TENNIS ELBOW (Lateral Epicondylitis).pptx

Tennis Elbow(lateral epicondylitis) is a degenerative condition characterized by painful wrist extension or pain on performing backhand strokes in tennis shots.
This ppt contains an overall description of this condition with proper evidence and conservative and physiotherapy management for this condition.

1. TENNIS ELBOW Dr AMIT PRASHAR (PT) MPT(SPORTS) ISIC-IRS

2. INTRODUCTION Lateral epicondylitis or tennis elbow is a common disorder which significantly impacts on the athletic population.[1] Definition : It is usually defined as the pain over the lateral epicondyle which is reproduced by digital palpation over the lateral epicondyle, resisted wrist extension, middle finger extension and gripping.[1] It effects approximately 4-7 per 1000 individuals.[1] In Lancet in 1882, Morris described epicondylitis in athletes and called it “lawn tennis arm.” The term “lawn tennis elbow” is attributed to Major in an 1883 article in the British Medical Journal. Since then, racquet sport athletes of all kinds have been noted to be particularly susceptible to the development of lateral epicondylitis.[2] It has been estimatedthat 10% to 50% of people who regularly play tennis do develop tennis elbow at some time in their career.[2]

3. Clinical Anatomy Elbow Joint Articular surfaces: upper- the capitulum and trochlea of the humerus lower - upper surface of radius head articulates with capitulum trochlear notch of ulna articulates with trochlea of humerus Ligaments- 1.capsular ligament 2.ulnar collateral ligament 3. radial collateral ligament

4. Anatomy of Elbow

5. Muscles involved in Tennis elbow:[3] 1. ECRB- EXTENSOR CARPI RADIALIS BREVIS(essential and universal lesioned) 2. EDC- EXTENSOR DIGITORUM COMMUNIS 3. ECRL- EXTENSOR CARPI RADIALIS LONGUS 4. ECU- EXTENSOR CARPI ULNARIS Capsular injury as well as thickening and tearing of lateral ulnar collateral ligament and radial collateral ligament have been identified in association with severe lateral epicondylitis.[3]

6. MUSCLE ORIGIN INSERTION FUNCTION ECRB Common extensor tendon dorsal aspect of base of 3rd metacarpal bone Extend the wrist EDC Common extensor tendon dorsum of 2nd through 5th digits Extend the wrist and second through 5th digits at the MCP joints ECRL Distal aspect of lateral suprcondylar ridge of humerus dorsum of base of 2nd metacarpal bone Extends and abducts the wrist ECU Common extensor tendon and dorsal aspect of mid ulna Ulnar aspect of base of 5th metacarpal bone Extends and adducts the wrist

7. PATHOPHYSIOLOGY Few inflammatory type cells are found in LE; instead, the condition is more commonly characterised by fibroblast enlargement, an abundance of disordered collagen, vascular element hyperplasia, and finally death and extracellular matrix breakdown.[15] Nirschl defined four stages of damage caused by repetitive microtrauma involved in LE: (1) initial inflammatory reaction; (2) angiofibroblastic tendinosis, which refers to degenerative changes due to failure of a tendon to heal properly with presence of active fibroblasts, vascular hyperplasia, and production of disorganized collagen; (3) structural failure or rupture; and (4) structural failure plus fibrosis, soft matrix calcification, and hard osseous calcification.[15] The healing process and normal collagen synthesis may be hampered by the absence of functioning cells. It has been proposed that this poor recovery can result in tissue weakness and increased vulnerability to damage.[15]

8. BIOMECHANICS Elbow biomechanics play important role in various sports that involve throwing motions including baseball pitch, the football pass, the javelin throw, the tennis serve, the cricket shot and many more . The tennis serve is the most energy-demanding tennis motion, and has been shown to comprise nearly 45-60% of all strokes performed in a tennis match.[14] The elbow functions as link in kinetic chain of ground stroke or the serve.[5] If energy transfer in one joint is not efficiently coordinated, subsequent joints can easily become overloaded.[14] The elbow is towards the distal end of tennis kinetic chains,receiving energy and force from more proximal links thereby adding more energy and force and passing them on the wrist and racquet.[5] manipulating kinetic chain is key to reduce impact forces on more distal joint which is often done by advance players.[14]

9. BIOMECHANICS OF TENNIS SERVE THERE ARE 8 STAGES- 1. BODY POSITIONING- set up the body for the force generation. 2. BALL RELEASE- tossing the ball and shoulder abduction 100 degrees. 3. LOADING- building power through the legs. 4. COCKING- Shoulder and pelvis tilt laterally spine move into hyperextension,lateral flexion and ipsilateral rotation. 5. Acceleration- Transitioning into forward movement of serve. 6. Contact- Ball velocity is determined by shoulder internal rotation and adduction. 7. Decelaration- eccentric contraction of post cuff, serratus, deltoid and errector spinae. 8. Finish- complet stopping of movement,require lower limb extensor eccentric force.

10. PATHOBIOMECHANICS 1. According to research, tennis play cause pain in lateral elbow due to dynamic stablisation of the wrist, repetitive loading of tendons and muscle activity. [13] 2. Ground strokes of tennis player shows most muscle activity of wrist extensors and ECRB. [13] 3. One hand backhand stroke places greater strain on these tendons. [13] 4. During backhand strokes, wrist supination and elbow extension produce more contact pressure between ECRB and capitulum leading to degenerative process.[13] 5. The motions and forces produce repetitive tensile loads on the ligamentous and muscular support systems around the elbow and compressive and shear loads on the bony constraints.[6] 6. It has been suggested that double hand backstroke leads to decreased occurance of tennis elbow because of decreased forces on the lead elbow at ball impact.[5]

11. ETIOLOGY Eccentric loading of the forearm extensors muscles, predominantly the ECRB.[7] faulty mechanics i.e leading with the elbow, off centre hits in racquet sports, faulty one hand backhand shot, faulty flick shot in cricket.[7] poorly fitted equipments i,e handle too small, bat too heavy in case of cricket,string too tight.[7] age factor 30 to 50 years.[7] pathological cause- repetitive contraction of ECRB results in microtearing with subsequent degradation ,immature repair and due to unique anatomic position the tendon has lack of vascularity which further contributes to degeneration.[4]

12. CLINICAL FEATURES Pain anterior or just distal to the lateral epicondyle that may radiate into the forearm extensors. pain initially subsides but becomes more severe with repetition. pain increases with resisted wrist extension. pain upon gripping or rotation pain upon backhand strokes

13. ASSESSMENT Subjective assessment findings may include : Symptoms will be present on the dominant arm with which player plays. Chief complain of pain on outer surface of elbow while performing particular shots in their respective game like single backhand shot and flick shot in cricket. History - Onset of pain 24-72 hours after provocative activity involving wrist extension or backhand serve. pain that may radiate down forearm as far as the wrist and hand and pain severity ranges from relatively trivial to almost incapacitating that keep patient awake at night. Aggravation by hitting and griping activities and changes in biomechanical factors e.g. new tennis racquet, wet ball, over training, poor technique, shoulder injury[8] Relief by rest .

14. . 2. Objective assessment Include: Pain and point tenderness over lateral epicondyle and/or 1-2 cm distal to epicondyle on palpation MMT- Forearm extensors muscle strength and grip strength is reduced. ROM- Significant reduction in ROM for wrist flexion,extension,pronation and supination. Pain and weakness on resisted wrist extension.

15. Functional assessment – By PTREE( Patient rated Tennis Elbow Evaluation) Questionnaire.[10] Special Test – Cozen’s Test- Resisted wrist extension test. 2. Mill’s Test- passive streching of wrist in flexion and pronation. 3. Maudsley’s Test- resisting third digit of hand while palpating the Lateral epicondyle.

16. Cozen’s test Maudsley’s test

17. Investigation- A plain X-ray (AP/Lateral) Ultrasound- may demonstrate degree of tendon damage. MRI- for differential diagnosis

18. MANAGEMENT OPERATIVE MANAGEMENT PT MANAGEMENT

19. Operative method Open surgery Arthroscopic surgery

20. Physiotherapy Management Modalities Cyriax physiotherapy Taping Exercises and return to sports Activity modifications

21. REHABILITATION STAGES[18] STAGE 1- pain relief STAGE 2- promotion of healing(consists of 4 phases) Phase 1- rehabilitatative exercise Phase 2- fitness exercise Phase 3- advanced rehabilitation techniques Phase 4- control of abusive overload by activity modification,bracing and proper equipment selection.

22. REHABILITATION STAGE PROGRAM MODALITIES/INTERVENTION STAGE 1 [PAIN RELIEF AND INFLAMMATION CONTROL] Conditioning program should include central aerobic exercises to enhance overall circulatory flow. Isometrics (30-60)seconds in pain free ROM. CRYOTHERAPY - to slow the rate of metabolic reaction,promote vasoconstriction and decrease swelling. US - to promote healing SHOCKWAVE THERAPY- t o relieve pain High voltage electrical stimulation- t o control pain and enhance tissue vascularity. COUNTERFORCE BRACING- Enables patient to initiate each phase of exercise and return to sport. KINESIO TAPING- To give controlled mobility DTF- To reduce pain .STAGE 2 [PROMOTION OF HEALING] Consists of exercises to restore strength,aerobics and general cv conditioning

23. PHASE 1[ REHAB EXERCISE] - Isometrics[multiangle] with symptom limited submaximal contraction. - Initial isotonic exercises - Flexibilty exercises[stretching] PHASE 2[FITNESS EXERCISE] - Consists of general fitness and aerobic exercises PHASE 3[ADVANCE TRANSISTIONAL STRENGTHENING AND NEUROMUSCULAR CONTROL] - Plyometrics with medicine ball(side throws,chest passes) - catching and throwing weighted resistance -theraband exercises - shoulder stability exercises - core strength training PHASE 4[FORCE LOAD CONTROL AND RETURN TO SPORT] -Emphasis on warm ups and cool downs. - adequate equipment - sports specific drills

24. Modalities/Interventions IN ACUTE PHASE OF INJURY- ICE- ice pack for 10 minutes help reduction in pain and in acute condition.[19] ULTRASONIC THERAPY- 1 cm2 application area, at 1.5 W/cm2, 1 MHz frequency,continuous mode in painful area, 5 min once a day, 5 days a week[16] SHOCKWAVE THERAPY- 10-15 Hz,1.5-2.5 bar energy density, 2000 pulses, once a week for three sessions.[16] K- TAPING- Diamond taping method may be useful for reducing pain and improving grip strength and functional performance[11] DRY NEEDLING- To release trigger points, to promote pain relief.[12]

25. TRIGGER POINTS NEAR ELBOW DRY NEEDLING K TAPING FOR TENNIS ELBOW

26. CYRIAX TECHNIQUE Cyriax technique combines the use of deep transverse friction (DTF) with Mill’s manipulations in LET. Both treatment components must be used jointly in the sequence specified. Patient must follow the protocol three times a week for four weeks.[11] 1. DTF[Deep Transverse friction]- it is to applied trasversely to the specific tissue involved or 10 mins untill numbing effect is produced, every other day at 28 hrs interval.

27. 2. Mill’s manipulation- It should be performed immediately after DTF. In this there is elongation of scar tissue by rupturing adhesions within teno-oseous junction

28. CYRIAX PT DTF MILL’S MANIPULATION .

29. TENNIS ELBOW EXERCISE PROGRAM[18] PHASE 1A - isotonic exercise to 1.5 kg daily Exercise for wrist flexion,extension,pronation,supination with elbow bent to 90 degree and forearm supported. (15 to 20 reps)*3 sets without resistance - Increase 0.5 kg weight as progression and cut back to 15-20 reps* 2 sets. -progress to 20 reps*3 sets. - follow the same protocol while increasing weight from 1 kg till 1.5 kg without aggravating the pain. -progress to phase 2 PHASE 1B- 50 to 100 reps of squeezing the tennis ball and opening the fingers againt rubberband throughtout day. Elbow is bent to 90 degrees.

30. . PHASE 2 Functional progression Theraband and isokinetic exercise 1. 3*/week isotonics- 10 reps* 2 sets, gradually work towards straightening of elbow progression when elbow becomes straight; increase resistance to 2kg 2. 3*/week isoflex wrist flexion, extension,ulnar and radial deviation, supination; work towards 50 reps of each. 3. if access to isokinetic equipment- 2*/ week isotonics (elbow almost straight) 2*/ week isoflex/theratube 2*/ week isokinetics - Continue squeezing and rubber band exercises throughout the day, but elbow just short of full extension. 4. Shoulder stabilisation exercises. 5. Core strengthening training. -PROGRESS TO NEXT PHASE WHEN COMFORTABLE AND PAIN FREE IN ALL ACTIVITY WITH FULL ROM. PHASE 3 - Maintenance exercises - Continue end point exercise for isotonic and isoflex program 3*/ week

31. GENERAL STRETCHING AND STRENGTHENING EXERCISES THERABAND EXERCISES

32. SHOULDER STABILISATION EXERCISES WOBBLE BOARD SHOULDER STABILITY EXERCISE SWISS BALL SHOULDER STABILITY EXERCISE MEDICINE BALL BALANCE SCAPULAR MUSCLE EXERCISE LAWN MOVER 151 DRILL

33. CORE STRENGTH TRAINING Core strength training improves physical fitness of tennis players.

34. PLYOMETRICS

35. playing with counterforce brace on Activity modification and equipments corrections

36. REFERENCES Johns N, Shridhar V. Lateral epicondylitis: Current concepts. Aust J Gen Pract. 2020 Nov;49(11):707-709. doi: 10.31128/AJGP-07-20-5519. PMID: 33123709. Van Hofwegen C, Baker CL 3rd, Baker CL Jr. Epicondylitis in the athlete's elbow. Clin Sports Med. 2010 Oct;29(4):577-97. doi: 10.1016/j.csm.2010.06.009. PMID: 20883898. Walz D, et al. Epicondylitis: Pathogenesis,Imaging,and treatment.Radiographics.2010;30(1):167-184 Loftice J et al. Biomechanics of the elbow in sports. ClinSports Med 2004 Oct;23(4):519-30 Kibler,W.B. Clinical biomchanics of the elbow in tennis;implications for evaluation and diagnosis.Med. Sci.Sports Exerc.,1994;26(10):1203-1206 Anderson KM,Hall JS, Martin M.Sports injury Management.2nd ed.chapter12,Upper arm,elbow and forearm conditions,pg 442-455. Brukner P. Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill; 2012. Lucado AM, Dale RB, Kolber MJ, Day JM. ANALYSIS OF RANGE OF MOTION IN FEMALE RECREATIONAL TENNIS PLAYERS WITH AND WITHOUT LATERAL ELBOW TENDINOPATHY. Int J Sports Phys Ther. 2020 Aug;15(4):526-536. PMID: 33354386; PMCID: PMC7735685 Rompe JD, Overend TJ, MacDermid JC. Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire. J Hand Ther. 2007 Jan-Mar;20(1):3-10; quiz 11. doi: 10.1197/j.jht.2006.10.003. PMID: 17254903. Stasinopoulos D, Johnson M. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med 2004; 38:675-677

37. 11. Mehta J, et al. Effect of Taping on Pain, Grip Strength, and Function in Deskbound Workers with Lateral Epicondylalgia World J Phys Med Rehab 2019; 1. 12. Navarro-Santana MJ,et al. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clin Rehabil. 2020 Nov;34(11):1327-1340. doi: 10.1177/0269215520937468. Epub 2020 Jun 23. PMID: 32576044. 13. Tosti, R., Jennings, J., & Sewards, J. M. (2013). Lateral Epicondylitis of the Elbow. The American Journal of Medicine, 126(4), 357.e1–357.e6. doi:10.1016/j.amjmed.2012.09.018 14. Chung KC, Lark ME. Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management. Hand Clin. 2017 Feb;33(1):175-186. doi: 10.1016/j.hcl.2016.08.009. PMID: 27886833; PMCID: PMC5125509. 15. Cynthia A. Kahlenberg, Michael Knesek, Michael A. Terry, "New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis", BioMed Research International, vol. 2015, Article ID 439309, 10 pages, 2015. https://doi.org/10.1155/2015/439309 16. Yalvaç B, Mesci N, Geler Külcü D, Yurdakul OV. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc. 2018 Sep;52(5):357-362. doi: 10.1016/j.aott.2018.06.004. Epub 2018 Jun 28. PMID: 30497658; PMCID: PMC6204478. 17.Viswas, Rajadurai et al. “Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A Randomized Clinical Trial.” The Scientific World Journal 2012 (2012): 18. Zachazewski J. Athletic injuries and rehabilitation: 19. Kuo, Chia-Chi1; Lin, Chiu-Chu2*; Lee, Wei-Jing3; Huang, Wei-Ta3. Comparing the Antiswelling and Analgesic Effects of Three Different Ice Pack Therapy Durations: A Randomized Controlled Trial on Cases With Soft Tissue Injuries. Journal of Nursing Research 21(3):p 186-193, September 2013. | DOI: 10.1097/jnr.0b013e3182a0af12

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