William J. Coon, ATC/L, PTA, CSCS, EMT
The general purpose of this article is to stimulate the ongoing thought process of each individual clinician while treating patients in outpatient orthopaedic setting. It is not designed to replace other crucial treatment techniques, but rather add to the clinicians already established base treatment skills.
The focus pathology in this case is lateral epicondylitis. We have all treated patients with this pathology at some point in our careers. Has anyone noticed that these patients tend to return to your clinic after a year or so, even after complete symptom deprivation at the time of discharge? Despite activity modification, work place ergonomic training/setup, and a complete home exercise program, these patients can become repeat customers. If a patient is returning to your clinic despite having previously accomplished past goals and is again symptomatic, that tells me that the source or true cause of the problem has not been accurately identified and was likely treated in symptomatic fashion.
Over the years I have found that poor posture, malalignment, and joint hypomobility in combination can be the cause of lateral epicondylitis. Once these factors are corrected the patient should essentially remain asymptomatic.
Typically the patient will present with increased forward head posturing, increased thoracic kyphosis, increased scapular protraction, and increased internal rotation of the humerus with increased anterior malalignment of the humeral head. This poor posturing will place the glenohumeral joint in a position of extension allowing for increased elbow flexion in a resting position. With the elbow remaining in a prolonged static position of flexion the bicep will ultimately have decreased soft tissue length and now presents in a dominant and problematic manner with increased tone and strength as compared to the antagonist triceps muscle. The agonist – antagonist relationship has now been disrupted leading to malalignment or as Brian Mulligan termed it, “Positional Fault”.
With the poor posture previously described and the increased tone and strength of the bicep as compared to the triceps now identified brings us to the issue of malalignment. With the bicep now being dominant, it will impart a valgus stress or valgus static positioning to the ginglymus, humeroulnar joint. The extensor carpi radialis longus will now slightly shorten and have an altered angle of pull. With this improper alignment there will be increased compression at the humeroradial joint and an associated anterior “positional fault” of the radial head secondary to the insertion of the now overly dominant bicep into the radial tuberosity and bicipital aponeurosis.
The poor posture and malalignment now leads us to joint hypomoblity. Being that humeroradial joint is compressed and the radius now rests slightly anteriorly as compared to the capitulum of the humerus, the synovial joint capsule will present with restriction over time. This restriction should/can be graded using Kaltenborn’s Classification.
A general conditioning and postural re-education program can be utilized to address deficits. Stretching to the anterior musculature with decreased soft tissue length such as the pectoralis major/minor, and the biceps along with strengthening of the posterior musculature is warranted to decrease scapular protraction, and malignment at the glenohumeral joint. Cervical retractions and isometrics for increased forward head posturing, and thoracic extension exercises for increased thoracic kyphosis are examples of some exercises that can be applied. The exercises chosen are left to the discretion of the treating clinician and should be directly related to the specific posturing of each individual patient.
I have adapted a mobilization technique with Brian Mulligan’s mobilization with movement (MWM) principle that is performed with the intention of decreasing the valgus alignment or carrying angle at the humeroulnar joint.
The mobilization is performed with the patient in supine. If it is the right extremity that is affected, the clinician shall cradle the distal extremity under their right forearm while grasping the proximal ulna with their right hand and the lateral epicondyle with their left hand. This should be performed or initiated in around 60-70 degrees of flexion which is the loose –packed position for the humeroulnar joint. A varus stress is then applied. When the alignment/varus stress has been applied the patient will actively extend the elbow against slight resistance of the clinician’s right forearm that is cradling the distal extremity from the 70 degrees of flexion to full or near full extension. This will activate the triceps to dynamically stabilize the joint in a decreased valgus malalignment.
After corrections have been made for poor posture and malalignment, joint hypomobility can now be addressed. The intention of this anterior to posterior mobilization is the decrease the previously mentioned capsular restrictions at the humeroradial joint. We know this joint will be hypomobile and that the radial head will be resting slightly anteriorly in relation to the capitulum.
This mobilization is performed with the patient in supine and the elbow at or near full extension. This is important because this is the loose-packed position for the humeroradial joint. The radial head is identified with deep palpation anteriorly. I tend to use my thumbs to apply the appropriate glide although the treating clinician may also use the hypothenar eminence of their left hand if it is the right side affected or vice versa. A posterior glide is then applied to the radial head on the capitulum of the humerus. Grading is dependent on the specific restrictions noted by the treating clinician.
It is important to note that manual muscle testing of the extensor carpi radialis longus should be performed before and after the mobilization to determine the effectiveness of the treatment. You as the treating clinician will be delightfully surprised at the increased grade of manual muscle testing with decreased pain that will follow if this protocol if executed properly.
© 2010 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
Lateral epicondylitis, also known as tennis elbow, is a very common condition that most commonly affects patients in their 40’s and 50’s but can affect any age. Patients may first notice the condition following some type of vigorous activity including sporting activities, such as racket sports, or heavy labor. It also can occur with repetitive work such as typing and computer usage.
Patients typically present with a pain on the lateral aspect of the elbow. Patients will often have a difficult time picking up heavy objects with an extended elbow. Very commonly patients will report pain with lifting a gallon of milk or a cup of coffee. Patients also experience pain with gripping, including shaking hands and often have discomfort when they fully extend their elbow. Numbness and tingling is not commonly seen in conjunction with this condition and if present an alternative diagnosis should be considered.
The most common structure implicated in the pathology of tennis elbow is the extensor carpi radialis brevis (ECRB) but other contributions including intra-articular synovitis and plica have been implicated. The tissue of the ECRB is pathologic in tennis elbow and demonstrates an angiofibroblastic dysplsia with mucoid degeneration and neovascularization when examined under a microscope.
Differential diagnosis for lateral elbow pain can include less common diagnoses such as radial tunnel syndrome, posterolateral plica, and posterolateral rotary instability. Presence of mechanical symptoms such as clicking, popping and a feeling of instability is not present with lateral epicondylitis and alternative diagnosis should be investigated. Patients previously treated for lateral epicondylitis with surgery or repeated injections should be carefully examined for damage to the lateral ligament complex with resultant instability.
Normal range of motion of the elbow is normally encountered, however, patients often have pain when they attempt to fully extend the effected elbow. This finding is due to the fact that the primary tendon involved, the extensor carpi radialis brevis (ECRB), crosses the elbow joint and is at maximal stretch when the elbow is fully extended. Weakness and pain are seen with resisted wrist extension as well as strong grip such as seen with a firm handshake. The area of maximal tenderness is seen over the lateral epicondyle of the humerus and will often radiate distally with the forearm extensors.
Radiographs of the elbow are typically normal without signs of arthritis or subluxation. Calcification can sometimes be seen surrounding the lateral epicondyle which can indicate patients that may be more recalcitrant to non-operative intervention.
Ultrasound imaging can display interstitial tearing and fluid over the lateral epicondyle. Increased vascularity can also be seen utilizing the color Doppler function with ultrasound.
MRI of the elbow while not usually necessary for the diagnosis but will demonstrate abnormalities in greater than 90% of cases. These MRI’s will with often demonstrate increased signal on T2 weighted images and edema surrounding the lateral epicondyle and ECRB.
Most patients who are newly diagnosed with lateral epicondylitis will notice improvement over a one to two year time period. A recent study demonstrated 80% of patients reported improved symptoms over a one year time period. A small percentage of patients, approximately 10%, will fail non-operative treatment and will go on to require surgical intervention.
Non-steroidal anti-inflammatories (NSAIDS) can initially be used on a scheduled basis to mitigate and improve symptoms. Orally administered has been shown to be more effective than topical but the latter can sometimes be used in patients who cannot tolerate symptoms with the oral application. Voltaren which is the topical version of diclofenac has the same side effects as other NSAIDS but with only a 6% systemic absorption can lessen some symptoms.
Physical therapy can be successfully utilized to reduce symptoms, increase strength, improve flexibility, allows healing and return to activities. Eccentric stretching and strengthening programs have been shown to reduce symptoms and induce hypertrophy of the myotendinous unit thereby reducing strain on the tendon.
Platelet rich plasma injections have been shown to be effective in the treatment in lateral epicondylitis. Randomized clinical trials have shown superiority of PRP to steroid injections both at one and two year intervals. PRP is an autologous blood product where platelets along with growth factors are concentrated in a centrifugation process. This concentration of platelet rich plasma is then injected into the ECRB origin releasing these growth factors and inciting a healing response. This modality has been used for various indications but has demonstrated significant promise for tennis elbow.
Steroid injections can often be incorporated into a multimodal approach to the treatment of lateral epicondylitis. A direct injection into the ECRB or a needling technique can be utilized. Studies have shown improvement in a patient’s symptoms over a three to six month time period. Long term benefits of injections for lateral epicondylitis are less clear. The effects of steroid injection seem to offer short term relief of symptoms and likely, last less than 3 months. It has been shown that PRP injections have been superior to corticosteroid at both one and two year intervals. Certainly, repeated injections over a period of time can have negative effects causing iatrogenic injury to the lateral collateral ligament complex and can lead to instability.
Counterforce braces worn around the proximal forearm are used to unload the pathologic area surrounding the lateral epicondyle. These braces can often help to improve symptoms by allowing the effected area to rest and prevent overuse. Wrist braces have also been advocated and acts to prevent the active use of wrist extensors. Both can be utilized to minimize clinical symptoms.
For patients who have failed non-operative treatment including all the aforementioned modalities will often benefit from surgical intervention. This can include both open and arthroscopic intervention. Arthroscopic intervention has the benefit of being able to assess all intra-articular pathology at the time of surgery than can be missed by MRI. When additional pathology is encountered such as an intra-articular plica or loose body it can be addressed concomitantly at the time of surgery.
Surgical outcomes are good with a low complication rate. Over 90 percent of patients will report feeling improved compared to how they felt before surgery but complete resolution of all symptoms is somewhat more guarded with 60-80 percent of patients reporting this.
The typical post-operative regimen includes splint immobilization for the first 48 hours followed by range of motion exercises. Physical therapy begins after the first post-operative visit at 10 days and gradual transition to a strengthening program begins at 6 weeks.