EPICONDYLITIS

EPICONDYLITIS
 A chronic, painful condition that is caused by excessive,
repetitive extension, flexion, pronation, and supination
motions of the forearm.
 These motions result in inflammation (TENDONITIS) and
minor tears in the tendons at the origin of the muscles on
the lateral or medial epicondyles.
 Lateral epicondylitis (i.e., tennis elbow) is frequently
identified in someone who repeatedly extends the wrist
with supination of the forearm. Pain develops over the
lateral epicodyle and in the extensor muscles. Medial
epicondylitis (i.e., golfer’s elbow) is consistent with
repetitive wrist flexion and pronation of the arm.
 Extreme tenderness occurs at the medial epicondyle.
 PATHOPHYSIOLOGY
 Microtears in the muscles originating at the elbow are the likely pathologic process
resulting in the symptoms of both lateral and medial epicondylitis.  In lateral
epicondylitis, lesions commonly occur within the origin of the extensor carpi radialis
brevis, but may also originate in the extensor digitorum communis or extensor carpi
radialis longus tendon.  In medial epicondylitis, lesions may occur in the pronator
teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor
carpi ulnaris.  The muscular microtears are generally thought to occur as the result of
repetitive valgus forces to the elbow, causing stress and muscle injury at the site of
origin. 
 It has also been proposed that a prominent synovial plica within the radial capitellar
joint may act as a mechanical irritant, thereby inducing lateral epicondylitis. 
 Areas of hypovascularity, proximal and distal to the lateral epicondyle, have
recently been identified by histologic studies and power-Doppler
ultrasound.  These areas of hypovascularity are closely related to regions
within the common extensor mass of the forearm with a high proportion of
microtears, potentially making this tissue more susceptible to damage.
 Following injury, damaged tendons are characterized by signs of edema, with
disruption of the normal parallel orientation of the collagen fibers.  An
invasion of fibroblasts and vascular granulation, known as angiofibroblastic
hyperplasia, occurring within epicondylitis tissue, has been described.  Further
histologic assessment of the common extensor mass tendon in patients with
lateral epicondylitis has demonstrated a loss of tenocytes with calcific
replacement, indicating that tissue remodeling has occurred after insult

RISK
Posture
FACTORS  Tennis
 Forceful work  Racquetball
 Among women, work involving  Squash
performing repeated movements of the  Fencing
arms.
 Weight lifting
 Among men, work with precision
demanding movements.
 Among both males and females, the https://www.webmd.com/fitness-exercise/tennis-elbow-lateral-epic
ondylitis#1
results for work with hand held vibrating
tools were inconsistent, partly because of
few exposed subjects.
 Low social support at work, adjusted for
physical strain, was a risk factor among
women.
SIGNS & SYMPTOMS
 Tenderness on the outside of the elbow
 Morning stiffness of the elbow with persistent aching
 Soreness of the forearm muscles
 Elbow pain is worse when grasping or holding an object.
https://www.emedicinehealth.com/tennis_elbow/article_em.htm
DIAGNOSTIC TEST
 Multiple electrophysical modalities, such as
transcutaneous electrical nerve stimulation, ultrasound,
extracorporeal shock wave therapy and laser therapy, may
effectively manage epicondylitis; however, more research
is necessary to validate their efficacy.
PHYSICAL EXAMINATION
Inspection of the affected elbow may reveal soft tissue swelling about the lateral aspect
of the elbow.
Tenderness to palpation is often present over the common extensor origin, just anterior
and distal to the lateral epicondyle.
 Typically, patients have full elbow and wrist range of motion.The patient’s pain can
usually be reproduced with resisted wrist extension with the elbow extended and forearm
pronated in addition to a positive Maudsley’s Test which is production of pain with
resisted middle finger extension. The chair test is another provocative test that can be
performed in the office.
Patients will have reproduction of their pain while attempting to lift a chair with forearm
in pronation.
Diminished grip strength may be present with dynamometer testing due to pain.
Imaging
 While lateral epicondylitis is a clinical diagnosis, plain radiographs
can exclude the presence of bony pathology.
 While AP and lateral views of the elbow are usually normal, patchy
calcification in the soft tissue overlying the common extensor
tendon origin may be seen.
 MRI usually demonstrates increased signal in the region of the
common extensor origin and may show thickening of affected
tendons, ECRB tendon tears and soft tissue calcification.
TREATMENT &
MANAGEMENT
 Rest, through cessation of aggravating actions, is the first line
treatment. Intermittent application of ice and administration of
NSAIDS usually relieve the pain.
 Arm is immobilized in a molded splint for support and pain relief.
 Local injection of corticosteroids may be used for symptom
management, but because of its degenerative effects on tendons,
this treatment is traditionally reserved for patients with severe pain
who do not respond to first line treatment methods.
 Rehabilitation exercise may also reduce pain and inflammation.
NURSING RESPONSIBILITIES
Reduce or relieve pain and inflammation (swelling) — This is the first step in the
treatment process and may include:
 Resting and avoiding any activity that causes pain to the sore elbow
 Applying ice to the affected area
 Using non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen
 Use of a counter-force brace such as a tennis elbow strap on the forearm for forceful
activities
 Use of a wrist splint at night to rest the muscles and tendons
 Using cortisone-type medication, provided by injection into the sore
area. This treatment may be needed for severe or prolonged
symptoms.

Allow the injured elbow to recover and heal — This step begins a
couple of weeks after pain has been reduced or stopped. The step
involves:
 Doing specific physical therapy exercises to stretch out and lengthen
and strengthen muscles and tendons near the injured elbow
 Avoiding activities that aggravate pain
Decrease stress and abuse on the elbow — This part of the treatment process
may include:
 Use of the proper equipment in sports and on the job
 Use of the proper technique in sports or on the job
 Use of a counter-force brace, an elastic band that wraps around the forearm
just below the injured elbow (tendon), to help relieve pain
 Use of a splint at night to keep your wrist in a neutral position
 More advanced treatments may be appropriate depending on the length and
severity of your symptoms and may include use of nitrogen products, PRP
(patient's own platelets), shockwave, or even surgery.
NURSING DIAGNOSIS