Oct 10, 2014

Lateral Elbow Pain - Tennis Elbow? - A Spectrum Physio Approach


Dr. E. Praveen. M.P.T (Musculoskeletal Physiotherapy) 
Head of the department,  Spectrum Physio Centre
                  Sita Bhateja Speciality Hospital, Bangalore.

Lateral elbow pain is a common clinical problem and mostly misdiagnosed as tennis elbow in clinical scenario. Physiotherapy diagnosis is an looking an anotomical and therapeutic way of pain contributing mecahnism to estabilish the physiotheray treatment, which is inevitable process in clinical decision making process for lateral elbow pain. Lateral elbow pain can occur because of variety of reasons, Because of the multifactorial nature of the condition it is essential that an accurate diagnosis is established early and that a management plan is instigated. 

Tennis elbow can be defined as “Chronic overuse syndrome affecting the common extensor origin at lateral humeral epicondyle, resulting in localized pain tenderness and painful movements of wrist and forearm”
The initial assessment of patients with acute and subacute elbow problems should focus on detecting clinical indications of potentially serious disease, termed red flags, and determining an accurate diagnosis. In absence  of redflag, Physiotherapist must access the pain controbuting factors to make the treatment oriented physiotherapeutic diagnosis.

Pathophysiology of Tennis elbow (Nirschi & Pettrone 1979) Microscopic tear of ECRB due to Reparative mechanism (angioblastic hyperplasia), which leads to Macroscopic tear of ECRB Muscle. ECRB Tear makes the structural failure Radio humeral bursitis periosteal reaction, which cause tennis elbow.           
Stages of tennis elbow (Nirschi & pettrone 1979)
Stage 1 - Inflammatory changes that are reversible
Stage 2 - Nonreversible pathologic changes to origin of the ECRB muscle
Stage 3 - Rupture of ECRB muscle origin
Stage 4 - Secondary changes such as fibrosis or calcification

Presence of swelling indicates Arthritis, Synovitis, Infection, Trauma or Tumour. Swelling, night pain and any patient dose not reflecting the clear therapeutic diagnosis need to send for expert orthopaedic opinion for acute medical management.

Lateral elbow – from physiotherapeutic perspective.  
Physiotherapeutic diagnosis
Physiotherapy Treatment plan
Cervical spine dysfunction – Cervical disc lesion which entrap the cervical nerve roots
Cervical Mobilization Techniques,
PIN Entrapment / Supinator syndrome – Where the supinator muscle strain compress the posterior interossei nerve near elbow cause elbow pain.
Supinator MET, Neural mobilization, Physical modalities
Habitual anterior translation of radius – More anterior translation of radius during
elbow flexion cause elbow pain
Mulligan posterior glide for elbow and mulligan tapping
Real Tennis elbow –
Tendo periosteal inflammation/               Myo tendineous inflammation due to over stain
Therapeutic ultrasound therapy, TENS, Rigid tape, Brace, Rest,
ECRL /ECRB Strain muscle strain
Acute elbow pain after the sudden overuse of elbow joint. 
TENS, Cyriax mobilization, Mills manual therapy,  Tennis elbow band
Myofacial Trigger point  - Presence of TrPt   at  Supinator, Brachioradialis, Extensor carpi radialis longus, Triceps brachii, Supraspinatus, Anconeus leads to later elbow pain.
Trigger point treatment approaches like Dry Needling, trigger point therapy, instrument assisted MFR, T Bar, Muscle energy technique…
Neural mobility – Neural shortening due to inadequate stretching and neural mobility issues also leads to nerve root pain and elbow pain. (ULTT2B Radial nerve)
Neural stretches, Neural sliding, Nerve tissue mobilization approaches.
Wrist ligament injury- Traumatic wrist injury and RSI of wrist can also leads to radiating pain and overuse injury of wrist muscles.
Wrist immobilisers, Electrotherapy and thermotherapy treatment for wrist  
Degenerative arthritis -  Rheumatoid arthritis, Gout arthritis, Pseudo osteoarthritis can cause elbow pain 
Electrotherapy and thermotherapy treatment for wrist.
Olecranon bursitis – Popularly known as student elbow due to direct constant contact pressure at elbow
Rest, patient education, Electrotherapy and thermotherapy treatment
Cubital Tunnel Syndrome and Radial Tunnel Syndrome – Common nerve entrapment at forearm cause elbow pain.
Ergonomics advice, Nerve glides exercise, stretching and strengthening, Electrotherapy and thermotherapy treatment.

All the elbow pains are not tennis elbow and lateral elbow pain must be comprehensively assessed and critically analysed. Physiotherapeutic diagnosis of elbow pain must guide the physiotherapist in clinical decision making process of treatment selection in clinical practise.