Tennis elbow

History, clinical features, examination, treatment

1. TENNIS ELBOW Subin S 2k14 MBBS JIPMER

2. What is tennis elbow? Tennis elbow/lateral epicondylitis is the tendinopathy of the common extensor-supinator tendon. Lateral periepicondylar pain and tenderness that is exacerbated by forceful repetitive wrist extension.

3. History In 1883, H.P.Major noted that this condition commonly affected tennis players, the complaint became popularly known as ‘tennis elbow’(Nirschl 1974). Seen in 13% of elite tennis players and 50% of non elite players. But 95% of cases occur in those who do not play tennis and are associated with manual occupations.

4. Pathology Degenerative microtears in common extensor-supinator tendon due to repetitive mechanical overload. The tendinous origin of Extensor carpi radialis brevis most commonly affected. Microscopic feature of surgical specimen: Hyaline degeneration Fibroblastic and vascular proliferation- angiofibroblastic hyperplasia Microscopic calcification

5. Etiology Tennis players: due to faulty playing techniques mostly a late mechanically poor backhand. Non tennis players: 95% of cases seen Housewives, carpenters, miners, drill workers, other sports. Use of computer

6. Clinical features Usually an Active individual of 30 or 40 years. Pain and tenderness over lateral epicondyle of elbow. Acute or insidious onset of pain. History of over use, involving forceful gripping, repetitive flexion-extension at wrist or pronation-supination activity. Pain aggravated by movements like pouring out tea, turning stiff door handle, shaking hands, lifting weights,etc. Elbow looks normal and flexion and extension are full and normal.

7. Physical Examination Localised tenderness at or just below the lateral epicondyle C ozen’s test : painful resisted extension of the wrist with elbow in full extension elicits pain at the lateral aspect of elbow Mill’s test : Elbow held in extension ,passive wrist flexion and pronation produces pain. Maudsley’s test : examiner resist the extension of third digit of hand , stressing the extensor digitorum muscle and tendon. A positive test is indicated by pain over lateral epicondyle.

8. Cozen’s test:

9. Mill’s test

10. Maudsley’s test

11. Differential diagnosis Radial tunnel syndrome: posterior interosseous nerve entrapment between the fibres of supinator muscle. Clinically pain will increase with resisted supination. Pain is located 3-4cm distal to lateral epicondyle. Osteochondritis dissecans of the elbow: patient may complaint of snapping or locking. Maximum tenderness found posterior to lateral epicondyle.

12. Imaging Not routinely performed Diagnostic ultrasound features include: In active severe disease- neovascularisation Local fluid collection In chronic cases- dystrophic calcification at tendon insertion

13. Conservative Treatment 90% of ‘tennis elbow’ will resolve spontaneously within 6-12 months. First step is to identify and restriction or modification of the activities which cause pain. In acute stages use of ice pack, use of NSAIDS(preferably topical) can be useful. Compression strap applied distal to bulk of extensor mass(to reduce maximum contraction) is helpful. It is used only during aggravating activity. Injection of tender area with corticosteroids and local anaesthetic relieves pain but is not curative. Physical therapy: ultrasound therapy, remedial exercises may be effective in long term

14. Compression strap

15. Ultrasound therapy

16. Operative treatment Indicated in sufficiently persistent or recurrent cases usually after 6-12 months of failed conservative management. Options : Open debridement of the diseased tissue of the ECRB Percutaneous release Arthroscopic debridement

17. Open debridement

18. Percutaneous debridement

19. Arthroscopic debridement

20. Newer experimental treatments Injections : autologous blood, platelet rich plasma , botulinum toxin Laser therapy Extra corporeal shock wave therapy

21. Extra corporeal shock wave therapy

22. In NEWS

23. Bibliography Apley’s system of orthopaedics and fracture, 9 th edition Oxford Sports injuries by Michael Hutson and Cathy Speed Textbook of orthopaedics by John Ebnezar, 4 th edition Essential handbook of practical orthopaedic examination by Kaushik Banerjee, 4 th edition Essential orthopaedics by Maheshwari, 5 th edition

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