. Textbook of Orthopaedic Medicine 1981 6^th Ed Vol.1 Balliere Tindall

Greenfield, C. and Webster, (2002)V.ChronicLateralEpicondylitis,Physiotherapy,88,10,578-594.

Kesson, M.and Atkins, E. (1998) Orthopaedic Medicine A practical Approach, Oxford: Butterworth Heinemann.