Literature Review: Lateral Elbow Tendinopathy

Differential Diagnoses
Joint	Local arthritis	℗ at Rest
Joint	Intra-articular pathology	Clicking with motion, Locking in Extension & Catching
Joint	Radiocapitellar Chondromalacia	℗ from throwing or racquet sports; valgus stress Clicking & Snapping Compression Test: Patient holds palm down & supinates & pronates fully extended arm
Nerve	Radial Tunnel Syndrome (RTS) & Posterior Interosseus Nerve (PIN) Entrapment	RTS: anatomy: from the level of the radiocapitellar joint, extending distally past the proximal edge of the supinator Night ℗ Localized tenderness over radial nerve 5cm distal to lateral epicondyle PIN: anatomy: branch of the radial nerve that provides motor innervation to the extensor compartment Strength deficits of extensor musculature Weakness in finger, wrist & thumb movements Impaired ability to extend thumb (DeQuervain’s tendinopathy) Impaired ability to extend wrist in neutral or ulnar deviation Tests: Resisted Hyperextension of Wrist (Cozen’s Sign) → ℗ in proximal radial forearm & over radial tunnel Resisted Supination (with wrist flexed) → ℗ in proximal radial forearm & over radial tunnel Passive Pronation, applying pressure on the posterior interosseous nerve → ℗ in proximal radial forearm & over radial tunnel + S1 supinator Resisted Extension of Middle Finger, Extended Elbow (Maudsley’s Test) → ℗ Neurodynamic Tension Test
Nerve	Cervical Referred ℗ or C5 Radiculopathy	Nerve Root; Disc Hernia Type of ℗ can vary Tests: Axial Loading (Spurling manoeuvre) Shoulder abduction relief (Bakody’s Sign) → ↓℗ Neck Distraction Valsalva manoeuvre Neurodynamic Tension Test
Ligament	Posterolateral Rotatory Instability (PLRI)	persistent insufficiency of LCL complex, particularly the lateral ulnar collateral ligament ℗ from trauma causing elbow subluxation or dislocation Tests: Posterolateral Pivot Shift (O’Driscoll’s Sign) (supine, arm overhead; supination & valgus with axial compression) → radial head subluxes at 40⁰ elbow flexion Posterolateral Rotary Drawer Test (supine, arm overhead, elbow flexed 40-90⁰)
Tendon	Extensor Tendinopathy Lateral Epicondylalgia	Tests: Tenderness on palpation over the lateral epicondyle Resisted Hyperextension of Wrist (Cozen’s Sign) → ℗ Resisted Supination (with wrist flexed) → PB Passive Wrist Flexion with Radial Deviation (Mill’s Test) → ℗ Passive Elbow Extension → ℗ Resisted Extension of Middle Finger, Extended Elbow (Maudsley’s Test) → ℗ Grip Strength Weakness

Stages of Tendinopathy
Tenosynovitis inflammation of tendon & tendon sheath ℗ worse with activity
Tendinosis response to an overuse injury resulting in a pathologic cascade of changes in normal tendon reparative process described as a cycle of degeneration & attempted failed regeneration ℗ worse @ night
Reactive Tendinopathy	Non-inflammatory proliferative response, which is a short-term adaptive thickening in an attempt to reduce stresses Generally follows a period of acute overload or direct blow Fusiform swelling
Tendon Dysrepair	Loss of parallel & longitudinal alignment of collagen bundles Neurovascular ingrowth/proliferation from failed healing response Increase matrix disorganization & evident swelling Increased Tendon Thickening → ℗
Degenerative Tendinopathy	Degenerative Changes Extensive compromise of the tendon

Management of Tendinopathy
Risk Level	Prognosis	Treatment Modalities
High Risk	Co-existing neck or shoulder ℗ Central Sensitization	Prescribed meds Ergonomic/sport-specific advice Ice, heat, taping, brace, orthoses Electrophysical agents* Cervical and/or elbow manual therapy Exercise therapy (isometric contractions†)
Moderate Risk	Repetitive manual loads Co-existing elbow pathology Neuromuscular impairments	Self-administered meds Ergonomic/sport-specific advice Ice, heat, taping, brace, orthoses Electrophysical agents* Elbow manual therapy Exercise therapy (progressive resistance‡, motor control, general upper limb)
Low Risk		General advice to reduce loads Self-administered meds Ice, heat
* EPAs include: cold (cryotherapy), heat (superficial thermal agents), electrical stimulation (TENS, NMES, HVPC), low-level laser therapy, short-wave diathermy, and therapeutic ultrasound
† Isometric contractions: wrist 20-30⁰ ext, elbow 90⁰ flex, 30-60 sec in duration
‡ Concentric/Eccentric loading: 2-3 sets of 10 reps, 4 sec for each direction Emphasis is placed on maintaining neutral radial-ulnar deviation of the wrist Progressions: (1) Increase load; (2) Greater elbow extension

References
Coombes, B.K., Bisset, L. and Vicenzino, B. (2015) ‘Management of Lateral Elbow Tendinopathy: One size does not fit all’, Journal of Orthopaedic & Sports Physical Therapy, 45(11), pp. 938–949. doi: 10.2519/jospt.2015.5841.