Tennis Elbow: A Review Tim Noteboom, MS, PT, ATC' Rob Cruver, MA, MS, PT2 julie Keller, MS, PT3 Bob Kellogg, MS, PT, ECS4 Arthur j. Nitz, PhD, PT, ECS, 0CS5

T ennis elbow (lateral epicondylitis) is a com- mon soft tissue condi- tion treated by many physical therapists in a

variety of clinical settings. T h e pur- pose of this paper is to review the relevant anatomy, clinical examina- tion, differential diagnosis, conserva- tive care, and surgical treatment for patients with tennis elbow. T h e inci- dence of lateral epicondylitis has been found to vary with different population groups. Allander (1) re- ported an incidence of 1-3% in a population study of 15,000 subjects. In two separate studies at industrial health clinics, lateral epicondylitis was found to be most commonly as- sociated with work-related activities, ranging from 35 to 64% of all diag- nosed cases (1 2.25). In fact, people who played tennis constituted a rather small proportion of the total, only 8% (1 1). However, as a group, tennis players d o run a higher risk of developing lateral epicondvlitis. Maylack (32) reviewed the epidemio- logical data available concerning in- juries among tennis players and re- ported that 50% of competitive ten- nis players will suffer from at least one episode of lateral epicondylitis.

ANATOMY

T h e elbow is a complex gingly- mus o r hinge joint that allows mo- tion of flexion and extension (54). T h e proximal and distal radio-ulnar joints allow the motion of pronation

Tennis elbow is a common yet sometimes complex musculoskeletal condition affecting many patients treated by physical therapists. The purpose of this article is to review the anatomy, clinical examination, differential diagnosis, conservative care, and surgical treatment for tennis elbow or lateral epicondylitis. Particular attention is given to determining the precise pathological cause of lateral epicondylitis, with consideration of intrinsic and extrinsic factors associated with this condi- tion. This information should assist health care practitioners who treat patients with this disorder.

Key Words: lateral epicondylitis (tennis elbow), conservative treatment, surgical treat- ment

' Physical Therapist, Therex Physical Therapy, Denver, CO ' Physical Therapist, Twinboro Physical Therapy Associates, Somerset, N l

Instructor of Anatomy, US Air Force Academy, Colorado Springs, C O ' Physical Therapist, Naval Hospital Millington, Millington, TN

Associate Professor of Physical Therapy, Division of Physical Therapy, University of Kentucky, Room 4, Annex I, UKMC, Lexington, KY 40536-0079

and supination. T h e distal humerus consists of two condyles forming the articular surfaces of the trochlea and capitellum (capitulum). Above the condyles are the medial and lateral epicondyles. T h e medial epicondyle serves as the attachment of the ulnar collateral ligament and the origin of the forearm flexor-pronator group of muscles. T h e lateral epicondyle, located just above the capitellum, is the origin of the extensor-supinator group. This lateral area is involved with tennis elbow. This review of anatomy will concentrate on struc- tures found on the lateral side of the joint: osseous, bursae, capsuloliga- mentous, nerve, and musculotendi- nous.

Osseous Structures

T h e lateral epicondyle is less prominent than the medial epicon- dyle. Just proximal to the lateral epi-

condyle is the supracondylar ridge o r column. T h e ridge is easily palpable and separates the lateral head of the triceps on the posterior surface of the humerus from the brachioradi- alis, extensor carpi radialis longus anteriorly, and the extensor carpi ra- dialis brevis. T h e distal end of the humerous is flattened anteroposte- riorly and is the widest part of the bone. At the junction of the shaft and the distal end, the humerus is anteriorly rotated 30-45" (33,34). T h e articular surface of the humerus is formed by the trochlea and capi- tellum. T h e trochlea is a hyperbo- loid, pulley-like surface that articu- lates with the semilunar notch of the ulna. T h e capitellum, on the other hand, is almost spheroidal in shape.

Hyaline cartilage is generally more thick on the capitellum than on the trochlea (2 mm compared with 1 mm) (35). T h e trochleocapi- tellar groove separates the capitel-

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lum from the trochlea, distinguish- ing the articulation with the head of the radius. Hyaline cartilage covers the radial head as well as the outside circumference that articulates with the ulna. The ulnar portion of the humeroulnar joint is made up by the sigmoid notch. Unlike the other joint surfaces, the notch does not have a continuous hyaline cartilage surface.

Capsuloligamentous Structures

The stability of the elbow joint is provided by the bony anatomy and the ligaments, which are actually spe- cialized thickenings of the joint c a p sule (33). The radial (lateral) collat- eral ligament is commonly described as originating from the lateral epi- condyle and terminating diffusely in the annular ligament (22). McVay (33) and Wadsworth (53) have de- scribed the lateral ligamentous struc- tures as a single complex. Morrey (34) described four separate liga- ments that comprise the lateral liga- ment complex. The radial collateral ligament originates at the lateral epi- condyle and attaches distally by blending into the annular ligament. The lateral ulnar collateral ligament arises posterior to the radial collat- eral ligament and passes superficial to the annular ligament to attach to a discrete bony tubercle on the prox- imal ulna. The accessory lateral col- lateral ligament fibers are intimately associated with the annular ligament and function to augment it during varus stress of the elbow. Finally, the annular ligament is a stout structure that attaches on the sigmoid notch of the ulna, encircles the radial head, and again attaches to the sigmoid notch.

The anterior joint capsule inserts proximally above the coronoid and radial fossae. Distally, the capsule at- taches to the anterior margin of the coronoid (medially) as well as to the annular ligament (laterally). The an- terior portion is taut in extension and becomes lax with flexion. The

posterior portion of the capsule is at- tached proximally just above the ole- cranon fossa and along the medial and lateral margins of the trochlea. Distally, attachment is along the me- dial and lateral articular margin of the sigmoid notch, and laterally along the lateral aspect of the sig- moid notch to form a confluence with the annular ligament (34).

A synovial membrane lines the capsule but is separated from the capsule by fat pads opposite the ole- cranon, coronoid, and radial fossae. A fold of synovial tissue has been de- scribed as projecting between the capitellum and radial head, forming the "meniscus" of the radiohumeral joint. A synovitis of the fold has

At industrial healfh clinin, lateral

epicondylitis was found to be most

commonly associated with work-related

activities.

been suggested as a possible cause of lateral epicondylar pain (34).

Bursae

The literature varies greatly on the number and importance of bur- sae located about the elbow (27.33, 34,35,53). Lanz and Wachsmuth (27) describe seven bursae, including three associated with the triceps (27). The most well known and consistent is the superficial olecranon bursa lo- cated between the olecranon process and the subcutaneous tissue. The ra- diohumeral, or subextensor carpi ra- dialis brevis, bursa lies deep to the common extensor tendon, below the brevis and superficial to the radiohu- meral joint capsule. This bursa has

been recognized and implicated by several authors (8.4 1) in the etiology of lateral epicondylitis. McVay (33) indicated that radioulnar bursitis may occur from the irritation of re- peated or violent extension of the wrist with the forearm pronated. Goldie (1 8). however, found no in- volvement of the bursae in 176 el- bows examined. Rather, his investi- gation identified the presence of a subtendinous space near the exten- sor carpi radialis brevis attachment to the lateral epicondyle that was filled with granulation tissue, hyper- vascularized, and edematous in pa- tients with tennis elbow (1 8). Goldie (1 8) concluded that this constituted the pathogenesis of lateral epicondy- litis and his contention was strength- ened by the observation that excision of the granulation tissue resulted in complete recovery from symptoms of the condition for the vast majority of the patients.

Neurologic Structures

The principal neurologic struc- ture found on the lateral aspect of the elbow is the radial nerve. As a continuation of the posterior cord, the nerve originates from branches of the C6, C7, and C8 nerve roots. After winding around the posterior surface of the shaft of the humerus from medial to lateral, the nerve pierces the lateral intermuscular s e p tum to enter the anterior compart- ment of the arm (Figure 1). Once the nerve reaches the anterior com- partment of the arm, it lies deep in a furrow bound on the medial side by the brachialis muscle with the exten- sor carpi radialis longus muscle over- lying it anterolaterally and the capi- tellum lying posteriorly. In this area. referred to as the radial tunnel, nerve branches are sent to the bra- chialis, brachioradialis, and extensor carpi radialis longus muscles, to the periosteum of the lateral epicondyle. and to anterior structures of the ra- diohumeral joint and annular liga- ment (23). In the antecubital space,

Volume 19 Number 6 June 1994 JOSPT

1 [[v- Radial N.

\\ Radial Collateral A.

FIGURE 1. Posterolateral view of the right elbow.

the nerve divides near the arcade of Frohse into the superficial and deep branches (Figure 2). At about the level of the radial head, the extensor carpi radialis brevis muscle receives its innervation from the superficial radial nerve. T h e deep branch passes through the arcade of Frohse be- tween the two heads of the supinator muscle which it innervates (47). It emerges from the muscle as the pos- terior interosseous nerve, innervat- ing the extensor digitorum commu- nis, extensor carpi ulnaris, and ex- tensor digiti quinti. T h e posterior interosseous artery accompanies the nerve, which sends motor branches distally to supply the abductor polli- cis longus, extensor pollicis longus, extensor pollicis brevis, and extensor indicis on the dorsum of the forearm (43).

Musculotendinous Structures

T h e extensor carpi radialis lon- gus originates from the supracondy- lar ridge below the origin of the brachioradialis. This attachment is

. Lateral Epkondyle of Humerus

Extensor Carpi Radialis

Longus and Brevls P

between the brachialis medially and the extensor carpi radialis brevis in- ferolaterally. T h e extensor carpi ra- dialis longus crosses the elbow and carpal joints to insert onto the dorsal

FIGURE 2.

base of the second metacarpal and is covered by the brachioradialis over most of the forearm. Its function is that of wrist extension, radial devia- tion, and possibly elbow flexion.

Originating from the lateral infe- rior aspect of the lateral epicondyle, the extensor carpi radialis brevis ori- gin is the most lateral of the exten- sor group. T h e extensor carpi radi- alis brevis is covered by the extensor carpi radialis longus and its fibers are almost indistinguishable from those of the extensor carpi radialis longus and extensor digitorum com- munis in most cases. T h e extensor carpi radialis brevis muscle also has additional attachments to the radial collateral ligament and the intermus- cular septa between it and the com- mon extensor muscles (48). T h e ex- tensor carpi radialis brevis tendon in- serts to the dorsal surface of the base of the third metacarpal bone. Pure wrist extension with some assistance in radial deviation are the main func- tions of the extensor carpi radialis brevis. Electromyographic studies by Kashiwagi (24) showed the extensor carpi radialis brevis contracted stren- uously at all times during daily func- tional activities. During the back-

Brachioradialis

Extensor Carpi Radialis Longus

Pronator T e r e s

Anterior view of the right elbow.

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stroke in tennis, the extensor carpi radialis brevis contracted more pow- erfully than any other forearm muscle.

T h e extensor digitorum commu- nis originates from the anterior dis- tal aspect of the lateral epicondyle and accounts for most of the contour of the extensor surface. Parts of the extensor digitorum communis are also attached to the septum and ten- don from which the extensor carpi radialis brevis arises (48). T h e exten- sor digitorum communis insertion contributes to the extensor mecha- nism for the index, long, ring, and little fingers. In addition to exten- sion of the wrist and digits, Wright (57) suggests that the extensor digi- torum communis may assist with elbow flexion when the arm is pronated.

T h e extensor carpi ulnaris mus- cle has two heads of origin. T h e hu- meral origin is the most medial of the common extensor group while the ulnar attachment is along the su- perior border and aponeurosis of the anconeus muscle. By inserting into the dorsal base of the fifth metacar- pal, the extensor carpi ulnaris acts as a wrist extensor and an ulnar devia- tor.

T h e supinator is a flat muscle taking its origin from the anteriolat- era1 aspect of the lateral epicondyle, lateral collateral ligament, and the proximal anterior crest of the ulna. T h e supinator runs distally and radi- ally to insert broadly onto the proxi- mal radius. T h e muscle is a forearm supinator whose effectiveness is not altered by degree of elbow flexion (34). An important feature of the su- pinator is that a branch of the radial nerve pierces the muscle to gain ac- cess to the extensor surface of the forearm. Therefore, the supinator muscle can be a site of nerve entrap- ment (43).

Goldie (I 8) described the devel- opment of a space distal to the lat- eral epicondyle as the bone attains adult shape. He termed this gap, deep to the aponeurosis, as the sub-

tendinous space. T h e space contains thin areolar tissue as well as fat tissue acting as a shock-absorbing pad when the extensor muscles contract. Goldie (1 8) documented that pa- tients suffering from tennis elbow re- place this areolar and fat tissue in the subtendinous space with fibrotic, granular-type tissue.

PATHOLOGY AND DIFFERENTIAL DIAGNOSIS

Lateral epicondylitis is a syn- drome characterized by pain over the outer aspect of the elbow and is usually aggravated by radial exten- sion of the wrist (3,11,12,15,25, 29,37). This syndrome most com- monly occurs in the 35-50 year age group, is found in men more than

Microscopically, avulsion fractures and round cell infiltration

may be present.

women, and tends to involve the subject's dominant arm. Tenderness is typically localized to the tendinous origin of the extensor carpi radialis brevis. T h e pain can be aggravated by gripping, heavy lifting, o r simple tasks of daily living. Chronic symp- toms are commonly associated with inadequate muscle power and endur- ance. Most investigators contend that repetitive and cumulative injury produces this condition. T h e conse- quent force overload may be due to factors localized at the elbow (intrin- sic) o r the result of factors acting at a distance from the elbow (extrinsic).

Intrinsic Factors

Intrinsic factors appear to be the most causal factors (3,l 1,12,15, 26,38,53) and occur when there is excessive loading of normal musculo-

skeletal tissue. Overexertion of the extensor muscles of the wrist as a re- sult of repeated gripping and twist- ing (ie., supination/pronation) move- ments may occur prior to the onset of symptoms. Cyriax (1 1) and La- Freniere (26) report that these force- ful contractions lead to irritation and partial tears of the involved muscula- ture. These repetitive high moments of force a re beyond the adaptive ca- pacity of the tissue with subsequent deterioration occurring (29). T h e site of tissue degeneration continues to be somewhat controversial, al- though the extensive work by Goldie (1 8), noted previously in this review, has done much to clarify the nature of the lesion. Cyriax (1 1) theorized that a muscle tears most easily at its attachment to the bone rather than at the musculotendinous junction o r the muscle belly. He stated that the site of maximal tenderness is the site of the injury. However. Garrett et al (1 6) state that muscle damage always occurs a t the musculotendinous junc- tion. Kivi (25) proposed that the con- nective tissue plays an important role. While muscle fibers are well supplied with blood and have good healing potential, the tendon fibers attached to the periosteum are rela- tively avascular and tend to heal more slowly. Lesions are character- ized by macroscopic and microscopic tears, which may be superficial o r deep. Microscopically, avulsion frac- tures and round cell infiltration may be present. Scattered foci of fine cal- cification and scar tissue with mar- ginal areas of cystic degeneration and fibrinoid degeneration may be evident in some cases (53). Repair is often by immature granulation tis- sue, but rupture of the extensor carpi radialis brevis tendon is rare.

Signs and Symptoms

Swelling o r eccymosis is rare, ex- cept in cases of external trauma. T h e arm is painless a t rest and during passive range of motion. With re- peated microtrauma, an inflamma-

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tory condition of the periosteum may develop, which can lead to for- mation of granulation tissue and adhesions. Granulation tissue con- tains a large number of free nerve endings which may be responsible for increased tenderness to palpation ( 1 1.38.53). T h e tenderness is most notable a t the anterior aspect of the lateral epicondyle and the lateral forearm. Palpation of the radial col- lateral ligament may elicit exquisite tenderness and is usually increased with varus (adduction) stress to the elbow. Grip strength may be de- creased, but the articular and neuro- logical signs are normal. In severe cases, pain at rest occurs along with varying decreases of motion at the extremes of flexion and extension.

According to Bosworth (3), it is difficult to determine whether the extensor muscle origin o r the annu- lar ligament is responsible for the symptoms, as they are firmly at- tached to each other. He contends that rotation of the radial head be- neath these structures during prona- tion and supination causes trauma. This movement produces a pulsating effect, which can cause a stenosis and fibrosis of the annular ligament and the extensor origin. Cyriax ( 1 1 ) and Leach and Miller (28) both concur with this explanation.

In most cases, the lesion will in- volve the junctional tissue a t the common extensor muscle origin of the lateral epicondyle, specifically, the extensor carpi radialis brevis (3,11,15,25,26,28,38,40,45,53). If the extensor carpi radialis brevis is involved, extension of the wrist will be more painful if resistance is given at the heads of the metacarpals rather than a t the fingertips ( 1 1). Radial extension will more specifi- cally indicate the extensor carpi radi- alis brevis o r extensor carpi radialis longus. Pain with resisted extension of the middle finger is present when the extensor carpi radialis brevis is involved (53). Tenderness above the epicondyle will indicate that the ex- tensor carpi radialis longus is in-

volved, while anterolateral tender- ness would arise from extensor carpi radialis brevis tissue inflammation. Ulnar extension will provoke the ex- tensor carpi ulnaris. Radial and ul- nar extension involve the extensor digitorum communis, but most au- thors agree that involvement of the extensor digitorum communis o r the extensor carpi ulnaris is rare (3 , l l ) .

T h e onset of pain is usually gradual. T h e force generated by muscle contraction may not produce pain until healing has begun and there is some adhesion between the tendon and the inflamed periosteum ( 1 1). Tendons may heal in a some- what lengthened position, forcing in- tact muscles to absorb a greater

Acupuncfure therapy - - resdted in complete

to marked improvement in

more than 60 % of the cases.

amount of the strain. Other simple diagnostic tests can include the forced elbow extension test, which is usually positive. T h e forearm is held fully pronated and the wrist palmarly flexed; passive elbow extension then produces lateral elbow pain, which may limit full extension of the joint. Grip limited by pain, as measured by dynamometry, has been shown to be yet another reliable and sensitive in- dex of irritibility among patients with lateral epicondylitis (5 1 ) .

Elbow radiographs are usually normal. Ectopic calcification of the lateral epicondyle appears in 25- 50% (25,28) of the cases, but its presence does not appear to alter the prognosis. Radiographs can be ob- tained to eliminate the possibility of arthritic changes at the radiohu-

meral articulation o r tumor within the substance of the supinator mus- cle. Although not advocated as part of the diagnostic work-up, arthros- copic exam may prove valuable in cases resistant to conservative meas- ures and caused by intra-articular problems, such as fibrillation of the radial head ( 1 3). Because lateral epi- condilytis may be part of a general- ized arthropathy with additional joint symptoms, other blood studies, such as erythrocyte sedimentation rate and uric acid concentration, tests for rheumatoid disease, and complete blood count may be war- ranted.

Diagnosis of tennis elbow may be confounded by regional nerve in- volvement, referred to as radial tun- nel syndrome (36). T h e deep branch of the radial nerve may be com- pressed (by pronation and flexion of the wrist) as it passes dorsal to the arcade of Frohse along the fibrous edge of the supinator muscle ( 1 1,29,45,53). Differential signs in- clude increased pain with deep pal- pation of the radial head and isomet- rically resisted supination c f the forearm, suggesting radial tunnel syndrome, as opposed to tenderness to palpation of the lateral epicondyle and isometrically resisted extension of the wrist, signifying true tennis el- bow (29). Lee, as reported by Gunn (29), found increased action poten- tials during electromyographic stud- ies of subjects with radial tunnel syn- drome. Compression may be from abnormal fibrous bands in front of the radial head, the radial recurrent fan of vessels, and the sharp tendin- ous origin of the extensor carpi radi- alis brevis. Rarely, a ganglion o r li- poma may cause compressive neu- ropathy. T h e posterior interosseous nerve may be compressed where it enters the supinator muscle, and 30% of subjects have a well-defined arcade of Frohse, which makes compression neuropathy more likely. Pain is more diffuse in compression neuropathy than in tennis elbow, and tenderness is located in the fore-

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arm musculature distal to the lateral epicondyle a t the level of the radial head. Weakness of extension of the middle finger with the elbow ex- tended can be an important diagnos- tic feature in the compressive neu- ropathy, but it must be differen- tiated from extensor carpi radialis brevis involvement (47). Compres- sion of the posterior interosseous nerve as the cause of tennis elbow is rare. T h e intrinsic factors cited for lateral epicondylitis have been identi- fied in Table 1 . Other conditions that must be considered during the process of differential diagnosis a re presented in Table 2.

Extrinsic Factors

T h e principal extrinsic factor to consider when evaluating a patient with complaint of elbow pain is cer-

Overexertion of wrist extensor muscles (primarily

Lapswar marlon or rne raalonumeral jomt (rw Pinched synovial fold (3,11,26) Radial collateral ligament inflammation (38) Annular ligament fibrosis (3,11,28) Ectopic calcification of lateral epicondyle (25,28) Radiocapitellar joint degeneration (40)

ECRB = Extensor carpi radral~s brews.

TABLE 1. Intrinsic factors cited as causative oilateral ep~condylitis.

Rheumatoid arthritis (blood tests, jl limited motion, erythema, and g are diagnostic features) (1 1,25,5:

Occult fractures of the radial head or lareral

oint instability, eneralized pain I )

I - . I - . . -. . . . - -. -. - - - . . . - . - -. -. . . - - - -. . - . -. -. humeral epicondyle (54)

Posterior epicondylitis at triceps attachment to olecranon (40) -. . . . , . . . . . .

L 'Y "I , O I L lvulvl I lruu \ > , I I,'.",

ong head of the biceps (due to I the radius) (53)

(Jhondromalarm nt thn rmital hnwi I2 11 7x1

Tendinitis of I insertion or

Carpal tunnel Radial tunnel ,ylluluwr \*IUU~. UI ~IUI I ,~-1 \W,WJ

Pannefs disease (avascular necrosis of lateral epicondyle) (54)

Tumor (of capitellum or in the supinator muscle) (54)

TABLE 2. Conditions to be considered in differential diagnosis of lateral epicondylitis.

vical spine dysfunction. Any evalua- tion of the elbow and forearm should include an evaluation of the cervical area for possible radiculop athy o r facet joint syndrome, espe- cially when the pain is resistant to therapy directed a t the elbow (1 1,25,28,29,40,53). T h e derma- tomes and myotomes of the lateral epicondyle and the lateral forearm are supplied by the C 5-6 and C 6-7 nerve roots.

According to Lee (29). nerve root ischemia, secondary to im- proper posture, facet, disc, o r other involvement can cause spontaneous firing of selected large unmyelinated fibers with resultant hyperaesthesia in the related dermatome. Infiltra- tion of the muscle by connective tis- sue may result in rigidity noted dur- ing palpation and is perceived by the patient as a focal point of muscle tenderness that is aggravated by deep palpation. Trigger points in the segmentally innervated spinal muscu- lature may occur. Submaximal con- tractions of the affected cervical muscles will not reproduce deep muscle pain, and there a re usually no complaints of local cervical pain. No abnormal neurological signs are noted, and the exam rarely indenti- fies a cervical contractile tissue le- sion.

A more severe cervical radicu- lopathy will be characterized by seg- mental demyelination of selective nerve endings and decreased nerve conduction velocities (29). Deep muscle tenderness is increased, and a "fatiguing" weakness is noted in re- peated testing of the wrist extensors. If denervation occurs, the collagen becomes weaker and more suscepti- ble to microscopic and macroscopic tears. Muscle weakness and atrophy may be present if denervation has occurred. Submaximal contractions of the wrist extensors a re painful. Fi- nally, Kivi (25) cites psychogenic fac- tors secondary to anxiety and depression to be possible causes of lateral epicondylar and forearm pain.

CONSERVATIVE TREATMENT

Successful conservative treat- ment of lateral epicondylitis gener- ally includes five distinct means of intervention to relieve pain, control inflammation, promote healing, im- prove local and general fitness, and control force loads (37). While the majority of the therapeutic efforts will be directed a t rehabilitation of the wrist extensor mechanism, it is important for the physical therapist to remember that dysfunction at any given site may be the cause of o r the result of dysfunction at a more prox- imal o r distal site. This concept is supported by the notion that lateral epicondylitis may present as a multi- factorial syndrome that will require a full upperquarter examination and possible treatment of proximal and distal areas (29).

Pain

T h e treatment of the patient's pain can be accomplished through a variety of therapeutic modalities (1 7). Cold application, either with ice massage, ice packs, o r ethyl chloride spray, is widely advocated during both the acute and chronic phases of lateral epicondylitis ( 1 7.26.38). Heating modalities such as hot packs, whirlpool, and ultrasound have been used in the subacute and chronic phases ( 1 7,20,38,40). Shortwave and microwave diathermy are considered ineffective in the treatment of over- use injuries such as lateral epicondy- litis ( I 7). Electrical stimulation with transcutaneous electrical nerve stim- ulation units can assist patients with their pain control (17). One of the most commonly used types of electri- cal stimulators in the treatment of lateral epicondylitis is the high-volt- age galvanic stimulator. Nirschl et al report that this modality is more use- ful than ultrasound and second only to ice in effectiveness (37,40).

Bracing is a commonly used form of intervention to assist with pain control. T h e commonly used

Volume 19 Number 6 June 1994 JOSPT

brace is a simple cock-up splint dur- ing the acute stage (1 0,11,25). The purpose of the cock-up splint is to put the wrist extensor mechanism at rest. The most frequently used brace is probably the tennis elbow strap or "counterforce armband" ( 1 4). This type of brace is advocated for con- trolling forces at the lesion site (27.28). Forearm support braces are used throughout the acute and chronic phases of the disease, and their mechanism of function is thought to result from counterforce control (19.37). The actual mode of action and its effect on muscle torque in normal subjects was stud- ied by Stonecipher and Catlin (49), who found no improvement in isoki- netic wrist extensor torque at 30°/sec but significant increases in torque development when tested at 1 20°/sec. In a study by Wadsworth et al (55), application of a counter- force armband was found to increase wrist extension and grip strength in the affected arm of patients with epi- condylitis. This finding is in partial agreement with Stonecipher and Catlin (49) and Burton (6). It was postulated by Wadsworth et al (55) that this increased strength could re- sult from the armband dispersing stress away from the lesion, thus re- ducing further tissue injury and re- lated pain inhibition mechanisms. Pain decrease with armband use was not found to be statistically signifi- cant by Wadsworth et al(55).

Inflammation

Physical therapists often use ice and electrical stimulation in an at- tempt to diminish the inflammatory response associated with this condi- tion. Nonsteroidal anti-inflammatory agents are usually prescribed for 2-3 weeks (28). No particular medication has been found to be superior, and the selection of the medication and its dosage will vary according to the patient's response (28,40). Steroid injections are often used if treatment by oral medication and therapeutic

modalities has failed to reduce the patient's pain and inflammation (28,40). In a study comparing the ef- fectiveness of early steroid injection with the use of splinting and oral medication in treating patients with lateral epicondylitis, Kivi found no significant difference in the treat- ment results (25). In a trial of acu- puncture therapy in patients with lat- eral epicondylitis who had failed to respond to steroid injection, Bratt- berg (5) found that acupuncture therapy resulted in complete to marked improvement in more than 60% of the cases. Chi-square analysis of Brattberg's data indicated that acupuncture was significantly more effective than steroid therapy (5). Halle et al (20) conducted a study comparing the response of patients to four different treatments, includ- ing ultrasound, ultrasound with hy- drocortisone phonophoresis, transcu- taneous electrical nerve stimulation, and steroid injection all accompanied by the same home program of brac- ing, ice, and painful task avoidance. The results from this study showed no significant differences in the treatment outcome (20).

Tissue Healing

Tissue healing is thought to be enhanced by use of therapeutic mo- dalities that promote increased circu- lation to the injured area (1 7). Both ultrasound and high-voltage galvanic stimulation are recommended to as- sist in this process (40). Patients should be encouraged to not overuse their extremity during the acute tis- sue healing phase and to avoid activi- ties that aggravate their symptoms. Patients are reminded that avoid- ance of pain does not necessitate complete immobilization and that gentle, controlled stresses are impor- tant for the appropriate alignment of connective tissue as it heals. This concept is particularly important if the treatment involves the use of ma- nipulative maneuvers such as Mill's or Cyriax's techniques (53). The tis-

sue should not be allowed to heal in a shortened position as this may pre- dispose the patient to recurrence of the condition (1 1). Passive and ac- tive-assisted stretching of the com- mon wrist extensors should be un- dertaken to encourage proper tissue alignment during healing so that such recurrences are avoided.

Transverse or deep friction mas- sage is often used by physical thera- pists for treating lateral epicondylitis. Cyriax believed this helped to pre- vent random binding of newly formed collagen fibers (1 1). Walker's (56) study, using deep friction mas- sage on healing medial collateral knee sprains in rabbits, did not s u p port this contention. Stratford et al (52) did not find deep friction mas- sage superior to no massage in their study with patients with epicondyli- tis.

Muscle Conditioning

Improving fitness should be a key element in the rehabilitation ef- fort. The treatment of the patient's

onse, pain and inflammatory re-p while initially important, does not complete the therapeutic interven- tion. The patient's functional ability should be assessed as thoroughly as possible. Leach and Miller (28) re- ported that the involved extremity will often demonstrate a reduction in passive wrist flexion of 10- 1 5 " when compared with the noninvolved side. If such a reduction in flexion is iden- tified, stretching exercises designed to improve the flexibility of the wrist extensor group should be instituted and continued until wrist range of motion is equal to the uninvolved side. The usual method of instituting strengthening exercises is by means of an intensity-graded protocol ac- cording to the patient's tolerance. These exercise programs should be started early in the treatment to as- sist with appropriate tissue remodel- ing. It is probably appropriate that early strength training should focus on low-load, high-repetition pro-

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grams to avoid symptom aggrava- tion. Strengthening programs may include a combination of isometric, isotonic, and isokinetic exercises. T h e recommended strengthening goal for competitive athletes is that their playing arm wrist extensor strength should be 10% greater than the nondominant arm, while a 5% differential is recommended for the recreational athlete (40). While clini- cal intuition and review of the exist- ing literature suggest the proceeding general guidelines for strength train- ing of patients with lateral epicondy- litis, there is virtually no scientific evidence to document the efficacy of such efforts.

Controlling Force loads

Controlling force loads will be vital both in the early and late treat- ment of lateral epicondylitis and is an important factor when consider- ing preventative measures. Tennis patients with lateral epicondylitis should be encouraged to use a rac- quet with a mid- to large-size head, a lighter weight, and a reduced string tension by 3-5 Ibs (30). T h e hand grip should also be the right size (37). A handle with too small of a diameter will require increased grasp effort, thus presumably increasing the stress upon the wrist extensor muscle attachment. T h e injured player should also play with new ten- nis balls, since old tennis balls re- quire more stroke force to achieve the same velocity. Clay courts, if available, are also helpful because horizontal ball velocity is decreased (30). T h e injured player should also undergo a thorough assessment of his/her playing technique. Stroke patterns that need to be examined include the player's use of weight transfer during all tennis strokes and the backhand stroke, in particular (28,37). In the occupational setting, an ergonomic analysis of task re- quirements is usually beneficial in determining which jobs may be likely to cause increased stress of the wrist

extensor mechanism (I 2). Once identified, these jobs may then be al- tered to reduce the stress loads which may, in turn, decrease the in- cidence of job-related lateral epicon- dylitis. Assessment of playing tech- nique and ergonomic analysis are im- portant not only for treatment of injured clients but for preventing re- petitive overuse injuries as well.

SURGICAL TREATMENT

Various reports indicate that a p proximately 10% of patients with lat- eral epicondylitis will be unrespon- sive to conservative methods (3,4,18,2 1). These patients offer a challenge to the clinician and may ultimately necessitate surgical inter- vention. A final approach prior to surgery is proposed by Wadsworth (53). who suggests that the Mill's ma- nipulation technique should be per- formed with the patient fully relaxed under local anesthesia. T h e tech- nique is performed following an in- jection of 0.5 ml methylprednisolone and 0.5 ml of 2% xylocaine into the extensor carpi radialis brevis tendon. With the anesthetized patient in the supine position, the wrist fully flexed, and the forearm maximally pronated, the patient's elbow is r a p idly and forcefully moved from a po- sition of full flexion to full extension. Wadsworth (53) reported that in over 100 resistant cases over the last 20 years, a repeat manipulation was necessary in only six patients and surgical intervention was needed in only one patient.

Many surgical procedures are currently advocated, with each tech- nique reflecting the differing view concerning the condition's etiology. In 1955, Bosworth (3) presented a study on the role of the annular liga- ment in tennis elbow. A follow-up study was published in 1965 to re- port further experience and com- pare results of various surgical tech- niques. Four operative techniques were performed in his study, which spanned the years of 1939- 1964. T h e techniques were listed by Bos-

worth (3) as follows: 1 ) transverse di- vision of the common extensor ori- gin with distal displacement of annu- lar ligament in 16 elbows (1939- 1953); 2) transverse division of the extensor origin with distal displace- ment of the annular ligament and re- moval of the synovial fringe in two elbows (1 949- 1953); 3) transverse division of the extensor origin and resection of the annular ligament in 16 elbows (1 943-1 963); and 4) ver- tical incision of the extensor origin in line with its fibers, with resection of the annular ligament and repair of the common origin in 28 elbows (1 953-1 964). Bosworth reported good results with all techniques, al- though the technique involving divi- sion of the extensor origin and distal displacement of the annular ligament was abandoned secondary to pro- longed periods of recovery. In re- cent years, numerous authors have published studies reporting the effi- cacy of the simple lateral release treatment first described by Bos- worth (2.7.44).

Boyd and McLeod (4) are propo- nents of what is termed tile Bos- worth 111 procedure. This involves excision of the extensor muscle ori- gin; bursa, if present; and the syno- vial fringe. Their report in 1973 claimed pain relief in all but a few patients. Full recovery was generally reported in 2-4 months.

Goldie (1 8) used a complete re- lease of the common extensor ten- don, which permits an approximate 1 cm distal muscle slide to a new resting length. He reported "excel- lent" results in 73% of cases, "good" results in la%, and 9% were "fail- ures" (1 8).

Garden (1 5) published an article in 196 1 describing a simple surgical technique involving lengthening of the extensor carpi radialis brevis ten- don just lateral to the wrist. He be- lieved that the extensor carpi radialis brevis was predominantly responsible for the condition and that release of tension on this tendon would result in the resolution of symptoms.

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In 1 968, Carroll and Jorgensen (9) reported "poor" results using Garden's procedure. In 1 978, how- ever, Stovell (50) claimed "excellent" results for 16 of 18 patients, with the technique supported for its simplic- ity, effectiveness, and short recovery period.

Nirschl and Pettrone (39) advo- cate a procedure in which the degen- erated extensor carpi radialis brevis origin is resected, and decortication of the lateral epicondyle is accom- plished. A 1987 report by Leach and Miller (28) supports this procedure after following it for a decade. They reported relief of pain symptoms in over 90% of the cases.

Spencer and Herndon (46) de- scribed a simple fasciotomy of the extensor origin as a surgical ap- proach for lateral epicondylitis. They reported "excellent" or "good" re- sults in 96% of the 23 patients stud- ied. A long-term follow-up study was published on this technique by Posch et al (42). who reported "excellent" or "good" results in 3 1 of 35 pa- tients. The authors recommended the simple fasciotomy because of its simplicity, minimal complications, and general rapid recovery of 3-4 weeks.

Kaplan (23) was the first to sug- gest that the radial nerve was in- volved, though not specifically en- trapped, in the syndrome known as tennis elbow. His gross dissection study revealed that the radial nerve innervated nearly all of the tissues (including the periosteum) in the re- gion of pain complaints by patients with lateral epicondylitis. Conse- quently, he proposed surgically in- terrupting most of the articular nerve supply to the lateral epicon- dyle to provide relief of symptoms for such patients. He reported three cases in which his denervation tech- nique was successfully applied (23), but we are unaware of any report of a prospective, randomized clinical trial in which this procedure has been explored further.

Roles and Maudsley (43) pro-

posed radial nerve entrapment as a possible cause of resistant tennis el- bow. Compression of the radial nerve was believed to occur at four clinically diagnosable sites. The cor- rective surgical technique they de- scribed involves dividing the deep fascia and freeing the superficial ra- dial nerve and posterior interosseous nerve along their courses. Lister et al (31) described an anterior trans- brachioradialis approach that ex- poses the compression sites. They re- ported "excellent" or "good" results in 19 of 20 cases, while Roles and Maudsley (43) reported "excellent" or "good" results in 35 of 38 cases.

This brief surgical review high- lights the primary approaches cur- rently being used in the intervention of resistant tennis elbow. As noted previously, the proponents for these various surgical techniques advocate the procedure on the basis of their understanding of the primary cause and focus of tissue of lateral epicon- dylitis. Conclusive data documenting superior efficacy of one or another of these procedures is, as yet, un- available.

SUMMARY

In most cases, lateral epicondyli- tis is a self-limiting condition that will generally resolve within 1 year (1 5). However, the condition can be quite disabling and cause significant impairment of function. This impair- ment of function will most readily manifest itself as pain in the elbow and lateral proximal forearm associ- ated with forceful gripping or wrist extension (repetitive microtrauma). Fortunately, the vast majority of pa- tients (89-97.376) respond readily to conservative or nonoperative treat- ment (4,10,25). For patients who fail conservative treatment, a wide vari- ety of surgical procedures that dem- onstrate a high success rate exist (3,15,28,43,46). A vital component of any treatment program is patient counseling and task analysis to avoid reinjuring the extensor mechanism,

along with a graded exercise pro- gram to provide controlled stresses to assist in tissue remodeling. JOSPT

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