Pathophysiology
- Repetitve Wrist extension causes micro tearing of CEO |
- Common tendon affected is ECRB (hypovascular) |
- Chronic cases- inflammatory cells are absent |
- Failure of the natural healing process (angioblastic degneration) |
Demographics
- Usually in 4th/5th decade of life |
- Affects men and women equally |
- Most of the time it presents in dominant arm |
Risk Factors
- Repeated wrist extension and forearm supination/pronation |
- Occupations/activies: carpenters, bricklayers, seamstresses, tailor, pianists, drummers, people who shake hands alot, tennis players.prolonged keyboard/mouse usage |
- Tennis rplayers - improper mechanics during backhands/serves |
- Ask about racquet: Heavy/new/tightly strung, excessive gripping, hitting wet/heavy tennisballs |
Presentation
- Insidious after overuse activity - usually no trauma |
- Pain over lateral aspect of elbow |
- Provoked by activities that involve gripping/wrist extension |
- Relieved by rest |
- Usually localised - but consider peripheral neuropathy (radial tunnel) if distal symptoms (nocturnal pain more common in radial tunnel than LE) |
- Pain on palpation of lateral epicondyle (over ECRB tendon 2nd one down) |
- Pain on RROM - wrist extension |
- +ve Cozen's, +ve long finger extension test |
- Consider Anconeus TrPs |
- Neurological exam normal unless radial tunnel syndrome( diminished sensitivity over dorsal aspect of the forearm/thumb and weakness of thumb extension |
Imaging
Further imaging if red flags: F# , dislocation, infection, hx of trauma, neoplasm |
US (can reveal asymptomatic damage at ECBR) - can pick up calcific tendinitis |
DDx
- Cx radiculopathy |
- Radial Tunnel syndrome |
- OA |
- F# |
- Infection |
- Neoplasm |
- Osteochondral loose body |
- Elbow synovitis |
- Triceps tendinitis |
- Sprain/strain |
- Myofascial pain syndrome |
- inflammatory Arthropathy |
Management
- Rest and avoidance of offending activity (wrist ext, pronation/supination) |
- Ice/Ice massage |
- Change mechanics (2 handed backstroke) |
- EMT/mobilisation of the elbow and wrist |
- SMT of Cx Tx |
- Deep friction massage of tendon |
- STM and stretching of wrist extensors and supinator |
- ECRB stretched by elbow extension, forearm pronation and wrist flexion |
- Slow and progressive (moderate effort and low reptitiions) - assessed by night pain (increased = load is excessive) |
Progression advances when patient tolerates a given level of tensile load |
- Resistance training - isometrically then eccentric |
- Tyler twist with theraband flexbar |
- Scapular stability deficits |
- Ultrasound treatment |
- Oral/topical NSAIDs |
- Corticosteriod injections |
- Surgical consideration/poor prognosis of conservative care if: failure of conservative care, heavy manual labour, LE in dominant arm, high pain perception, poor coping strats |
Medial Epicondylopathy
- Pronator teres, FCR, Palmaris Longus, FDS, FCU |
- Most frequent cause of medial elbow pain |
Causes
- Repetitive flexion and pronation and valgus stress |
- Injuries (trauma, excessive stretch, eccentric overload) |
- Microtearing - disorganised healing process, failure to regenerate |
- FCR and pronator teres origin most commonly affected |
- Affects men and women equally
4th and5th decade
Dominant arm mostly affected
athletes (golfers - top of their back swing until ball impact, baseball players (acceleration phase of throwing), racquet sports , bowling, javelin throwing, football, archery, weight lifting |
- Occupations that require repetitive flexion and pronation |
- Obesity |
- Smoking |
- Type II diabetes |
Presentation
- Dull pain over medial elbow |
- Grip weakness |
- Swelling often present |
- TTP over <1 finger breadth distal and anterior to the centre of the medial epicondyle |
- Pain during resisted forearm pronation + resisted wrist flexion + resisted elbow flexion (in chronic cases) |
- Ulnar neuritis, Cubital tunnel syndrome and UCL instability (moving valgus stress test) must be considered |
Imaging
- Only if unresponsive to conservative care/trauma (rule out avulsion f#) |
- MRI for stress f#. infections, tumours, ligamentous injuries and osteochondritis dissecans |
- US for ruling in medial epicondylopathy |
DDx
- Cubital tunnel syndrome |
- Little league elbow (children) |
- Muscle strain |
- Cx radiculopathy |
- F# |
- Infection |
- Neoplasm |
- Bursitis |
- Flexion contracture |
- Pronator Quadratus syndrome |
- Intraarticular injury |
- Osteochondritis dissecans |
- Anterior interosseous nerve entrapment |
- Rheumatologic disease |
Management
- Prone to recurrence, prolonged discomfort present |
- Rest , ice/ice massage NSAIDs for acute cases |
- If chronic - bracings (counter force), eccentric rehab, activity modification |
- Limitation/stopping offending activity |
- Cock up wrist splints for night time |
- Myofascial/stretching of common flexor tendon |
- Mobilisation/manipulation into ext if flexion contracture |
- SMT/EMT of the Cx, elbow, wrist and shoulder |
- Moderate efforts with low reps on rehab |
- Stretching then strengthening |
- Reverse tyler twists |
- Surgery if unresponsive to conservative care after 3-6 months |
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