Lateral Epicondylitis

LATERAL
EPICONDYLITIS &
TENNIS ELBOW
...INTRODUCTION
• Overuse injury that results in micro tearing &
scar tissue formation of the common wrist
extensor tissue.
• Peak incidence between the ages of 40 & 50.
• 50% of all tennis players experience tennis
elbow .
By Saravanan Krishnan
…ANATOMY
…ANATOMY
…ANATOMY
…DEFINITION
Inflammation of the tissue at the lower end of the
humerous at the elbow joint, caused by the
repetitive flexion & extension of the wrist against
resistance is called lateral epicondylitis (LE).
The primary structure involved:‐
Is the tendon of the ECRB muscle & less
frequently, the ECRL muscle.
…PREVELANCE
Although tennis elbow commonly affects tennis
players, it also affects other athletes & people
who participate in leisure / work activities that
require repetitive arm, elbow, & wrist movement.
Examples include golfers, baseball players,

bowlers, gardeners / landscapers, house / office
cleaners (because of vacuuming, sweeping &
scrubbing), carpenters, mechanics, & assembly‐
line workers.
…AETIOLOGY
• Occurs idiopathically.
• Primarily considered to be a mechanical

disorder of the elbow.
• Onset of pain usually occurs due to exertion

i.e. characterized by repetitive / forced
extension of the wrist combined with
squeezing / grasping.
…RISK FACTORS
1. Intrinsic tendon overuse
2. Inadequate conditioning
3. Constitutional Factors
4. Decreased flexibility of muscles
5. Physical activities
6. Forceful grasping
7. Tennis player with poor playing style
8. Poor backhand stroke
9. Incorrect equipment
…PATHOMECHANICS
• Acute traumatic origin.
• Micro damage is increased due to increased
internal strain to tendon fibers over time.
• Occur with normal activity levels if the

tendons capacity to attenuate tensile loads
is reduced.
…TYPES
• Type 1: A lesion of the muscular origin of the
ECRL , just proximal to the lateral epicondyle.
• Type 2: Is the most frequent type of tennis
elbow. It is an insertion tendinopathy of the
ECRB
• Type 3: A tendonitis of the
ECRB tendon at the level of
the radial head.
Cont...
…TYPES
y Type 4: A sprain of the musculotendinous
junction / proximal part of
the muscle belly of the ECRB.
y Type 5: Occurs frequently.
The origin of the ED at the
laterodistal aspect of the
lateral epicondyle is affected.
…CLINICAL PRESENTATION
• SIGNS:
• Pain ie localized at the anterior aspect of the
lateral epicondyle.
• Exertion, characterized by repetitive/ forced
extension of the wrist
• Pain with athletic activity
• Pain with movement
• Pain when forcibly gripping an object or lifting
…SYMPTOMS
• Pain may radiate down the dorsal aspect of
the forearm to the wrist / the dorsum of the
hand, & sometimes the middle & ring fingers.
• Occasional dysesthesia / numbness from the

elbow to the hand .
• A limitation of ADL due to severe symptoms

may result in approximately 1/3rd of cases.
…CLINICAL FINDINGS
• Well‐localized tenderness is present at the
lateral epicondyle .
• Myofascial trigger points in the wrist extensor
muscles .
• Due to fibrosis & loss of tissue extensibility,

there may be a loss of passive wrist flexion.
…SPECIAL TEST
• Mills’ test : A passive stretch of the extensor
tendons produced by full elbow extension,
forearm pronation, wrist flexion & ulna
deviation.
• Cozen’s Test : Resisted extension of the wrist

performed with the elbow & wrist fully
extended & pronated.
• Maudsley’s Test : Resisted extension of the

middle finger with the elbow fully extended.
…SPECIAL TEST
Kaplan’s Test :
• With the upper limb extended straight forward, the
patient squeezes a grip strength dynanometer as
hard as possible.
• The test is then repeated with the examiner firmly

encircling the patient’s forearm with both hands (1‐2
inches below the antecubital crease).
• A positive test for lateral epicondylitis is indicated if

the induced pain is reduced & the grip strength is
increased when the muscles of the proximal forearm
are compressed.
…EVIDENCE
The Short‐term Efficacy of Laser, Brace, & Us
Treatment in LE : A Prospective, Randomized,
Controlled Trial.
Oznur Oken
AIM: To evaluate the effects of LLLT & to compare these
with the effects of brace / US treatment in tennis elbow.
RESULTS: In patients with LE, a brace has a shorter

beneficial effect than US & laser therapy in reducing
pain, & that laser therapy is more effective than the
brace & US treatment in improving grip strength.
…EFFECT OF OEMT ON LE
JOURNAL OF HAND THERAPY
JULY 2008, Mohammed Reza
AIM:
To investigate the effect of OMET on pain , grip
strength & functional abilities of subjects with
chronic LE.
OUTCOME MEASURE:
Dynamometer, patient specific functional scale,
numerical rating scale.
…EFFECT OF OEMT ON LE
RESULTS:
OEMT seems to be viable, effective & efficient
alternative treatment for LE.
COMPARISON OF EFFECTS OF CYRIAX PT
, A SUPERVISED EXS. PROGRAM &
POLARISED POLYCHROMATIC NON -
COHERENT LIGHT FOR RX OF LE
Clinical Rehab 2006 Dimitrios Stasinopoulos
AIM:
To compare effectiveness of cyriax physiotherapy,
a supervised exercise programme & polarized
polychromatic non‐coherent light in treatment of
LE.
Cont….
…COMPARISON OF EFFECTS
OUTCOMES:
Pain was evaluated using a VAS & function using
VAS & pain free grip strength.
CONCLUSION:
The supervised exercise programme should be 1st
treatment option for therapist when they manage
LE patients. If this is not possible cyriax
physiotherapy & polarized polychromatic non‐
coherent light may be suitable.
SHOCK WAVE THERAPY FOR
PATIENTS WITH LE OF ELBOW
Ching‐ Jen wang. Am J Sports Med 2000.
HYPOTHESIS:
SWT is an effective treatment treatment for patients
with LE of elbow & long‐ term results will be favorable
as short‐term ones.
CONCLUSION:
SWT is safe & effective modality in treatment of
patients with LE of elbow.
NO EFFECT OF FOREARM BAND &
EXTENSOR STRENGTHENING EXS
FOR RX OF LE
Rolf luginbuhl Feb’08
AIM:
To analyse the effect of forearm support band & of
strengthening exercises for Rx of LE.
CONCLUSION:
No beneficial influence was found either for
strengthening exercise or for forearm support band.
Improvement seems to occur with time, independent
of method of treatment used. By Saravanan Krishnan
…NO EFFECT OF FOREARM
OUTCOMES:
Pain was evaluated using a VAS & function
using VAS & pain free grip strength.
CONCLUSION:
The supervised exercise programme should be 1st
treatment option for therapist when they manage
LE patients. If this is not possible cyriax
physiotherapy & polarized polychromatic non‐
coherent light may be suitable.
SHOCK WAVE THERAPY FOR
PATIENTS WITH LE OF ELBOW
Ching‐ jen wang. Am J Sports Med 2000.
HYPOTHESIS:
SWT is an effective treatment for patients with LE of
elbow & long‐ term results will be favorable as short‐
term ones.
CONCLUSION:
SWT is safe & effective modality in treatment of
patients with LE of elbow.
NO EFFECT OF FOREARM BAND &
EXTENSOR STRENGTHENING EXS
FOR RX OF LE
Rolf luginbuhl Feb’08
AIM:
To analyse the effect of forearm support band & of
strengthening exercises for Rx of LE.
CONCLUSION:
No beneficial influence was found either for
strengthening exercise or for forearm support band.
Improvement seems to occur with time, independent
of method of treatment used.
AN EXS PROGRAMME FOR THE MX OF LE
British Journal of Sports Medicine 2005
D Stasinopoulos, K Stasinopoulou, M I Johnson
AIM:
To describe the use & effects of strengthening &

stretching exercise programme’s in the treatment
of LET.
Cont…
AN EXS PROGRAMME FOR THE MX OF LE
Discussion:
• A well designed trial is needed to study the
effectiveness of a supervised exercise programme
for LET consisting of eccentric a& static stretching
exercises.
• The issues relating to the supervised exercise

programme should be defined so that therapists
can replicate the programme.
EFFECTS OF LLLT & PLYOMETRIC
EXS IN Rx OF LE
Photomedicine & Laser Surgery. June 2007
Apostolos Stergioulas
Objective:
This study was undertaken to compare the
effectiveness of a protocol of combination of laser
with plyometric exercises & a protocol of placebo
laser with the same program, in the treatment of
tennis elbow.
FFECTS OF LLLT & PLYOMETRIC
EXS IN Rx OF LE
Conclusion:
The results suggested that the combination
of laser with plyometric exercises was more
effective treatment than placebo laser with
the same Plyometric
exercises at the end of
the treatment as well as
at the follow‐up.
A RCT OF EXTRACORPOREAL
SWT FOR LE
Margret P. Staples, Andrew Forbes
JOURNAL OF RHEUMATOLOGY,2005
Objective:
The aims of this double‐blind, randomized,
placebo ‐ controlled trial were to determine
whether US ‐guided extracorporeal
SWT(ESWT) reduced pain & improved
function in patients with LE in the short term &
intermediate term.
SWT FOR LE
Margret P. Staples, Andrew Forbes
JOURNAL OF RHEUMATOLOGY, 2005
Objective:
The aims of this double‐blind, randomized,
placebo‐controlled trial were to determine
whether US‐guided extracorporeal SWT(ESWT)
reduced pain & improved function in patients
with LE in the short term & intermediate term.
SWT FOR LE
Conclusion:
Our study found little evidence to support the use
of ESWT for the treatment of lateral epicondylitis.
AN ISOKINETIC ECCENTRIC PROG.
FOR Mx OF CHRONIC LE
British Journal of Sports Medicine, April 2007.
Croisier, Jean‐Louis
Objective:
To compare the outcome of patients performing
an isokinetic eccentric training with that of age,
gender, activity‐matched patients receiving a
non‐strengthening classical rehabilitation.
Cont…
AN ISOKINETIC ECCENTRIC PROG.
FOR Mx OF CHRONIC LE
Conclusion:
These results highlight the
relevance of implementing
isokinetic adapted eccentric
training in the management
of chronic lateral epicondylar
tendinopathy
AN ALTERNATIVE APPROACH TO TREAT
LE: A RANDOMIZED , PLACEBO-
CONTROLLED, DOUBLE – BLINDED STUDY
Clinical Rehab 2008
Reza Nourbakhsh , Fearon
OBJECTIVE:
To investigate the effect of noxious level ES on pain,
grip strength & functional abilities in subjects with
chronic LE.
DESIGN:
Randomized, placebo – control, double‐blinded study.
AN ALTERNATIVE APPROACH TO TREAT
LE: A RANDOMIZED , PLACEBO -
CONTROLLED, DOUBLE – BLINDED STUDY
MAIN MEASUREMENTS:
Grip strength, functional status, pain intensity &
limited activity due to pain were assessed before
& after treatment.
CONCLUSION:
The results of this study indicated that symptoms
of chronic LE could be effectively treated by
noxious level low‐frequency ES.

Lateral Epicondylitis

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Lateral Epicondylitis

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LATERAL

Examples include golfers, baseball players,

• Primarily considered to be a mechanical

• Onset of pain usually occurs due to exertion

• Occur with normal activity levels if the

• Occasional dysesthesia / numbness from the

• A limitation of ADL due to severe symptoms

• Due to fibrosis & loss of tissue extensibility,

• Cozen’s Test : Resisted extension of the wrist

• Maudsley’s Test : Resisted extension of the

• The test is then repeated with the examiner firmly

• A positive test for lateral epicondylitis is indicated if

RESULTS: In patients with LE, a brace has a shorter

To describe the use & effects of strengthening &

• The issues relating to the supervised exercise

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