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.

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