A review of the histopathology, assessment, measurement and
three commonly used manual therapy treatment options for lateral
epicondylalgia.
Charles Markey 20-4-2012.
Word count: 2073
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A review of the histopathology, assessment, measurement and three commonly used
manual therapy treatment options for lateral epicondylalgia.
Introduction:
First described as ‘writers cramp’ by Runge (1873) and later called ‘Lawn Tennis Arm’ in
the Lancet by Henry Morris (1882) this common condition has been known as tendonitis,
lateral epicondylitis and tendonosis to name but a few. Also commonly known as ‘tennis
elbow’, it is rarely found in elite tennis players but more commonly in recreational tennis
players (Giangarra, 1993). Studies investigating the pathophysiology of ‘tennis elbow’
have failed to show inflammatory cells (Macrophange, Lymphocytes and Neutrophils) in
the affected tissues so it is now agreed that the prefix ‘itis’ is inaccurate (Maffulli, 2003).
More accurately and recently the terms tendinopathy and epicondylalgia are being used to
describe this condition which affects office workers and sports people alike. This
condition can be characterised by a spectrum of severity from mildly irritating to a
debilitating condition that can have a significant social and occupational impact.
Allander (1974) and Varhaar (1999) found 1-2% of the general population had this
condition and it is particularly common in the 40-50 year-old age group. Chiang et al.
(1993) and Ranney et al. (1995) proposed that 15% certain manual occupations suffered
lateral epicondylalgia and Haahr (2003) found that while most recovered within three
months, 17% still had symptoms a year later and Hamilton (1986) found 7 in 1000 doctor
visits were for lateral epicondylalgia.
Whereas a diagnosis is relatively easy to arrive at, an effective evidence based treatment
that is successful across age, sex and activity level has to date been elusive.
Mills (1928) speculated that ‘There is probably nothing that brings the surgical profession
into greater discredit at the present time than the inability to cure ‘tennis elbow’’.
Cyriax (1936) describes it arising from a single instance of exertion involving wrist
extension (macroscopic tears) or it can develop typically 24-48 hours after overloading
the wrist extensor tendons (particularly the extensor carpi radialis brevis tendon) 1-2 cm
distal to the humeral insertion (microscopic tears). The cardinal symptoms of this
condition are sharp pain or diffuse ache (may radiate into forearm) and decreased
function (particularly gripping).
By understanding the histopathology, assessment criteria, and multimodial treatment
options of lateral epicondylalgia we can facilitate pain reduction and accelerate the return
to sport or employment.
The purpose of this report is to provide a review of the current information regarding
lateral epicondylalgia. I begin by considering the histolpathology and then briefly
describe the assessment techniques and measurement scales and end by considering the
efficacy of the conservative treatment modialaties being used by physical therapists.
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Discussion:
Clinical Findings:
Tendons function by joining muscle to bone through contributions from the continuous
parts of the deep fascia (the epimysium, perimysium and endomysium) and providing
leverage (Tortora and Grabowski, 1993) to create movement.
Tendons are primarily composed of large diameter type 1 collagen fibrils with some type
3 collagen and proteoglycans and elatic fibers supported in the matrix.
One popular but early theory proposed by Cyriax (1936) is that tendonitis results from
microscopic or macroscopic tears in the common extensor tendon. This theory has been
refined by Khan et al. (1999) who describes under microscope, mucoid degeneration, loss
of collagen tight bundled structure, fibrosis and what Kraushaar and Nirschl (1999) called
neo-vascularization. Additionally, there is an excess of both fibroblasts and blood vessels
which Alfredson (2007) calls ‘neovessels’. The degenerative program is characterised by
dense populations of fibroblasts, vascular hyperplasia and disorganised collagen
(angiofibroblastic hyperplasia), Nirschl (1975 and 1995).
Tendinopathy is the result of overuse of the hypovascular zone which leads to
neovascularisation.
This abnormal tissue has a large number of nocioceptors which may be responsible for
the pain (Frontera, 2003). Additionally, Substance-P and CGRP (calcitonin gene related
peptide) are peptide markers indicating the possibility of neurogenic inflammation as
another possible cause of pain (Zeisig, 2006).
Frequently, a chronic complaint by the time the client attends for treatment due to the
insidious nature of the problem and a wait-and-see approach by the many clients.
Figure 1.
Histology of a normal tendon.
Figure 2.
Histology of a damaged tendon. Note the collagen disorientation and fibre separation
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Cook (2008) provides a new pathology model to explain the clinical presentation of load
induced tendonopathy in a continuum of at least 3 phases. This has similarities to Nirschl
(1988) where he proposed 4 progressive phases.
1. Reactive tendonopathy is often brought on by acute tensile or compressive loading of a
tendon. A non-inflammatory proliferate response occurs in the cells and matrix. This
thickens the tendon to adapt to the force unlike normal tendon adaption where there are
little changes in tendon thickness (Magnusson, 2008). Here the collagen and
neurovascular structures remain unchanged and given time and rest between loadings the
tendon can revert to normal.
2. In the degenerative tendon disrepair phase there is failed healing response and greater
matrix breakdown. Proteins produced from an increase of chondrocytic cells result in
collagen separation and a disorganised matrix. There is a vascularity increase and neural
ingrowths develop (Danielson, 2003).
3. The third phase is the degenerative phase which has little chance of being reversed.
Here there is evidence of tenocyte death from exhaustion and the matrix is disorganised
and invaded with neovessels. Most of the type 1collagen is absent. (Nirschl 1989; Regan
et al.1992; Verhaar et al. 1993). Degenerative changes have also been shown in other
chronic tendinopathies (Nirschl, 1989; Khan & Cook, 2000; Khan et al, 2000).
Cook also mentions a tendon can have each of these phases going on in different parts of
a tendon at the same time.
Diagnosis:
MRI and Ultrasound are the ‘gold standard’ tests but rarely needed. However, a detailed
case history must be taken to decide on the possible aggravating activities/factors so
appropriate advice regarding activity can be given.
The physical examination should include observation, palpation and orthopaedic tests to
differentiate between differential diagnoses as well as the acute and chronic presentation.
Specific orthopaedic tests for an effective physical examination of the elbow joint
includes: Gripping test (dynometer), Maudolsky’s middle finger test (Roles N, Maudsley
R, 1972), Chair test (Gardner, 1970), Crozens Test and Mills Test (Mills, 1928) amongst
others which are outlined in Bruckner and Khan (2006).
One of the chief problems encountered by clinicians is the classification of the condition
and a number of scales have been developed to address this issue.
The Visual Analogue Thermometer (VAT) (Choiniere, 1996) although subjective, this is
the scale in commonest use for pain intensity today. Pain is plotted along a line. It is good
to look at individual case changes but less so across groups.
The DASH (Disabilities of the Arm, Shoulder and Hand) (Atroshi et al, 2000), it is a self-
reported questionnaire of 30 items concerned with symptoms and function developed by
the American Academy of Orthopaedic Surgeons. There is also a shortened version the
QuickDASH. Both are valid and reliable.
McDiarmid was involved in the PRFEQ (Patient Rated Forearm Evaluation Questionnaire)
devised in Canada 1999 that looks specifically at the elbow. It is made up of 15 questions
you plot on a visual analogue scale (VAS). It was updated by McDiarmid (2005) after
being validated by Overend (1999).
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The Gotenburg Quality of Life instrument (GQL) (Sullivan, 1993) is validated and used
extensively. It looks at Yes/no answers for 30 symptoms over the past 3 months.
The Roles-Maudsley a subjective pain scale between 1= no pain and 4 = pain limiting
activities.
Hand held dynometers are reliable with an 8.2% coefficient of variables (Bonhonnon,
1986). They are a useful in quantifying changes. Two separate tests are considered,
maximum grip test and start of pain grip test.
Physical Therapy Treatment Options:
Eccentric Exercising: Resistive training aims at progressively overloading by the gradual increase of stress
placed upon a body during training.
One of the earliest recommendations in favour of the use of eccentric exercises was
Standish et al. (1986) where they suggested that eccentric exercise effectively ‘lengthened
the muscle tendon complex resulting in structural remodelling of the tendon with
hyperthrophy and increased tensile strength of the tendon’.
Eccentric exercises help promote the formation of new collagen and are supported by
Alfredson (1998), Svemlov (2001), Ohberg (2004), Martinez-Silvestrini (2005), Crozier
(2007) and Page (2010).
The Nicholas Institute of Sports Medicine and Athletic Trauma developed the novel
Theraband Flexibar (They recommend 3 sets of 15 each daily).
Tim Tyler further developed this with the ‘Tyler Twist Technique’ because eccentric
loading helps collagen cross fibres. (Tyler 2010).
In his prospective, randomised, quasi control study 22 tennis elbow sufferers were split
up between a control group (getting standard physical therapy) or a physical therapy
group with the Theraband Flexibar exercise.
Using the Visual (VAS), Disability of the arm, shoulder and hand) DASH and hand held
dynmoeter it was found that the group using the Theraband Flexibar’s pain level reduced
by 81% against 22% for the control group and The DASH score was 76% for the
Theraband Flexibar group against 13% for the control.
Eccentric and concentric resistance exercises stress the wrist extensors and produce dense
collagen scar tissue at the attachment site reducing pain. (Curwin and Standish, 2000).
Eccentric exercises appear to work by reversing neovascularization although the
mechanism is not clearly understood (Alfredson & Cook 2007). There is general
agreement to following Alfredson’s heel drop protocol of 3 X 15 repetitions twice a day
for 12 weeks with theses exercises.
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Cross fibre friction: Deep Transverse Friction (DTF) was popularised by Dr James Cyriax (Cyriax 1936) for
the treatment of tendonitis. He proposed it would reduce fibrous adhesions and maintain
scar mobility by breaking the cross bridges and reduce pain producing metabolites
(Lewis’s substances). However a Cochrane Review (level 1, grade c for pain)
(Philadelphia 2001) found poor evidence to support deep transverse friction (DTF) for
treating tendonitis. This is supported by Brosseau et al, (2003) and Stasinopoulos (2007).
Interestingly Cyriax only called it ‘Cyriax Treatment’ when the Mills Manipulation was
also carried out as part of the treatment.
Mulligan Concept: Mobilization with Movement.
Brian Mulligan, a New Zealand physiotherapist launched his first book on manual
therapy in 1989 and it is now in use throughout the world by physiotherapists and manual
therapists alike.
The Mulligan Mobilization with Movement (MWM) (Mulligan 1999) has become
popular as there is no high velocity thrust involved. Here the therapist provides a lateral
glide to the extended elbow as the patient clenches his fist. This technique is supported by
a number of placebo controlled studies Vincenzino (2001) and Paungmali (2003) and
further develops the theories of Freddie Kaltenborn with whom he worked.
One recent single blind randomised controlled trial of 189 compares the efficacy of
physiotherapy (MWM), wait and see and corticosteroid injection over a year period
(Bisset, 2006). It concluded that Physiotherapy (MWM) was superior to wait and see in
the first 6 weeks and better than corticosteroid injections after 6 weeks as there was a
substantial number of reoccurrences. After a year follow 72 % of those injected reported
reoccurrences compared to the wait and see group (9%) and the physiotherapy group
(8%).
I followed the CONSORT guidelines (Moher et al, 2010) to appraise the Blinding,
Concealment of allocation and Intention to treat analysis. This trial used a blinded
assessor and statistical analysis was carried on out on an intention to treat basis and an
individual per protocol analysis was also carried out.
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Conclusion:
Despite all the research, there is no consensus in how to treat epicondylalgia. Moher et al.
(2010) are continually updating the Consort Statement with a view to improve the quality
of reporting in randomised controlled Trials (RTC).
As the purpose of this review was to consider the efficacy of manual therapy modialaties
I did not consider (sclerosing agents, blood injections, electro therapy or acupuncture) as
they are not available or used by all physical therapist.
In my view large Randomised Controlled Trials (RCT) are required to investigate the
benefits between eccentric exercises and combination eccentric and concentric exercises.
Although promising, the Mulligan MWM and Tim Tyler’s research are limited by the
small group sizes and that it only looked at the groups in the short term. However the fact
that a client need attend the therapist less frequently and can assist in their own healing
has many benefits including both time and financial aspects.
So despite the frequency of visits to the doctor and the large number of studies there is
insufficient evidence for most physiotherapy treatments of lateral epicondylalgia.
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References:
Alfredson H. (2002) The chronic painful achilles and patellar tendon: research on basic
biology and treatment. Scand J Med Sci Sports. 15:252–9.
Alfredson H, Cook Cook J. (2007). A treatment algorithm for managing Achilles
tendonopathy: new treatment options. Br J Sports Med. 41:211-216
Alfredson H, Pietila T, Jonsson P, Lorentzon R. (1998) Heavy-load eccentric calf muscle
training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 26:360–6.
Allander E. (1974) Prevalence, incidence, and remission rates of some common
rheumatic diseases or syndromes. Scand J Rheumatol. 3:145–53. [PubMed]
Atroshi I, Gummesson C, Andersson B, Dahlgren E, Johansson A.(2000) The disabilities
of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and
validity of the Swedish version evaluated in 176 patients. Acta Orthop Scand,
71(6): 613-8.
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. (2006) Mobilizations with
movement and exercise, corticosteroid injection, or wait and see for tennis elbow:
randomised trial. BJM. 333: (7575):939.
Bohannon RW. (1986)Test-retest reliability of hand-held dynamometry during a single
session of strength assessment. Phys Ther. 66:206–9. [PubMed]
Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell T, Wells G. (2003) Deep
transverse friction for treating tendonitis (Cochrane review) in the Cochrane library, Issue
4. CD003528.
Brukner P, Khan H. (2004) Clinical Sports Medicine. 3rd ed. McGraw Hill.
Chiang HC, et al. (1993) Prevalence of shoulder and upper limb disorders among workers
in the fish processing industry. Scandinavian Journal of Work and Environmental
Health.19:126-131.
Choiniere M, Amsel R. (1996) A visual analogue thermometer for measuring pain
intensity. J Pain Symptom Manage. 11(5): 299-311.
Cook JL, Purdam CR. (2011) Is tendon pathology a continuum? A pathology model to
explain the clinical presentation of load induced tendonopathy. BMJ 342:d2687
Crozier J-L, Foidart M-D, France T, Crieland J-M, Forthomme B. (2007) An isokinetic
programme for the management of chronic lateral epicondylar tendonopathy. Br j sports
Med. 41(4) 269-275.
8
Curwin S. (1984). Tendonitis its etiology and treatment. Toronto, ON, Collamore Press.
DC Health and company.
Cyriax JH. (1936) The pathology and treatment of tennis elbow. J Bone and Joint Surg.
18:92:1-940.
Cyriax HJ, Cyriax JP. (1983) Cyriax’s Illustrated manual of orthopaedic medicine.
Oxford: Butterworth-Heinemann.
Danielson P, Alfredson HK, Forsgren S. (2006) Distribution of general (PGP 9.5) and
sensory
(substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports
Traumatol Arthrosc. 14:125–32.
Frontera W. (2003) Rehabilitation of sports injuries: scientific basis. Blackwell Science.
Gardner RC. (1970) Tennis elbow: diagnosis, pathology and treatment. Nine severe cases
treated by a new reconstructive operation. Clin Orthop Relat Res. 72: 248-53.
Giangarra CE, Conroy B, Jobe FW, Pink M, Penny J. (1993) Electromylographic and
cimenatographic analysis of elbow function in tennis players using single- and double
backhanded strokes. American college of sports medicine. 21: 394-399.
Haahr JP, Andersen JH. (2003) Prognostic factors in lateral epicondylitis: a randomized
trial with one-year follow-up in 266 new cases treated with minimal occupational
intervention or the usual approach in general practice. Rheumatology (Oxford). 42:1216–
25. [PubMed]
Hamilton PG. (1986) the Prevalence of humeral epicondylitis: a survey in general
practice. J R Coll Gen Pract. 36(291:464-4.
Kaltenborn F, Robinson B. (1976) 2nd ed. Manual therapy for the extremity joints:
specialised techniques: tests and joint mobilizations. Oslo. Olaf Norlis Bockhandle.
Khan K, Cook J (2000) Overuse tendon injuries: where does the paincome from? In:
Dilworth Cannon W, DeHaven K (eds) SportsMedicine and Arthroscopy Review, Vol. 8.
Lippincott Williams& Wilkins, Philadelphia, 17–31.
Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. (1999) Histopathology of common
tendinopathies. Update and implications for clinical management. Sports Med. 27:393-
408.
Khan KM, Cook JL, Maffulli N, Kannus P. (2000) Where is the paincoming from in
tendinopathy? It may be biochemical, not onlystructural, in origin. British Journal of
Sports Medicine 34:
81–83
Kraemer WJ, Ratamess NA. (2004) Fundamentals of resistance training: progression and
exercise prescription. Med Sci Sport Exerc. 36:674-8.
9
Kraushaar B, Nirschl R. (1999) Tendinosis of the elbow (tennis elbow). Clinical features
and
findings of histological, immunohistochemical, and electron microscopy studies.
J Bone Joint Surg Am. 81-A:259–78.
Kraushaar B, Nirschl R (1999). Orthopaedic and sports medicine; Emerson New Jersey
Feb; 81(2)
Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CNirschl R. (1989)
Patterns of failed healing in tendon injury. In:Leadbetter W, Buckwalter J, Gordon S (eds)
Sports-induced
Inflammation. American Academy of Orthopaedic Surgeons,Illinois. 577–585
MacDermid JC .(1996) Development of a scale for patient rating of wrist pain and
disability. J Hand Ther, 9(2):178-83.
Magnusson SP, Narici MV, Maganaris CN, et al. (2008) Human tendon behaviour and
adaptation, in vivo. J Physiol. 586:71–81.
Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW.
(2005) Chronic lateral epicondylitis: comparative effectiveness of a home exercise
program including stretching alone versus stretching supplemented with eccentric or
concentric strengthening. J Hand Ther. 18(4): 411-9.
Maffulli N, Wong j Almekinders LC. (2003) Types and epidemiology of
tendonopathy. Clin Sports Med. 22:675-92.
Mills G. (1928) Treatment of tennis elbow. BMJ, 1:12-3.
Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D,
Egger M, Altman DG, (2010) Consort 2010 Explanation and Elaboration: update
guidelines for reporting parallel group randomised controlled trials. BMJ 340:c869.
Morris H. (1882) The rider’s sprain. Lancet. 2:133– 4.
Mulligan B. Manual Therapy. ‘Nags’, ‘Snags’, MWM’s’etc. (1999) 4ed. Plane View
Services. Wellington NZ.
Nirschl RP. (1988) Prevention and treatment of elbow and shoulder injuries in the tennis
player. ClinSports Med. 7:289– 94.
Nirschl RP. (1995) Tennis elbow tendinosis: pathoanatomy, nonsurgical and surgical
management. Repetitive motion disorders in the upper extremity. American Academy of
Orthopaedic Surgeons. 467-479.
Nirschl RP, Pettrone FA. (1979)Tennis elbow: the surgical treatment of lateral
epicondylitis. J Bone Joint Surg Am. 61:832–9.
Nirschl RP, (1975) Tennis elbow tendinosis: pathoanatomy, non surgical and surgical
management of repetitive motion disorders of the upper extremity. American Academy of
Orthopaedic Surgeons. 467-479.
10
Ohberg L, Lorentzon R, Alfredson H. (2004) Eccentric training in patients with chronic
Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br
J Sports Med. 38:8–11.
Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. (1999) Reliability of a patient
rated forearm evaluation questionnaire for patients with lateral epicondylitis. J Hand
Ther. 12(1): 31-7.
Page P. (2010) A new exercise for tennis elbow that works. N Am J Sports Phys Ther. 5(3)
189-193.
Paugmali A, O’leary S, Souvlis T, Vincenzino B. (2003) Hypoalgesia and
sympathoexcitatory effects of mobilizations with movement for lateral epicondylagis. J
Pain. 83:374-383.
Peterson M, Elmfekld D, Svardsudd K. (2005) Treatment practice in chronic epicondylitis:
a survey among general practitioners and physiotherapists in Uppsala County, Sweden.
Scand J Prim Care 23(4):239-41.
Ranney D. (1995) Upper limb musculoskeletal disorders in highly repetitive industries:
precise anatomical physical findings. Ergonomics. 38-7.
Regan W, Wold LE, Coonrad R, Morrey BF (1992) Microscopic
histopathology of chronic refractory lateral epicondylitis.
American Journal of Sports Medicine. 20:746–749.
Roles NC, Maudsley RH. (1972) Radial tunnel syndrome: resistant tennis elbow as nerve
entrapment. J Bone Joint Surg Br. 54-B:499-508.
Runge F. (1873) Zur Genese und Behandlung des Schreibekrampfes. Berliner Klin
Wochenschr. 10:245-248.
Smidt N, Assendelf WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, van der Windt
DA, Bouter LM (2003) Effectiveness of physiotherapy for lateral epicondylitis: a
systematic review. Ann Med. 35(1) 51-62.
Smidt N, van der Windt AWM, Assendelft WLL, et al. (2002) Corticostetoid injections,
physiotherapy, or a wait and see policy for lateral epicondylitis: a randomised control trial.
Lancet. 359:657-62.
Standish WD, Rubinovich RM, Curwin S. (1986) Eccentric exercises in chronic
tendonitis. Clin Orthop Relat Res. 208:65-68.
Stanish W, Curwin S, Mandell S. (2000) Tendonopathy: Its etiology and treatment.
Oxford, England: University Press.
Stanopoulous D, Johnson M. (2007) It may be time to modify the Cyriax treatment of
lateral epicondylitis. Journal of bodywork and movement therapies. 11(1):64-67.
Sullivan M, Karlsson J, Bengtsson C, Furunes B, Lapidus L, Lissner L. (1993) ‘The
Goteborg Quality of Life Instrument’—a psychometric evaluation of assessments of
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symptoms and well-being among women in a general population. Scand J Prim Health
Care. 11:267–75. [PubMed]
Svernlov B, Adolfsson L. (2001) Non-operative treatment regime including eccentric
training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 11(6):328-34.
The Philadelphia Panel. The Philadelphia Panel evidence based clinical practice
guidelines as selected rehabilitation interventions for knee pain.
Tortora GJ, Grabowski SR. (1993) The principles of anatomy and physiology. 7th ed.
Harper Collins.
Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. (2010) Addition of isolated wrist
extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a
prospective randomized trial. J Shoulder elbow Surg.19(6):917-922
Verhaar JA. (1994) Tennis elbow. Anatomical, epidemiological and therapeutic aspects.
Int Orthop. 18:263–7. [PubMed]
Verhaar J, Walenkamp G, Kester A, Vanmameren H, Vanderlinden T. (1993) Lateral
extensor release for twennis elbow-a prospective long-term follow up study. Journal of
Bone and Joint surgery-American Volume 75A:1034-1043.
Vicenzino B, Paugmali A, Buratowski S, Wright A. (2001) Specific manipulative therapy
treatment for chronic lateral epicondylagia produces uniquely characteristic hyopalgesia.
Man Ther. 6:205-212.
Zeisig E, Ohberg L, Alfredson H. (2006) Extensor origin vascularity related to pain in
patients with tennis elbow. Knee surgery Traumatol arthrosc. 14659:663-663.
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Correct posture is important throughout any exercise and it is important to involve ‘Core Bracing’.
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Initially, the weight can be adjusted closer to the patients hand to reduce the stress.
Advanced and incorporating propioception training.
15
Daily homecare mobility exercises in conjunction with strengthening exercises prescribed by
therapist following assessment.
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The Progressive Stages of the Rehabilitation Program are: 1. Provide the correct management to reduce pain and promote healing
during the early phase of an injury.
Identify and correct predisposing factors,
Restore full range of motion (ROM) and flexibility.
2. Restore function: Muscular strength, power and endurance.
Re-establish neuromuscular control.
3. Improve postural stability and co-ordination and propioception.
Graduated return to activity/sport.
Educate and support client to avoid re-occurrence and chronicity
developing.
Eccentric exercise was proposed by Standish et al (1986) to ‘lengthen the muscle tendon complex
resulting in structural remodelling of the tendon with hyperthrophy and increased tensile strength
of the tendon’. This idea of forming dense collagen scar tissue appears to reverse
neovascularisation and reduce pain (Alfredson and Cook, 2007).
Day 1 program: Acute presentation with high SIN (Severity, Irritability, Nature of condition) use RICE protocol.
For example complete rest if there is significant elbow pain lifting a cup.
Therapist treatment:
The Mulligan Concept elbow MWM technique can be applied and should be pain free, immediate
and long lasting if suitable.
Client:
Active pain free (almost) elbow and wrist Rang of Motion (ROM) from the first day. 30sec each
joint per day.
Between 3 and 7 days the inflammatory phase should be eased sufficiently to implement treatment
plan.
Therapist: Soft tissue massage to release muscular hypertonicity in wrist flexors and extensors.
Grade 1 and 2 joint mobilizations to elbow joint if restrictions present.
Transverse friction to epicondyle and ice massage for pain control.
Daily client self care:
Continue elbow and wrist active ROM (allow a small amount of pain). 30sec each joint twice a
day.
Isometric Wrist flexion (ie; elbow stretch with elbow extended and also with elbow flexed to 90
degrees) 3 of each with 30 sec. hold, once a day.
Low resistance eccentric strength exercise. 8 sec. for 3 sets or until fatigued. After a few days
when client is able to complete 8 sec for 3 sets you may add light Theraband (yellow) resistance.
Wringing out a tea towel with arms out straight.
Squeeze and hold a tennis ball 10 sec. for 3 reps to improve grip strength.
Begin addressing any postural factors:
Commonly you will find short internal rotators and protractors of the shoulder while the lower
trapezius, rhomboid, infraspinatus, teres minor, serratus anterior and deep neck flexors muscles
are weak and lengthened.
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From the beginning, shoulder and trunk exercises to maintain conditioning levels and retrain the
kinetic chain system as shoulder dyskinesis may be a contribution factor. (Bruckner and Khan,
2006).
Low row and robbery exercises for any shoulder dyskinesis. (Kibler, 2008)
Self massage and icing ice in towel (10min. on every 2 hours).
Maintain general fitness levels by walking in a pool or a stationary bike.
High intensity exercises can maintain fitness levels for 15 weeks.
Always go back a step back if you aggravate symptoms significantly.
Neurodynamic stretching for the radial nerve if weak supination present.
The Theraband Flexibar (3x15 reps twice daily for 12 weeks)
Tim Tyler because eccentric loading helps collagen cross fibres. (Tyler, 2010)
Concentric loading is not recommended as it continues the condition.
Mahieu (2007) found although static stretching has no affect on tendon stiffness ballistic
stretching causes tendon compliance.
All home exercises to be preformed while engaging the core muscles. Also Carroll (2006)
recommends the use of contralateral training while the involved limb is rested.
Cyriax (1936) popularised Deep Transverse Friction (DTF) for treating tendonitis but recent trials
(Brosseau et al, 2003 and Stasinopoulus, 2007) did not show consistent benefits in a Cochrane
review (2002). This is supported by Brosseau et al, (2003) and Stasinopoulos (2007). Interestingly
Cyriax only called it ‘Cyriax Treatment’ when the Mills Manipulation was also carried out as part
of the treatment.
The criteria for progressing to Phase 2 are ‘full pain free AROM, minimum pain and good
strength’. Bandy and Sanders (2001).
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Day 7 Continue the early phase program and progress the exercises.
Do not increase the time under tension (reps) but rather increase the resistance by using a darker
Theraband.
Additionally introduce a dowel (stick) for supination and pronation. 5-8 reps 3 sets.
Introduce propiocention exercises. Throwing up a ball and catching it. This can be progressed by
throwing a ball against a wall and catching it. Later standing on a wobble board or altering the
weight of the ball can create new challenges.
Therapist can apply:
The active release technique (ART) breaks down scar tissue which lessens the load to restore
elasticity.
Therapeutic exercise and home care program:
Exercises to improve muscle endurance progress from isotonic to isometric.
‘The goals in this phase are to increase muscular strength, muscular endurance and neuromuscular
control. The majority of exercises in this stage are isotonic. The criteria for progressing to Phase 3
are full pain free AROM, no pain on palpation and at least a minimum of 70% strength’. Bandy
and Sanders (2001).
Day 20 Introduce radial and ulnar deviation of the wrist using a hammer (hold close to the top initially and
progress to holding further down the shaft to increase the load).
Progress all the exercises and propioception
Introduce plyometrics . Early plyometrics (jumping explosive exercises) are used to get a person
ready for the return to sport and should be specifically tailored to the client’s sport.
Address psychological issues around return to sport/activity. Discuss their concerns and offer
support and advice.
Only return to sport when able to perform functional sport specific exercises properly with normal
strength and power and no pain.
Note: Without completing appropriate rehabilitation, epicondylalgia can result in physiological and
functional losses that predispose to further re-injury.
Clients tend to expect tendons to heal quickly and then fail to complete the rehabilitation program
developing chronic conditions that are easily aggravated with repetitive activities.
Load, Velocity and Frequency are key element of eccentric exercising:
Load- increased based on patient’s symptoms.
Velocity (speed). Increasing velocity is recommended by Standish (1986) to facilitate a return to
activity but Alfredson does suggest altering his exercise velocity.
19
Frequency. This varies between authors but 3 sets of 10 is commonly used (Standish 1986). This
is similar to Alfredson’s 3 sets of 15 twice a day for 12 weeks.
The Therapist Role:
The therapist role is very important for a number of reasons:
To identify aggravating factors.
To decide at what stage a client is so the appropriate phase of rehab can begin.
To decide when to progress to the next phase.
To educate the client to avoid re-injury.
To consider bio-phyco social factors involved in each case.
To refer for further evaluation if a client is not making progress while doing the rehabilitation
program.
Client education/support and commitment to the rehabilitation program is important for return to
activity and avoid re-occurrences.
Maintaining cardiovascular fitness has psychological benefits for an athlete.
Check for elbow capsular flexion contractures or valgus deformity particularly with throwing
sports. The anterior joint capsule can develop micro tears, scarring and calcification. This will
need to be addressed by active stretching in Phase 1 and 2 (within clients comfort zone).
In Phase 2 the addition of joint mobilizations if full elbow range has not returned.
In Phase 2 and 3 active assisted and passive stretching to improve wrist, elbow and forearm
motion.
Phase 3, adding increased resistance and diagonal motions prepare for plyometric exercises.
As the highly irritable acute phase reduces rehabilitation begins.
Cautions/Red Flags: Particular attention with children involved in throwing sports as bony changes can develop with
repetition and more serious pathologies progress more quickly in the young.
Psychological considerations: A therapist should develop a rapport with his client. This will assist him in motivating the client
and recognising potential problems.
To much rest has a detrimental effect on recovery. Appell (1991).
Client education ensures client empowerment and supports compliance. This can also be used to
prevent re-occurrences.
An effort should be made to make the program interesting and varied to prevent de-conditioning
and again to ensure compliance.
The setting of long and short term objective and measurable goals helps motivate client.
20
Bibliography:
Alfredson H. (2002) The chronic painful achilles and patellar tendon: research on basic
biology and treatment. Scand J Med Sci Sports. 15:252–9.
Alfredson H, Pietila T, Jonsson P, Lorentzon R. (1998) Heavy-load eccentric calf muscle training
for the treatment of chronic Achilles tendinosis. Am J Sports Med. 26:360–6.
Allander E. (1974) Prevalence, incidence, and remission rates of some common rheumatic
diseases or syndromes. Scand J Rheumatol. 3:145–53. [PubMed]
Appell HJ. (1990) Muscular atrophy following immobilization. A review. Sports Med 10:42-58
Bandy W, Sanders, B (2001) Therapeutic Exercise Technique for Intervention. Philadelphia.
Lippincot, Williams and Wilkins
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. (2006) Mobilizations with
movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial.
BJM. 333: (7575):939.
Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell T, Wells G. (2003) Deep
transverse friction for treating tendonitis (Cochrane review) in the Cochrane library, Issue 4.
CD003528.
Brukner P, Khan H. (2004) Clinical Sports Medicine. 3rd ed. McGraw Hill.
Carroll TJ, Herbert RD, Munn J et al. (2006) Contralateral effects of unilateral strength training:
evidence and possible mechanisms. Journal of Applied Physiology. 101: 1514-1522
Chiang HC, et al. (1993) Prevalence of shoulder and upper limb disorders among workers in the
fish processing industry. Scandinavian Journal of Work and Environmental Health.19:126-131.
Cook JL, Purdam CR. (2011) Is tendon pathology a continuum? A pathology model to explain the
clinical presentation of load induced tendonopathy. BMJ 342:d2687
Crozier J-L, Foidart M-D, France T, Crieland J-M, Forthomme B. (2007) An isokinetic
programme for the management of chronic lateral epicondylar tendonopathy. Br J Sports Med.
41(4) 269-275.
Curwin S. (1984). Tendonitis its etiology and treatment. Toronto, ON, Collamore Press. DC
Health and company.
Cyriax JH. (1936) The pathology and treatment of tennis elbow. J Bone and Joint Surg. 18:92:1-
940.
Danielson P, Alfredson HK, Forsgren S. (2006) Distribution of general (PGP 9.5) and sensory
(substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports
Traumatol Arthrosc. 14:125–32.
Fradkin AJ, Gabbe BJ, Cameron PA. Does warming up prevent sports injury? The evidence from
randomised controlled trials? J Sci Med Sport 2006; ((3):214-20
21
Frontera W. (2003) Rehabilitation of sports injuries: scientific basis. Blackwell Science.
Gardner RC. (1970) Tennis elbow: diagnosis, pathology and treatment. Nine severe cases
treated by a new reconstructive operation. Clin Orthop Relat Res. 72: 248-53.
Haahr JP, Andersen JH. (2003) Prognostic factors in lateral epicondylitis: a randomized trial with
one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual
approach in general practice. Rheumatology (Oxford). 42:1216–25. [PubMed]
Hamilton PG. (1986) the Prevalence of humeral epicondylitis: a survey in general practice. J R
Coll Gen Pract. 36(291:464-4.
Houglum P. Therapeutic exercises for musculoskeletal injuries. 3rd ed. Human Kinetics (2010).
Khan K, Cook J (2000) Overuse tendon injuries: where does the paincome from? In: Dilworth
Cannon W, DeHaven K (eds) SportsMedicine and Arthroscopy Review, Vol. 8. Lippincott
Williams& Wilkins, Philadelphia, 17–31.
Khan KM, Cook JL, Maffulli N, Kannus P. (2000) Where is the paincoming from in tendinopathy?
It may be biochemical, not onlystructural, in origin. British Journal of Sports Medicine 34:81–83
Kibler B, Aaron D, Timothy L, Tambay N, Cunningham T. (2008) Electromyographic Analysis of
Specific Exercises for Scapular Control in Early
Phases of Shoulder Rehabilitation. Am. J. Sports Med. 36;1789.
Kraemer WJ, Ratamess NA. (2004) Fundamentals of resistance training: progression and exercise
prescription. Med Sci Sport Exerc. 36:674-8.
Kraushaar B, Nirschl R. (1999) Tendinosis of the elbow (tennis elbow). Clinical features and
findings of histological, immunohistochemical, and electron microscopy studies.
J Bone Joint Surg Am. 81-A:259–78.
Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CNirschl R. (1989) Patterns of
failed healing in tendon injury. In: Leadbetter W, Buckwalter J, Gordon S (eds) Sports-induced
Inflammation. American Academy of Orthopaedic Surgeons,Illinois. 577–585
Maffulli N, Wong j Almekinders LC. (2003) Types and epidemiology of tendonopathy. Clin
Sports Med. 22:675-92.
Magnusson SP, Narici MV, Maganaris CN, et al. (2008) Human tendon behaviour and
adaptation, in vivo. J Physiol. 586:71–81.
Mahieu N, McNair P, De Muynck M, et al. Effect of static and ballisticstretchingon the muscle-
tendon tissue properties. Med Sci Sports Ex, 2007, inpress..
Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P,
Arendt KW. (2005) Chronic lateral epicondylitis: comparative effectiveness of a home
exercise program including stretching alone versus stretching supplemented with
eccentric or concentric strengthening. J Hand Ther. 18(4): 411-9.
Mulligan B. Manual Therapy. ‘Nags’, ‘Snags’, MWM’s’etc. (1999) 4ed. Plane View Services.
Wellington NZ.
22
Nirschl RP. (1995) Tennis elbow tendinosis: pathoanatomy, nonsurgical and surgical management.
Repetitive motion disorders in the upper extremity. American Academy of Orthopaedic Surgeons.
467-479.
Nirschl RP. (1988) Prevention and treatment of elbow and shoulder injuries in the tennis player.
Clin Sports Med. 7:289– 94.
Nirschl RP, Pettrone FA. (1979) The surgical treatment of tendonitis. J Bone Joint Surg (AM)
61:832-839.
Nirschl RP. (1992) Elbow tendonosis/tennis elbow. Clinics in sports medicine. 11,851-870.
Ohberg L, Lorentzon R, Alfredson H. (2004) Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 38:8–11.
Page P. (2010) A new exercise for tennis elbow that works. N Am J Sports Phys Ther. 5(3) 189-
193.
Peterson M, Elmfekld D, Svardsudd K. (2005) Treatment practice in chronic epicondylitis: a
survey among general practitioners and physiotherapists in Uppsala County, Sweeden. Scand J
Prim Care 23(4):239-41.
Ranney D. (1995) Upper limb musculoskeletal disorders in highly repetitive industries: precise
anatomical physical findings. Ergonomics. 38-7.
Regan W, Wold LE, Coonrad R, Morrey BF (1992) Microscopic histopathology of chronic
refractory lateral epicondylitis. American Journal of Sports Medicine. 20:746–749.
Smidt N, Assendelf WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, van der Windt DA,
Bouter LM (2003) Effectiveness of physiotherapy for lateral epicondylitis: a systematic review.
Ann Med. 35(1) 51-62.
Smidt N, van der Windt AWM, Assendelft WLL, et al. (2002) Corticostetoid injections,
physiotherapy, or a wait and see policy for lateral epicondylitis: a randomised control trial. Lancet.
359:657-62.
Standish WD, Rubinovich RM, Curwin S. (1986) Eccentric exercises in chronic tendonitis. Clin
Orthop Relat Res. 208:65-68.
Stanish W, Curwin S, Mandell S. (2000) Tendonopathy: Its etiology and treatment. Oxford,
England: University Press.
Stanopoulous D, Johnson M. (2007) It may be time to modify the Cyriax treatment of lateral
epicondylitis. Journal of bodywork and movement therapies. 11(1):64-67.
Svernlov B, Adolfsson L. (2001) Non-operative treatment regime including eccentric
training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 11(6):328-34.
The Philadelphia Panel. The Philadelphia Panel evidence based clinical practice guidelines as
selected rehabilitation interventions for knee pain.
Tortora GJ, Grabowski SR. (1993) The principles of anatomy and physiology. 7th ed. Harper
Collins.
Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. (2010) Addition of isolated wrist extensor
eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective
randomized trial. J Shoulder elbow Surg.19(6):917-922
23
Verhaar JA. (1994) Tennis elbow. Anatomical, epidemiological and therapeutic aspects. Int
Orthop. 18:263–7. [PubMed]
Vincenzino B. (2003) Lateral epicondylalagia:a musculoskeletal physiotherapy perspective.
Manual Therapy. 8(2),66-79.
Verhaar J, Walenkamp G, Kester A, Vanmameren H, Vanderlinden T. (1993) Lateral extensor
release for twennis elbow-a prospective long-term follow up study. Journal of Bone and Joint
surgery-American Volume 75A:1034-1043.
Zeisig E, Ohberg L, Alfredson H. (2006) Extensor origin vascularity related to pain in patients
with tennis elbow. Knee surgery Traumatol arthrosc. 14659:663-663.