What Is Lateral Epicondylitis?
It is an orthopedic problem that affects the elbow due to repetitive usage of the wrists. It is also known as tennis elbow. It occurs in tennis and badminton players, dentists, and pianists. The lateral epicondyle is a bony bump present outside the elbow and at the base of the humerus (the largest bone present in the arm). The primary tendon involved in lateral epicondylitis is the extensor carpi radialis brevis (ECRB). Tendons are the tissue that connects muscles to bones.
How Does It Occur?
It occurs due to overuse of the elbow and repetitive strain caused in the tendons near the elbow. It is called tendinosis since it is a degenerative process. The repetitive strain causes degradation of the tendon (micro tear in the tendon) that, in turn, affects the muscles of the forearm, namely extensor carpi radialis brevis (ECRB), extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris, out of which ECRB is commonly affected. Excessive stress on the tendon leads to micro-tear and ultimately leads to tendinosis (degeneration of tendon).
What Are the Symptoms?
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Pain that is sharp, mild to moderate, and intermittent.
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Limitation in elbow extension.
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Weakness in the elbow area while grasping.
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Burning sensation along the elbow and forearm region.
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Grip strength is decreased.
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Sometimes pain occurs even while resting.
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Pain when twisting or bending the arm.
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Swelling and redness near the elbow joint.
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Stiffness in the forearm.
Who Is Prone to This Condition?
It not only occurs in tennis players but anyone who uses their hands and elbows repetitively in their profession. The following people are prone to tennis elbow:
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Dentists.
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Carpenters.
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Pianists and other musicians who use their hands often.
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Plumbers.
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Cooks and butchers.
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Heavy machinery workers who lift weights of more than one kilogram often.
How Is Lateral Epicondylitis Diagnosed?
X-ray is taken to assess arthritis. MRI (magnetic resonance imaging) is done to see the tendons clearly, and also electromyography is taken to see if there are any other nerve abnormalities. Electromyography is a diagnostic procedure in which electricity is used to test nerve and muscle dysfunctions.
Specific tests are done by the physician to diagnose lateral epicondylitis:
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Classic Chair Test: When the individual is asked to lift a chair using the three fingers from the thumb to the middle finger, the patient has pain in the lateral epicondyle.
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Maudsley’s Test: When the individual is asked to extend the middle finger, the individual has pain which is due to damage to the extensor carpi radialis brevis (ECRB).
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Coffee Cup Test: When the patient tries to lift a coffee cup, there is resistance to grip strength and pain.
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Mill’s Test: The patient is asked to relax in a chair, and the examiner lifts the patient’s forearm while fully extending the elbow and flexing the wrist. This causes pain near the lateral epicondyle.
How Is Lateral Epicondylitis Treated?
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Patients are asked to reduce the usage of the affected hands until the symptoms subside. In addition, proper warm-ups and exercises are important for athletes to educate the muscles and tendons to prevent injury.
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NSAIDs (non-steroidal anti-inflammatory drugs), including Acetaminophen, Ibuprofen, or Naproxen, are used to reduce inflammation and pain.
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Usage of braces near the affected elbow to avoid movement.
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PRP (platelet-rich plasma) treatment is done in the affected site.
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Physical therapy includes ice massage, ultrasound, and muscle stimulation techniques.
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Steroid injections help relieve inflammation.
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Extracorporeal shock wave (ECSW) therapy is a technique in which shock waves are artificially sent to the elbow in short intervals, causing microtear and, in turn, leading to the natural healing process.
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Arthroscopic surgery in untreated and long-standing cases.
Extracorporeal Shock Wave Therapy (ECSW):
It is a non-invasive method in which sound waves are directed at specific frequencies using a generator over the affected area for short periods. It, in turn, increases microcirculation and helps stimulate the tendon in healing. As a result, it effectively reduces pain and helps in functional rehabilitation. Extracorporeal shock wave therapy (ECSW) produces some amount of energy that promotes tissue healing and stimulates nerve fibers to release an analgesic substance and uses this energy to relieve pain. It has been proven effective in reducing pain half-fold.
Cyriax Physiotherapy:
In this technique, Mill’s manipulation and deep, transverse friction (DTF) are combined and put to use. DTF (deep, transverse friction) is a type of massage applied over the soft tissue of the affected area. It creates an analgesic effect, and subsequently, Mill’s manipulation is done. Mill’s manipulation is done with a high speed, and low amplitude thrust with the wrist and hand flexed. It helps in the elongation of scar tissue and thereby making the area mobile and pain-free.
Stretching:
Stretching and strengthening should be done to restore muscular function. The principle behind this is that stretching can elongate the tendons and muscles, which thereby reduces pain and pain reduction during offending exercises in epicondylitis-affected patients.
Physiotherapy Rehabilitation:
Three stages of rehabilitation can be conceptually applied to the patient:
- Protected function.
- Total arm strength.
- Return-to-activity phase.
1. Protected Function Phase: During this first phase, care is taken to protect the injured muscle-tendon unit from stress but not function. The patient is advised to protect themselves from offending activities. Cortisone injection and ECSW (extracorporeal shock wave therapy) is done at these stages.
2. Total Arm Strength Rehabilitation:
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Early application of resistive exercises for the treatment of epicondylitis. The exercises are meant to strengthen the upper extremities. It is a low-resistance and high-repetition exercise format.
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Specific exercises such as wrist flexion and forearm pronation provide most of the tensile stress to the medially inserted tendons that are not directly involved in lateral epicondylitis.
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The gradual addition of wrist extension and forearm supination, as well as radial and ulnar deviation exercises, are added as signs and symptoms reduce.
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Once the patient finishes these basic exercises, they are allowed to extend the range of motion by doing exercises such as ball dribbling, theraband resistance bar external oscillations, boxing, and seated rowing.
a) Wrist Extension and Flexion:
Place one pound of weight in the hand with the palm facing downward, keeping the forearm supported at the edge of a table or on the knee. Raise the wrist slowly and lower slowly.
b) Wrist Pronation and Supination Strengthening:
Grasp hammer or similar devices in hand with forearm support. Rotate the hand to the palm-down position and return to the start position; rotate to the palm-up position and repeat. Do the same with the hand further away or closer to increase or decrease resistance.
c) Theraband Exercise:
Fix the theraband firmly under the foot and fold the end with the affected hand. Then, keeping the elbows straight and the wrist towards the floor, use the free hand to pull the wrist back, stretching the band with it. Now release the free hand and allow the affected hand to slowly pull the wrist down towards the floor. Do this 15 times and rest for 1 minute and another 15 times.
d) Bar Exercise:
It is done using a flex bar. It is done by holding the bar on one end using the affected hand and the other end using the unaffected hand. The bar is twisted by flexing the unaffected hand in flexion and holding the involved wrist in extension. Now both hands are fully flexed to bring the bar forward while also twisting the bar. Now it is slowly untwisted by allowing the affected hand to flex.
3. Return-To-Activity Phase: This stage is reached only after the tolerance of previously stated resistive exercises. Strength is calculated using MMT (manual muscle testing) or isokinetic testing (measuring muscle strength and stability) and using a dynamometer (used to measure strength). This program outlines the progression of the patient. Continued application of resistive exercises and modification or evaluation of the patient’s equipment is made in this stage. Continuation of total arm strength rehabilitation using elastic resistance, medicine balls, and isotonic or isokinetic resistance is vital to enhance strength and muscular endurance.
Conclusion:
Shock wave therapy and traditional physiotherapy techniques have been used for the reduction of pain and to improve muscle performance in lateral epicondylitis patients. Patients have shown significant improvement in grip strength after undergoing these treatment modalities. Extracorporeal shock wave therapy not only reduces pain but also restores function. It is also painless and can be done for those not willing for surgery. Surgery is done only on patients who are unresponsive to traditional methods.
