LE is a diagnosis based on
clinical history and physical examination. Factors to assess when considering a
diagnosis of LE in the subjective assessment are;
The onset of pain 24-72 hours after
provocative activity involving wrist extension
the above patient, this would be playing badminton, which she hasn’t been able
to do for 3/52.
Difficulty with lift
is indicated by the patient being unable to do any DIY due to pain when
gripping as well as unable to lift and pour a kettle.
Changes in biomechanical factors (Bisset
& Vicenzino, 2015).
stated she started to increase badminton training where she noticed soreness of
the elbow at the end of her session but continued regardless
Pain located at the origin
of the extensor of the wrist located at the lateral epicondyle suggests LE. The specific clinical test for LE has
the aim of reproducing the pain experienced by the patient. Specific tests such
as the Cozen’s test, will be positive when the patients reports pain in the
lateral epicondyle. The alternative test, known as Mill’s test, is positive if
the patient feels pain in the lateral epicondyle (Cohen & da Rocha Motta Filho, 2012). Maudsley’s test further
supports the diagnosis of LE. During this test the examiner resists extension
of the third digit of the hand, while palpating the lateral epicondyle. A
positive test is indicated by pain over the lateral epicondyle (Valdes &
LaStayo, 2013). The sensitivity for Cozen’s test is 84%, Maudsley test is 88% and
Mills test was found to be 53%. The specificity for Cozen’s, Maudsley and Mills
test was found to be 0%, 0% and 100%. Therefore, Mills test has the greatest value
for diagnosing LE. Positive results would support my primary hypothesis of LE.
To support diagnosis, an assessment
of pain and disability can be performed. ‘The
Patient Rated Tennis Elbow Evaluation’ is a condition-specific questionnaire
which comprises of both pain and function. The results are
accumulated to give one overall score of 0 (no pain or disability) to 100
(worst possible pain and disability). It is worth noting that a difference of
11 points is clinically important (Bisset and Vicenzino, 2015).
Although the patient’s pain
appears to be predominately from the elbow, it
could be caused by a cervical radiculopathy in the C6-7 nerve route. When compressed, pain can develop and radiate along
the arm. In view of the patient’s reported history of
neck pain, the neural tissue should be evaluated. If impairments are found upon
examination, treatment is essential (Coombes, Bisset and Vicenzino, 2014).
Eccentric exercise is now widely known to lengthen the muscle-tendon complex. Stanish et al in 1986 were amongst the first academics to
recommend the use of eccentric exercise for managing tedinopathies. The
lengthening contraction initiates the structural re-modeling of the tendon with
added tensile strength (Page, 2010). Eccentric exercise has a neuromuscular
benefit via the central adaptation of both agonist and antagonist muscles. This
gives a structural and functional advantage with tendinopathy rehabilitation. A study in 2015 found that several patients with LE displayed
lower pain thresholds and larger referral patterns; suggesting a central
nervous system mediation of pain (Kenas, Masi & Kuntz, 2015). Several conditions that
trigger pain are able to stimulate neuropathic pain. In the peripheral nervous system there are three main mechanisms:
Conditions that result in spontaneous firing of damaged nerve fibers.
Oversensitivity of afferent pathways due to denervation.
sympathetically maintained pain.
though stretches do not have a role in the prevention of the injury; slow extensor stretching exercises can be used following
eccentric exercises. This has been shown to offer advantages in the
conditioning process and aid in the desensitisation of the painful soft
tissues (Coombes, Bisset & Vicenzino, 2009).
Mill’s manipulation is used
in the management of LE. This is a small-amplitude high-velocity thrust
performed at the end of elbow extension while the wrist and hand are flexed. It
targets the common extensor tendon and should only be performed if pain reduces
back down to a zero on the VAS scale. It should only be attempted three times
to achieve this (Vicenzino, Cleland & Bisset, 2007). It is usually coupled
with transverse friction massage to break down scar tissue, align connective
tissue fibrils and increase blood flow. Deep transverse friction massage also works
as pain relief due to the pain gate theory (Bisset & Vicenzino, 2015). The amount of manual force applied together with
orientation of the glide by the therapist is essential to the effectiveness of
this technique. The lateral glide
force being focused directly lateral or slightly posteior is most effective and
shown to maximize the hypoalgesic effect (Rahman, Charturvedi, Apparao &
Education and advice of how
to manage and restrict activities of the forearm
In relation to this patient,
amending or adjusting the patients gripping angle of badminton racket to prevent the patient from over extension. Calculations
can be performed of the circumference of racket handle to ensure correct grip. Lifting
should be completed with palm facing up when possible. Both arms should be used in an optimum position that reduces
forcible elbow extension, supination and wrist extension. The action of typing without support may exacerbate pain,
therefore placing the elbows on staked towels can help to prevent the onset of
pain (Bisset & Vicenzino, 2015).
Strapping or taping the forearm
to offload structures of the common extensor tendon is a valid option whilst
the patient is at work and regularly performing painful activities. The tension is modified
to comfort while the muscles are relaxed so that maximal contraction of
the finger and wrist extensors is inhibited by the band (Whaley & Baker,
Pain control such as transcutaneous
electrical nerve stimulation (TENS) and analgesia should
be considered for this patient as she has a VAS of 6/10 (Chesterton et
LE is recognised as being
difficult to treat and patients tend to be predisposed to recurrent episodes.
The average duration of a LE ranges from 6 to 24 months. 89% of patients achieve
recovery after 1 year. In a recent randomised trial, 72% of patients reported a
recurrence in their conditions within 12 months of receiving a corticosteroid
injection in comparison to the 9% with a “wait and see” policy (Coombes, Bisset
& Vicenzino, 2009). Another study identified that 5- 10% of EL patients
developed chronic symptoms and eventually underwent surgical interventions (Bisset
& Vicenzino, 2015).
A treatment plan
using a combination of education, advice, manual techniques and eccentric
exercises should lead to a positive prognosis, particularly as the patient has
sought treatment before her symptoms have turned to the chronic stage. However,
the overall prognosis heavily depends on the patient’s compliance to exercise and
advice, which can be difficult to predict.