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Tennis Elbow – Case Study 9.

 

Tennis Elbow – Case Study 9.

Category: Acupuncture, Corticosteroid Injection, Counterforce braces, Elbow Pain, Extensor Carpi Radialis Brevis, Hydrotherapy, Lateral Epicondylitis, Medial Epicondylitis, Radial Tunnel Syndrome, Tennis Elbow

Tennis Elbow (Lateral Epicondylitis) – Case Study 9.

(also read our dedicated page on hand, arm and shoulder pain)

Mr. G was a 44 year old accountant who presented to the clinic with a 7 week history of right elbow pain radiating into his forearm. Right-handed, he found it increasingly more difficult to do very basic day to day to activities, such as shaving, driving and use a computer mouse. His symptoms started gradually but after three weeks he needed to attend his local Medical Centre and was diagnosed with ‘RSI’ by his GP and prescribed a two week course of Naproxen (Non-steroidal anti-inflammatory drugs). He described transient improvement of his symptoms during this 2 week period but that his elbow became worse after the course was complete and he was becoming increasingly frustrating as it was an extremely busy time of year at work. A colleague of his suggested trying osteopathy and recommended our clinic. Following a comprehensive consultation we arrived at the working diagnosis of tennis elbow (Lateral Epicondylitis).

It appears that Mr. G had decided to take on a large DIY project, several months before presenting to our clinic, building a large decking area in his garden. Although he enjoyed the achievement he was starting to regret the impact it had had on his body and his work life. When we talked him through his condition, describing the tissue involved and the mechanism of injury it became clear which particular activities had been the driving force behind his symptoms. Lacking an electric screwdriver he had manually screwed down all the decking boards.

Treatment outlines

We are pleased to report that Mr G made a full recovery and has now purchased an electric screwdriver! The following is an outline of the program of treatment that we designed for Mr. G.

* Hydrotherapy – 10 to 15 minutes four to six times daily.

* Gentle soft tissue and stretching techniques.

* Rest – Important to outline the mechanism of injury and how to avoid it.

* Pain Relief & Non-steroidal anti-inflammatory drugs (NSAID’s).

* Workstation advice and assessment.

(See below for further information on all available treatment modalities)

 

Background

  • The epicondyles are the two bumps on the inside (medial) and outside (lateral) part of the elbow. They form the end of the long bone in the upper arm.
    Tennis Elbow (Lateral Epicondylitis)

    Tennis Elbow (Lateral Epicondylitis)

  • The common extensor tendon is a tendon shared by a number of extensor muscles in the forearm and is attached to the lateral epicondyle.
  • Tennis Elbow (Lateral Epicondylitis) is related to excessive wrist extension.
  • Commonly referred to as “tennis elbow,” but it is actually more common in non-tennis players.
  • Microscopic evaluation of the tendons does not show signs of inflammation.
  • The tendons are relatively hypovascular proximal to the tendon insertion.
  • Most typically, the primary pathology is tendinosis of the extensor carpi radialis brevis (ECRB) tendon 1-2 cm distal to its attachment on the lateral epicondyle.

Incidence

  • Incidence is 1-3% of the population.
  • It is the most common overuse syndrome.
  • Men and women are equally affected.
  • Age range, 40 to 60 year olds.
  • It occurs in the dominant arm in about 75 percent of people.
  • Only 1 in 20 play tennis (e.g. symptoms can occur after an improper backhand hitting technique).
  • Lateral epicondylitis occurs 7:1 more frequently than medial epicondylitis (golfers elbow).

Onset

  • Can be caused by repetitive arm movements or gripping (such as typing, painting, using a screwdriver, wringing wet clothes or knitting).
  • Patients most typically report an insidious onset.
  • Symptom onset generally occurs 24-72 hours after repeated wrist extension activity.
  • Associated conditions – Radial Tunnel Syndrome is present in 5%.

Examination

  • Very rarely do you notice swelling.
  • Pain is increased with resisted wrist extension, with the wrist radially deviated and pronated and the elbow extended
  • Resisted extension of the middle finger is also painful secondary to stress placed on the ECRB tendon.
  • Increased pain is noted with resisted supination and hand shaking.

Treatment

  • Nonsteroidal anti-inflammatory drugs ( NSAIDS) may offer some short-term relief.
  • Corticosteroid injection demonstrated greater benefit at 4 weeks when compared with NSAIDS, but no long-term differences were seen.
  • Counterforce braces are used in an attempt to reduce the tension forces on the wrist extensor tendons.
    Counterforce Brace - Tennis Elbow.

    Counterforce Brace – Tennis Elbow.

  • Laser therapy treatments have not been proven to be an effective method to treat patients with pain from lateral epicondylitis.
  • Acupuncture reviews have demonstrated some evidence of short-term improvement in pain reduction at 2 to 8 weeks in patients suffering from lateral epicondylar pain.
  • Ultrasound (US) therapy has demonstrated modest pain reduction.

Osteopathy

  • Hydrotherapy – Applying a cold pack to the elbow (15 mins up to six times a day) to reduce pain.
  • Manual Therapy – Soft tissue work and stretching has been shown to decrease pain.
  • Managing Recovery – Recognising causative factor and setting realistic goals.
  • Osteopathic treatment may also include the use of braces, Laser therapy and Ultra-sound.

Surgery

  • Most of the time the above treatments work. But if you have a severe case of tennis elbow that doesn’t respond to two to four months of conservative treatment, you may need surgery.
  • The damaged section of tendon usually is removed and the remaining tendon repaired.
  • Surgery is estimated to work in 85%-90% of cases.

References

Lateral Epicondylitis – http://emedicine.medscape.com/article/96969-overview

Tennis Elbow (Lateral Epicondylitis) – http://www.webmd.com/fitness-exercise/tennis-elbow-lateral-epicondylitis

Tennis Elbow / Lateral Epicondylitis – http://www.sportsinjuryclinic.net/sport-injuries/elbow-pain/tennis-elbow

 

Tennis Elbow (Lateral Epicondylitis) – Case Study 9.

 

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