|Year : 2015 | Volume
| Issue : 1 | Page : 13-19
Therapeutic management of tennis elbow
Fozia Bashir, Shibili Nuhmani
Department of Rehabilitation Sciences, Jamia Hamdard, New Delhi, India
|Date of Web Publication||19-Jan-2015|
Department of Rehabilitation Sciences, Jamia Hamdard, New Delhi
Patients with conditions like tennis elbow are frequently referred to physiotherapy. Patients with this condition suffer from pain and tenderness over lateral epicondyle, which hampers their activities of daily living. Lateral epicondylitis (tennis elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. Muscular biomechanics characteristics and equipment are important in preventing the conditions. This article presents on overview of the current knowledge on lateral epicondylitis and focuses on, conservative treatment and recent surgical techniques are outlined. This information should assist health care practitioners to manage symptoms, improve activity and reduce relapse who treat patients with this disorder.
الاجراءات العلاجية لمرفق التنس:
المرضى الذين يعانون حالات مرضية مثل مرفق التنس كثيرا ما يحالون لأقسام العلاج الطبيعي. والمرضى من هذا النوع يعانون آلاماً ورقة على اللقميمة الوحشي الأمر الذي يعوق نشاطهم اليومي. ويعدّ التهاب مرفق التنس المسئول عن الآلام الأساسية و فقدان العضو المصاب لوظيفته. وتعد الخصائص الحيوية للعضلات و المعدات عوامل مهمة للوقاية من المرض. هذه المقالة تقدم نظرة عامة عن التهاب مرفق التنس و تركز على العلاج التحفظي والتقنيات الحديثة للعلاج الجراحي. هذه المعلومات يمكن أن تفيد العاملين في حقل الرعاية الصحية لمعاجة االأعراض و تحسين النشاط و تقليل حالات الانتكاس.
Keywords: Extensor muscles, lateral elbow pain, myofascial trigger points
|How to cite this article:|
Bashir F, Nuhmani S. Therapeutic management of tennis elbow. Saudi J Sports Med 2015;15:13-9
| Introduction|| |
Tennis elbow has many analogous terms, including lateral elbow pain, lateral epicondylitis, rowing elbow, tendonitis of the common extensor origin (CEO), and peritendonitis of the elbow. Tennis elbow is characterized by pain and tenderness over the lateral epicondyle (LE) of the humerus and pain on resisted dorsi-flexion of the wrist, middle finger, or both.  For the purposes of this review, tennis elbow was restricted to lateral elbow pain or lateral epicondylitis. Tennis elbow is a painful condition affecting the tendinous tissue of origins of wrist extensor muscles at the LE of the humerus, leading to loss of function of the affected limb. It can have a major impact on patient's social and professional life. 
Research into the etiology of tennis elbow has revealed that it is primarily an overuse injury that results in micro tears of the hyaline region of the extensor muscles that attach on the lateral side of the forearm. However, pain localized on the medial side of the elbow is also possible. The actual diagnosis of tennis elbow is often incorrect because it is termed tendonitis. This expression has been disputed by elbow injury experts, who note that tendonitis implies inflammation of the affected region. The most common form of tennis elbow (LE tendinosis) is a painful condition that rarely presents with any inflammation. This terminology echoes the belief that this injury is degenerative rather than acute.
One of the common problems with tennis elbow is incorrect diagnosis. This occurs because at least 43 different pathologies of the elbow joint have been documented. Because the pathology of the injury is seen primarily at the microscopic level, it is relatively easy to misclassify tennis elbow in the intact human arm as bursitis, arthritis, or one of many other ailments. 
| Epidemiology|| |
According to the observational study, the prevalence of lateral epicondylitis is 1.3%, and medial epicondylitis is 0.4%. The incidence may approach 1-3% in the general population while the incidence in general practice is approximately 0.4-0.7%. Lateral epicondylitis is equally common among men and women, occurs more frequently among whites and in dominant arm and increases with age, peaking between ages 30 and 50 with a mean age 42. It seems to occur equally among blue-collar and white-collar workers and between socioeconomic classes.  The natural course of the condition seems to be favorable with spontaneous recovery within 1-2 years in 80-90% of the patients.
| Anatomy|| |
The human elbow is the summation of three articulations. The first 2 are the ones traditionally thought of as constituting the elbow: The humeroulnar articulation (the synovial hinge joint with articulation between the trochlea of the humeral condyle and the trochlear notch of the ulna) and the humeroradial articulation (the articulation between the capitulum of the humeral condyle and the concavity on the superior aspect of the head of the radius). The third is a pivot-type synovial joint with articulation between the head of the radius and the radial notch of the ulna. These 3 articulations, forming two different aspects, allow flexion and extension of the elbow, as well as supination and pronation of the forearm and wrist at the elbow. When the elbow is in anatomic position, the long axis of the forearm typically has an offset (lateral inclination or valgus at the elbow) of about 19° from the long axis of the humerus.  This angle shows no difference between genders but does increase slightly with age into adulthood.
| Causes of tennis elbow|| |
Any activity that involves repetitive twisting of the wrist can trigger tennis elbow. This includes tennis and other racquet sports, swimming, golfing, turning the key, or using a screwdriver, hammer, or computer. The tendon is the part of a muscle that attaches to the bone. Forearm muscles attach to the outer bone of the elbow. Researchers are finding that tennis elbow often occurs when a specific muscle in the forearm - the extensor carpi radialis brevis (ECRB) muscle - is damaged. The ECRB helps stabilize the wrist when the elbow is straight.  Repetitive stress weakens the ECRB muscle, causing microscopic tears in the muscle's tendon at the point where it attaches to the outside of the elbow. These tears produce inflammation and pain. Based on clinical studies, other factors suggested as contributing to the occurrence of tennis elbow are playing experience, ability and racket type. Inexperienced players more often use improper stroke techniques and are more prone to mishit the ball that results in greater mechanical stress on the elbow joint. Heavier, stiffer or more tightly string rackets increase the muscle stress required during swing and impact. Colt reported that metal rackets were a cause of tennis elbow because they allow shock waves to pass unimpeded. 
| Signs and symptoms|| |
Symptoms of the condition generally include tenderness over the anterior aspects of the epicondyle of the humerus. Pain in extensor muscles of the forearm induced by gripping or resistive movements in the wrist and localized pain in the olecranon region induced by carrying weight. The pain ranges from an occasional throbbing to severe agony although passive movements are generally pained free. 
| Proper stroke biomechanics in tennis players|| |
Tennis elbow is thought to result from overuse of ECRB muscle by repetitive micro trauma resulting in a primary tendinosis of ECRB with or without involvement of extensor digitiform communis. In tennis, the predominant activity of wrist extensors in all strokes (serve, forehand, one or two-handed backhand) might be one explanation for predisposition to the condition. It is generally believed that tennis players using a two-handed backhand hardly develop tennis elbow as the nondominant arm appears to absorb more energy, which changes swing. Electromyography (EMG) showed reduced amplitude in extensor muscle during a two-handed backstroke. The higher occurrence of tennis elbow among recreational tennis players compared with experienced players has been shown to be due to the ability of experienced players to reduce impact transmission from racquet to the wrist and elbow. EMG studies showed a significant difference between both groups.
Tennis players should be instructed to release their grip tightness quickly after the ball to racquet impact in order to reduce impact transmission to wrist and elbow. Aberrant techniques should be identified and corrected. The forehand stroke should allow the players to hit the back in front of the body with the wrist and elbow extended. This allows the torso and upper arm to provide the majority of power and reduce stress on wrist extensors. The two-handed backward stroke allows a distribution of force between upper extremities and also diminishes the force on LE. Proper equipment is also essential in preventing tennis elbow. According to Nirschl, the proper grip size is assessed by measuring from the proximal palmar crease to tip of finger along its radial border, currently most tennis players use a racquet grip size 2-3 (size 1 for children). Lighter racquets are easier to maneuver but provide less momentum for impact. Using racquets with less string tension or with a higher string count per unit area and playing on slower surfaces such as clay courts, will diminish the loads transmitted to the elbow.  The wrist kinematics and EMG data show that novice players eccentrically contract their wrist extensors muscles through the stroke that could contribute to tennis elbow. 
Research published in the American Journal of Sports Medicine claims that your tennis swing technique, not the racket grip size, may be the main cause of tennis elbow (lateral epicondylitis). In the past, many sports medicine physicians would recommend players with a tennis elbow switch to a different size racket grip to treat and prevent these injuries. This new study finds no correlation between grip size and incidence of overuse injuries.
The study authors indicate that grip size changes the impact forces, but that is unlikely to contribute to overuse injuries and tendonitis. They go on to recommend that players use the grip size they find most comfortable. The study followed 10 male and six female NCAA tennis players-none of whom had any history of elbow problems. The players then performed one-hand backhand strokes using identical tennis rackets with three different grip sizes. Researchers then measured the firing patterns of forearm muscles during the swings. They found no difference in the firing patterns of the muscles with different grip sizes. The findings further support previous research that finds improper form is one of the biggest causes of tennis elbow. This reinforces the recommendation that players with elbow pain work more on their tennis swing mechanics and stroke instead of changing equipment. 
| Treatment|| |
Rest is the first line of defense against this condition, because the tennis elbow is an overuse injury, the first practical action would be to stop playing tennis until the pain is gone. Anything, within reason, that causes the pain to become stronger or more intense, should be avoided. Continuing to play the sport or other activity that caused the injury, will only make the problem worse. 
Icing will work only if the condition is inflammatory, cases dominated by muscle dysfunction will not respond, especially well to ice. Ice is recommended for its local vasoconstrictive and analgesic effect. Experts recommend it to do it every 20-30 min every 3 hourly or 2-3 days or until the pain is gone. 
Ultrasound has been widely used and accepted adjunct modality for the management of many musculoskeletal conditions. It was introduced as therapeutic modality in 1950s. In late 1960s and 1970s, reports on the nonthermal therapeutic effects of US, primarily in the area of enhanced tissue healing further bolstered its popularity, According to survey of orthopedic certified specialist, the most common use is for where to decrease soft-tissue inflammation, increase tissue extensibility, enhance scar tissue remodeling, increase soft-tissue healing, decrease pain and decrease soft tissue swelling. Other uses were to deliver medication for soft-tissue inflammation, pain management and soft-tissue swelling. 
Therapeutic eccentric exercise (TEE) has been found to be an effective intervention for a variety of tendinopathy including Achilles tendinosis, shoulder impingement, and patellar tendinopathy. One of the first recommendations in the literature regarding the use of eccentric exercise for managing tedinopathies was made by Stanish et al. in 1986. They suggested that the eccentric exercise effectively "lengthened" the muscle-tendon complex resulting in structural remodeling of the tendon with hypertrophy and increased tensile strength of the tendon. 
Eccentric exercise may also provide neuromuscular benefits through central adaptation of both agonist and antagonist muscles; therefore, TEE may provide both a structural and functional benefit during tendinopathy rehabilitation. Interestingly, some patients with LE exhibit lowered pain pressure thresholds (PPT) and larger referred pain patterns than would occur solely due to the presence of trigger points, suggesting a central nervous system mediation of pain. Many questions remain as to the mechanism of the effectiveness of TEE, as well as the appropriate dosage. In a recent systematic review, Woodley et al. noted a lack of high-quality studies comparing the effectiveness of eccentric exercise to standard management of tendinopathies. 
Historically, a popular choice for treating tendonitis was deep friction massages. However, as evidenced by the 2002 Cochrane review, there is simply not a large enough sample size to draw any conclusions in regards to control of pain or improvement in function. The concepts of cross-friction techniques have since evolved into an augmented soft-tissue mobilization, more commonly known as the "Graston Technique Instrument-Assisted Soft Tissue Mobilization" or simply Graston. The Graston protocol for epicondylosis uses specifically designed stainless steel instruments, which are moved with multidirectional strokes around the bony prominence of the elbow. Preliminary studies utilizing this Graston technique have shown promising results when compared to a traditional physiotherapy protocol in the treatment of lateral epicondylitis.
Perhaps the most popular of soft tissue techniques to gain recent notoriety is Active Release Technique. This therapy is based on the observation that the anatomy of the forearm has been traversing tissues situated at oblique angles to one another that is prone to reactive changes producing adhesions, fibrosis and local edema and thus pain and tenderness. During active release therapy, the clinician applies a combination of deep digital tension at the area of tenderness and the patient actively moves the tissue through the adhesion site from a shortened to a lengthened position.  For example, in order to treat ECRB. The clinician applies proximal tension distal to the LE while the patient extends the elbow and pronates and flexes the wrist. A preliminary report on the use of ART® for a variety of upper extremity overuse syndromes found a 71% efficacy rate.
The muscle-strengthening program was initially proposed by Dr. Ernest W. Johnson (oral communication, October 2003), an American physiatrist from Ohio State University in Columbus. The program encompasses a 10 repetition maximum of eccentric and concentric movements of the wrist extensor muscles in two different positions: First with the elbow flexed to 90°, then with the elbow extended to 180° The forearm is pronated in both positions. Slow full-wrist extensions are followed by slow full-wrist flexions; each full-wrist extension and full-wrist flexion should take 5-10 s. A "10 repetition maximum" means that it is difficult (or impossible) to do more than 10 repetitions with a given weight (handheld dumbbell). It is normal for pain to be present while performing the exercises. The weight is progressively increased when 10 repetitions can be completed without pain. 
Cyriax physical therapy
cyriax and cyriax claimed substantial success in treating tennis elbow using deep transverse friction in combination with mills manipulation that is performed immediately after deep transverse friction. Patient must follow protocol 3 times a week for 4 weeks. Deep transverse friction is performed only at the exact site of the lesion with the depth of friction tolerable to the patient. It produces vasodilatation and increases blood flow to the area. 
Trigger point release: In a study, two groups were taken blindly and were examined for the presence of myofascial trigger points (TrPs).The quality and location of the evoked referred pain and PPT at the LE on right upper extremity were recorded. Several lateral elbow parameters were also evaluated. Result suggested that in patients with LE the evoked referral pain and its sensory characteristics shared similar patterns as their habitual elbow and forearm pain, consistent with active TrPs. Lower PPT and larger referred pain pattern suggest that peripheral and central sensitization exist in LE. 
In 1999, David Simons, M.D, discovered that a trigger point is a dysfunction that occurs at the point where a nerve enters a muscle, trigger points result in muscle, which had been traumatized by accidents, sports, occupational stress and overuse. It can remain for life unless treated. When pressure is applied to trigger points, the chemical/pressure cycle is interrupted, which helps to stop the contraction and pain in muscle.
Biomechanical data on most bracing and protective equipment systems is lacking. To better understand the clinical success of counter force bracing, a biome chemical analysis of braced and unbraced tennis players (serve and backhand strokes) was undertaken. Three-dimensional cinematography and electromyographic techniques were used. Three commonly used counter force braces (lateral elbow, medial elbow, and radial ulnar wrist) were compared with the unbraced condition. The overall results basically reveal positive bio mechanical alterations in forearm muscle activity and angular joint acceleration dependent upon the brace, and joint area analysed.  Jafarian et al. compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylosis. In a randomized, controlled study of 52 patients, maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength; consequently, the researchers suggest that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength. 
A study in 2008 by "Altan" and "Kanrtn" compared treating 50 individuals with symptoms of lateral epicondylitis for <12 months with either a typical counter force forearm brace versus treatment with 10-15° dorsi-flexion wrist splint. Parameters of pain at rest and with wrist extension sensitivity, hand grip strength and subjective response to treatment were measured at baseline 2 weeks and 6 weeks. No formal physical therapy (PT) or home exercise program was recommended. The counter force brace group demonstrated a significant reduction in pain at rest and during movement at 2 weeks while sensitivity and grip strength was not changed at 2 weeks. At 6 weeks, significant improvement was noted in all parameters with implementation of counter force bracing  Elbow strapping is done to protect the injured tendon from further strain. Ergonomic measures are often initially recommended.
Preliminary evidence exists for use of scaphoid thrust manipulation techniques in the treatment of lateral epicondylitis. In a pilot, study Strujis et al., randomly assigned 31 patients with lateral epicondylitis to receive either scaphoid thrust manipulation or a multimodal treatment approach consisting of ultrasound, friction massage and strengthening exercise. All patients underwent treatment over 6-week period.  At termination of PT, the group receiving scaphoid manipulation exhibited significantly less pain during day measured by visual analog scale.
Mulligan's mobilization with movement
Mulligan's mobilization with movement (MWM) is a nonthrust manipulative technique. Vicenzino and wright initially investigated the effects of a course of MWM treatments on the outcome of pain and function in a patient with lateral epicondylitis using a single-subject design and the results were encouraging, resulted in rapid reduction in pain and improved function that followed.  In a pilot study, collagen-producing cells derived from skin fibroblasts were used for treatment of refractory lateral epicondylitis (CEO tendinosis) was done on twelve patients (five men and seven women; mean age 39.1 years) with clinical diagnosis of refractory lateral epicondylitis. Laboratory-prepared collagen-producing cells derived from dermal fibroblasts were injected into the sites of intra-substance tears and fibrillar discontinuity of the CEO under ultrasound guidance. The outcome assessment was done over 6 months using (i) Patient-Rated Tennis Elbow Evaluation scale for pain severity and functional disability and (ii) The tendon healing response was measured using four criteria on ultrasound - tendon thickness, hypo echogenicity, intra-substance tears and neovascularity.
Successful preparation of cell cultures rich in collagen-producing cells was possible in the laboratory. After injection, the median PRTEE score decreased from 78 preprocedure status to 47 at 6 weeks, 35 at 3 months and 12 at 6 months (P < 0.05). The healing response on ultrasound showed the median decrease in - (a) number of tears from 5 to 2, (b) number of new vessels from 3 to 1 and (c) tendon thickness from 4.35 to 4.2 (P < 0.05). Eleven of the 12 patients had a satisfactory outcome such that only one patient proceeded to surgery following failure of treatment at the end of 3 months. Our pilot study suggests that these collagen-producing cells can be injected safely and may have therapeutic value in patient's suffering from refractory CEO tendinosis. 
Low-level laser therapy (LLLT) five systematic reviews were identified. The most recent (which covered tendinopathy generally) 27 utilized laser dose standards defined by the World Association for Laser Therapy (WALT) to assess the adequacy of treatment within included studies. 28 Twelve (from 25) included studies showed positive outcomes in the short-term. In a previous review specific to LLLT for LE, 29 13 trials (n = 730 patients) showed reductions in pain and increased grip strength (comparably, corticosteroid injections show a more rapid onset in pain reduction and a larger effect size in the same period). A subgroup analysis showed these effects were associated with narrowly defined doses of 904 nm wavelength LLLT (the treatment procedure is described as direct irradiation of approximately 5 cm 2 of the tendon insertion at the lateral elbow, with a dose of 0.25-1.2 J, and mean output 5-50 mW. WALT also recommended peak pulse output. One Watt, and power density of <100 mW/cm 2 30) and an added value effect of combining LLLT with exercise therapy. The authors suggest these positive findings are in spite of a negative publication bias across a relevant LLLT literature. Only 2 studies present results for medium-term outcomes of LLT that show positive effects observed up to 24 weeks. 29 Although no adverse responses were reported for LLLT in either systematic review, this treatment may not be universally available therapy.  A recent study done by Bhatt et al. suggests that weakness of the shoulder region especially rotator cuff and scapular musculature is responsible for lateral epicondyalgia. In this study strengthening of lower and middle trapezius muscle for 10-week period has shown good results, and the grip strength has improved in patients with lateral epicondylgia. 
Animal studies suggest that the nitric oxide stimulate collagen synthesis by wound fibroblasts and therefore, may play a role in healing extensor tendons. One randomized controlled trial (RCT) suggests that topical nitrate patches may be effective in patients with lateral epicondylitis, but confirmatory studies are needed. The RCT of 86 patients compared a nitroglycerin transdermal patch with a placebo patch. The nitroglycerin patch reduced elbow pain with activity at 2 weeks, reduced epicondylar tenderness at 6 and 12 weeks, and increased wrist extensor mean peak force and total work at 24 weeks. At 6 months, 81% of treated patients were asymptomatic during activities of daily living.  Many physicians are skeptical about using corticosteroid injection to manage treatment for workers and other patients suffering from LE tendinopathy (tennis elbow). These doubts are well founded, based on compelling evidence regarding the long-term outcomes for tennis elbow sufferers who are being treated with corticosteroids.
Manual therapy versus injections: In February 2013 the results of a clinical trial by Coombes and colleagues entitled, "Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A RCT," were published in the Journal of the American Medical Association. In this trial, 43 patients with chronic tendinopathy randomly received corticosteroid injection, 41 received placebo injection, 40 received corticosteroid injection plus physiotherapy, and 41 received placebo injection plus physiotherapy. Patients receiving corticosteroid injection - with or without physiotherapy treatment - were found to have a greater rate of recurrence of their condition at 1-year (54% versus 12% in the placebo injection group).
The key finding of the study was that although corticosteroids reduced pain for these patients as early as 4 weeks, they were 4-5 times more likely to be worse off in the long run. By contrast, the group that received placebo injections combined with physiotherapy experienced a substantial improvement in pain after 4 weeks, with no worsening in the rate of recurrence, compared with those receiving the placebo injection alone. In this clinical trial, physiotherapy treatment consisted of the previously described combination of specific exercises and manual therapy. Despite the research findings, it may not be sufficient to reassure patients with LE tendinopathy that their condition is usually self-limiting within 8-12 months, and that ongoing symptoms do not necessarily signify ongoing tissue damage. Most patients would prefer to receive a list of treatment options that will hasten their recovery without increasing the risk of recurrence. 
| Summary|| |
There is no true consensus on the most efficacious management of lateral epicondylitis, especially for long-term outcomes. Furthermore, most studies do not differentiate between clinical and statistical significant effects. Although, corticosteroid injections do show large effects in pain reduction. This is seen in short-term and treatment is associated with risk of adverse events in long-term reoccurrence. If available LLLT may be a safe alternative choice for beneficial but smaller short-term effects, especially if considered as an adjunct to exercise therapy. Combined physiotherapy treatment packages have been shown to give relief in medium-term, but effects are only slightly better than advice and a wait and see approach in long-term. There is very limited evidence to support injections of blood plasma, botulinum toxin in refractory lateral epicondylitis. Advice with a wait and approach are recommended as first-line treatment in primary cases for most cases. 
| Acknowledgments|| |
We express our sincere thanks to Dr. Zoheb A. Siddiqui and Dr. Nayeem U. Zia for helping in the review process.
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