Chapter. Elbow tendinopathy: lateral epicondylalgia Bill Vicenzino INTRODUCTION CHAPTER CONTENTS

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2 Chapter 23 Elbow tendinopathy: lateral epicondylalgia Bill Vicenzino CHAPTER CONTENTS Introduction 312 Diagnostic considerations 313 Pathologic considerations 313 Prognostic considerations 314 Considerations in conservative treatment 314 Conclusion 316 INTRODUCTION The common tendon of the extensor muscles of the wrist and fingers is the most frequently implicated tendon in elbow tendinopathy and will be the focus of this chapter. There is contention as to the correct nomenclature for the tendinopathy of the extensor muscles of the wrist and fingers. A number of terms are used in reference to this tendinopathy, such as, tennis elbow, lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia. Tennis elbow is frequently used colloquially, but this term confuses many patients, as the condition is also very prevalent in those patients who do not play tennis. Epicondylitis infers inflammation, which has long been shown not to be the case (Nirschl & Pettrone 1979, Regan et al 1992, Potter et al 1995, Kraushaar & Nirschl 1999, Alfredson et al 2000). Epicondylosis or tendinosis connotes a degenerative change, but whilst there has been identified elements of disarray, breakdown or degeneration of collagen fibrils in such tendons (Regan et al 1992, Kraushaar & Nirschl 1999), the relationship to presenting pain symptoms and associated clinical signs is not clear (Khan & Cook 2000). Lateral epicondylalgia indicates that there is pain over the lateral epicondyle which may be an accurate term to use for the patient presenting with pain over the lateral epicondyle, but it provides little information about the underlying pathology. Recent reports of neovascularization and associated increased concentrations of algogenic mediators such as glutamate, substance P and calcitonin gene-related peptide (Ljung et al 1999, 2004, Alfredson et al 2000, Zeisig et al 2006, du Toit et al 2008) suggests that tendinopathy is far more complex than any of these commonly used terms suggest. For this chapter, the term lateral epicondylalgia will be used to describe the patient who attends the clinic with pain over the lateral epicondyle, as will be highlighted, this may be due to some pathology in the tendon, that is, tendinopathy, but the pain may also be associated with other conditions, which need to be considered to fully rehabilitate the patient. Although there is no definitive evidence, the incidence of lateral epicondylalgia varies from 1% to 3% in the general population (Allander 1974, Verhaar 1994), which contrasts to reports of prevalence rates as high as 35 64% in occupations requiring repetitive manual tasks (Kivi 1982, Dimberg 1987, Feuerstein et al 1998), where it is one of the most costly of all work-related injuries (Kivi 1982, Dimberg 1987, Feuerstein et al 1998). A survey of United States of America Department of Labor, Office of Worker s Compensation Programs, accepted claims of occupational upper extremity disorders demonstrated that lateral epicondylalgia was responsible for approximately 27% and 48% of all work related claims for upper limb tendinopathies and enthesopathies, respectively (Feuerstein et al 1998). This chapter focuses on the most common tendinopathy about the elbow, lateral epicondylalgia, with specific consideration of the Elsevier Ltd. DOI: /B

3 Chapter 23 Elbow tendinopathy evidence in regards to diagnosis, pathology, conservative management and prognosis. DIAGNOSTIC CONSIDERATIONS Lateral epicondylalgia is usually identified or diagnosed on the basis of a clinical examination. Classically, the patient presents with pain over the lateral elbow and may spread into the dorsal forearm as far as the wrist, but no further than the wrist and not proximally to the elbow (see Slater et al (2003, 2005) for patterns of pain maps). Those with pain and symptoms into the hand and fingers or proximal to the elbow should be considered to have concomitant problems (e.g. cervical spine referral, neuropathy) in addition to, or instead of, lateral epicondylalgia. Patients with lateral epicondylalgia will have pain and weakness with tests that challenge the wrist extensor muscles, for example, muscle contraction tasks of gripping, wrist extension, and middle finger extension (clinically described as a test of extensor carpi radialis brevis, largely due to the insertion of that tendon at the wrist). It is commonly reported that stretch of the wrist and finger extensors is present in these patients, though while pain may be reproduced on stretching, it is not an uncommon observation by this author that patients exhibit increased length of these muscles (i.e. increased range of flexion of the wrist and fingers) associated with pain reproduction in those with chronic conditions. The pain reproduction is limited to the lateral epicondyle and at most some spread down into the dorsal forearm. Palpation will identify areas of hyperalgesia in and around the lateral epicondyle, at the site of the common extensor tendon as well as in some cases pain into the dorsal forearm muscles. These palpation findings need to be present with impairment in muscle contraction; otherwise it is more likely that the symptoms could be largely referred from other regions, such as the cervical spine. Typically patients attending general practice with lateral epicondylalgia will characteristically be in their 4th or 5th decade of life. There is upper limb dominance bias, but not sex. Patients who perform repetitive tasks requiring sustained or repeated gripping of an implement or tool, such as those playing tennis or undertaking manual labour, may be outside of this decade (i.e. younger), but there should be a higher degree of suspicion of an alternative underlying cause and diagnosis. For example, in younger people consideration needs to be given to osteochondritis dissecans of the capitellum and radius in cases with insidious onset, and bursitis, radio-humeral joint synovitis and other soft tissue sprains in more acute onset pain and swelling, whereas in more elderly patients the practitioner will need to consider degenerative conditions of the radio-humeral joint and referral from the cervical spine (Brukner & Khan 2007). Lateral epicondylalgia is by definition a clinical entity not usually requiring confirmatory diagnostic imaging or other medical pathology tests. Diagnostic imaging is likely more helpful in excluding differential diagnoses. For example, radiographs may be used to identify injuries of bone, such as, fractures, apophysitis and sub-chondral arthritic changes. Ultrasound has taken on a greater role in the direct identification of grey scale hypoechoic lesions, which imply dysfunction in the connective tissues. These grey scale changes are not necessarily linked to pain in the tendon (Cook et al 2001, 2004, du Toit et al 2008) and so they could be legitimately termed tendinopathy, meaning some pathology in the tendon, and is most likely due to degenerative breakdown of collagen fibrils (epicondylosis), though fusiform swelling may be more indicative of cellular and matrix dysfunction (Cook & Purdam 2009). Increasingly, evidence is pointing towards a link between neovessels and symptoms, namely pain (Cook et al 2001, 2004, du Toit et al 2008), with a recent study showing that in a patient with longstanding lateral elbow pain, which has failed to respond to treatment, the lack of neovessels strongly indicates that the pain is not due to tendinopathy, thus prompting the practitioner to consider other diagnoses (du Toit et al 2008). Magnetic resonance imaging may be used to follow up recalcitrant cases where there are no radiographic or ultrasonographic changes present, but these cases will be in the minority. PATHOLOGIC CONSIDERATIONS Nirschl & Pettrone (1979) described the underlying pathology of lateral epicondylalgia to be one of angiofibroblastic hyperplasia with the following identified histological changes: (a) proliferation in the number of cells and in ground substance, (b) neovascularization or vascular hyperplasia, (c) higher levels of algogenic substances, as well as (d) disorganized immature collagen (Nirschl & Pettrone 1979, Nirschl 1992, Regan et al 1992, Fredberg et al 2008). In an effort to more adequately explain different clinical presentations, Cook & Purdam (2009) have recently proposed a clinical model of histo-pathological changes across a continuum from: (a) reactive tendinopathy, (b) tendon disrepair to (c) degenerative tendinopathy. A brief summary of this proposed clinical model follows and the reader is referred to their paper for more detail. Reactive tendinopathy is a non-inflammatory proliferative cellular and matrix response in response to either an acute tensile overload as may occur with a bout of unaccustomed physical activity or from a compressive overload due to a direct contact injury. This is likely to occur in the younger athlete who rapidly increases the intensity or volume of physical activity and is managed well with a 313

4 Part 4 The elbow region short period of absence from the increased loading activities before restoring pain free function. Consequently the classic presentation of lateral epicondylalgia is not likely to fall into this category, though it is important to keep this category in mind for younger athletes such as tennis players or manual labourers, as well as patients who present with pain after an acute traumatic blow to the common extensor origin at the elbow. At the other end of the spectrum the degenerative phase is characterized by angiofibroblastic hyperplasia changes, with considerable breakdown in the collagen framework and neovascularization. This tends to occur with chronic overloading in the older person; hence more appropriately fits that which is likely to be present in a classical presentation of lateral epicondylalgia. There is a sound argument that exercises need to be a fundamental inclusion in the treatment plan for degenerative tendinopathy (Cook & Purdam 2009, Khan & Scott 2009). PROGNOSTIC CONSIDERATIONS Lateral epicondylalgia is widely regarded as being self-limiting and resolving within 6 months to 2 years, however this is low-level evidence as the natural history of this condition has not been definitively determined. Notwithstanding this, recently a number of randomized clinical trials that have followed cases over 12 months (Smidt et al 2002, Bisset et al 2006, 2007, Smidt & van der Windt 2006) and provide data that may be used in determining prognosis. The evidence from two randomized clinical trials (n ¼ 383) (Smidt et al 2002, Bisset et al 2006), which included randomizing a group of patients to following a wait-andsee policy indicates that 87% of patients reported being much improved or completely recovered 12 months after inclusion into the study (Bisset et al 2007). When considering that patients had on average approximately 6 months duration of pain at inclusion into the study (Bisset et al 2007), an approximate indicative natural history of the condition is in the order of 18 months for the majority of sufferers. It is important to keep in mind that the patients allocated to the group following the wait and see policy were given advice on avoiding aggravating activities (e.g. ergonomic advice on how to lift objects and manipulate implements without aggravating pain) as well as being closely monitored in a clinical trial (and thereby prone to the Hawthorne effect), which is not necessarily the same as a person with lateral epicondylalgia not seeking out advice and doing nothing about the condition. Furthermore, Bisset et al (2006) reported that those in the group allocated to wait and see policy were 2.7 times more likely to seek out other treatments than those allocated to a mobilization with movement and exercise group (OR, 95% CI: 4.7, ), which is not the same as doing nothing about the lateral epicondylalgia. To the contrary it tends to indicate that despite being recruited into a clinical trial and being closely monitored patients do not feel comfortable in doing nothing about their condition. Smidt et al (2006) prospectively followed 349 patients from two randomized clinical trials (Hay et al 1999, Smidt et al 2002) over a 12-month period and found that those who had more severe pain of longer duration had greater likelihood of a worse outcome (more severe pain) at 12 months. Another prognostic factor of poor outcome was concomitant neck pain (Smidt et al 2006). This finding is interesting because it indicates that the patient pool recruited in this study had a heterogenic pain presentation, including cases with more complex presentations (e.g. lateral epicondylalgia plus neck pain) and did not consist solely of patients with isolated lateral epicondylalgia. CONSIDERATIONS IN CONSERVATIVE TREATMENT A wide range of conservative treatments, such as, medication, electrophysical agents, exercise and manual therapy are advocated for lateral epicondylalgia, which usually is an indication that no one treatment has proven superiority, but also in part a product of an inconclusive understanding of the underlying pathology of the condition. Corticosteroid injections are the most common conservative medical intervention for lateral epicondylalgia and accordingly they have been studied the most in high quality rigorous clinical trials. There is level 1 evidence from a number of randomized clinical trials of short term efficacy with success rates over 80% in the first 4 6 weeks (Hay et al 1999, Smidt et al 2002, Bisset et al 2006, 2007, Smidt & van der Windt 2006), but this needs to be considered in light of post-6 weeks poorer outcomes in the form of lower success rates compared to the adoption of a wait and see policy (Smidt et al 2002, Bisset et al 2006, 2007, Smidt & van der Windt 2006), higher recurrence rates (70% vs 8%) and greater use of other not per protocol co-interventions (49% vs 21%) than those patients undergoing mobilization with movements and exercise intervention (Bisset et al 2006, 2007). The poorer downstream effects are sufficient to prompt caution in their use and some have advocated against their use in lateral epicondylalgia (Young et al 1954, Osborne 2009, Vicenzino 2009), at least in the first instance without a concerted attempt at other interventions that do not have such a poor longer-term effect on the condition. Others have advocated combining the use of these injections with physiotherapy (Coombes et al 2009a, Olaussen et al 2009), but there has not been the same level of enquiry. There is a sound level of evidence in support of exercise in treating lateral epicondylalgia, but unlike in lower limb 314

5 Chapter 23 Elbow tendinopathy tendinopathy, eccentric exercise is not necessarily better than concentric exercise (Woodley et al 2007). Perhaps the most illustrative evidence comes from a randomized clinical trial comparing an exercise programme versus ultrasound in a group of patients who had recalcitrant lateral epicondylalgia having failed other treatments including corticosteroid injections and other common modalities (Pienimaki et al 1996). Follow up some 3 years later revealed that the exercise group required fewer medical consultations, had less surgery (NNT ¼ 3) and 586 fewer sick days than the group that had ultrasound (Pienimaki et al 1998). The exercise programme was graduated and progressive from isometric to isotonic contractions of the wrist and forearm muscles, culminating in pragmatic exercises that replicated patient s required function. It was supervised two times per week for approximately 8 weeks. A recent study has shown that supervision of the exercise programme returns superior effects to a home based one (Stasinopoulos et al 2009), which should be considered when prescribing exercise. Electrophysical agents such as LASER, ultrasound, and extracorporeal shock wave therapy (ESWT) have attracted attention. Low level LASER therapy has been shown to be effective in improving pain levels in the short term compared to control, but only at wavelength of 908 nm (Bjordal et al 2008). There appears to be less conclusive evidence and some contention for or against the use of ultrasound and ESWT in the treatment of lateral epicondylalgia, perhaps because of a lack of specification and stratification of dosage parameters. Elbow orthotics or tennis elbow bands that fit about the proximal forearm are frequently used, often on a selfselection basis by patients. Systematic reviews have been unable to find sufficient high quality clinical trials to support or refute their use (Struijs et al 2001, 2002, 2004). Joint (high and low velocity) and soft tissue manipulations have been proposed for use in treatment of lateral epicondylalgia (Lee 1986, Vicenzino et al 2007a). The initial effects of elbow mobilizations with movement (Vicenzino 2003) used as a single modality have been shown in a number of studies (Vicenzino et al 1996, 2001, 2007b, Abbott et al 2001, Paungmali et al 2003) and shown to be effective when used in combination with exercise (Kochar & Dogra 2002, Bissetetal2006). There are conflicting interpretations of the literature regarding the use of Mill s manipulation and friction massage, also referred to as Cyriax physiotherapy (Vicenzino et al 2007a, Kohia et al 2008), which may be in part due to the lack of high quality clinical trials (Bisset et al 2005). There is a randomized clinical trial that has shown that wrist manipulation was efficacious when compared to ultrasound, friction massage and exercise (Struijs et al 2003). As identified in a prognostic analysis, patients with concomitant neck pain have a poorer outcome (Smidt et al 2006), but the neck was not treated and so it is not possible to determine if it would have been beneficial to have added neck treatment to the elbow treatment. However, there are several other studies that show benefits of adding treatment of the cervical spine to elbow treatment (Gunn & Milbrandt 1976, Cleland et al 2004, 2005). Gunn & Milbrandt (1976) treated 50 recalcitrant cases of lateral epicondylalgia with non-thrust manipulation and traction of the cervical spine and showed an 86% success rate after treatment that persisted at 6 months. In a retrospective case audit of 112 cases, Cleland et al (2004) showed significantly fewer treatments were required for those (n ¼ 51) who received additional manual therapy to the cervical spine in the form of non-thrust oscillatory manipulations, mobilization with movements and/or muscle energy techniques. More recently in a pilot trial of 10 cases, Cleland et al (2005) reported a better result on pain free grip force and the Disability of the Arm, Shoulder and Hand questionnaire. Furthermore, there are a number of studies that show both high and lowvelocity manipulations of the cervical spine produce an initial improvement in pain at the elbow (Vicenzino et al 1996, 1998, Fernández-Carnero et al 2008). This evidence provides a basis for the cervical spine to be treated if found to be implicated on physical examination, especially since there have been reported significant differences in pain provocation on manual examination of the cervical spine and significant reductions in sagittal plane motion in patients with lateral epicondylalgia when compared to age-matched controls (Waugh et al 2004, Berglund et al 2008). The challenge facing the practitioner is how to best select a treatment approach for each individual patient, who is likely to be somewhat different in their individual clinical presentations. The continuum model of presentation of tendinopathy (Cook & Purdam 2009) outlined above along with the proposed integrative model of lateral epicondylalgia (Coombes et al 2009b) may provide some guidance on how the practitioner may wish to select from the many proposed treatments. In brief, Coombes et al (2009b) propose that each patient presents with a different proportional representation of dysfunction in the pain and motor systems as well as in tendon structure and physiology, which could be used to select specific interventions. For example, if a patient presents with relatively greater pain system impediment as would be seen clinically with large deficits in pressure pain thresholds and high pain severity scores, then pain relieving medications, electrophysical agents and manual therapy should be favoured. In contrast, a patient who presented with a progressed stage of degenerative tendinopathy with moderate to low levels of pain would be managed more so with specific exercise (Coombes et al 2009b, Khan & Scott 2009) and possibly injections of medication/materials (Rabago et al 2009) or glyceryl trinitrate transdermal patches (Paoloni et al 2003, 2009, Murrell 2007) that promote collagen synthesis. Further detail regarding the integrative model of lateral epicondylalgia can be found in Coombes et al (2009b). 315

6 Part 4 The elbow region CONCLUSION Tendinopathy at the elbow is commonly experienced over the lateral epicondyle. Over the past decade there has been an increase in the knowledge of our understanding of the underlying pathology, conservative management and prognosis of this pain condition. While this has provided more information and data for practitioners to consider when treating patients with lateral epicondylalgia, the challenge still remains to selectively apply specific treatments to individual patients in order to drive optimum outcomes. This chapter provides a synopsis of the recent evidence and some indication of possible means by which to apply such evidence clinically. REFERENCES Abbott, J.H., Patla, C.E., Jensen, R.H., The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man. Ther. 6, Alfredson, H., Ljung, B.O., Thorsen, K., Lorentzon, R., In vivo investigation of ECRB tendons with microdialysis technique no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop. Scand. 71, Allander, E., Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scand. J. Rheumatol. 3, Berglund, K.M., Persson, B.H., Denison, E., Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man. Ther. 13, Bisset, L., Paungmali, A., Vicenzino, B., Beller, E., A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br. J. Sports Med. 39, Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., Vicenzino, B., Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ bmj AE. Bisset, L., Smidt, N., Van der Windt, D.A., Bouter, L.M., Jull, G., Brooks, P., et al., Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford) 46, Bjordal, J.M., Lopes-Martins, R.A., Joensen, J., Couppe, C., Ljunggren, A.E., Stergioulas, A., et al., A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet. Disord. 9, 75. Brukner, P., Khan, K., Clinical Sports Medicine. McGraw-Hill, Northe Ryde, NSW. Cleland, J.A., Whitman, J.M., Fritz, J.M., Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J. Orthop. Sports Phys. Ther. 34, discussion Cleland, J., Flynn, T., Palmer, J., Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot clinical trial. J. Man. Manip. Ther. 13, Cook, J.L., Purdam, C.R., Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br. J. Sports Med. 43, Cook, J.L., Khan, K.M., Kiss, Z.S., Coleman, B.D., Griffiths, L., Asymptomatic hypoechoic regions on patellar tendon ultrasound: A 4-year clinical and ultrasound follow-up of 46 tendons. Scand. J. Med. Sci. Sports 11, Cook, J.L., Malliaras, P., De Luca, J., Ptasznik, R., Morris, M.E., Goldie, P., Neovascularization and pain in abnormal patellar tendons of active jumping athletes. Clin. J. Sport Med. 14, Coombes, B., Bisset, L., Connelly, L., Brooks, P., Vicenzino, B., 2009a. Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison. BMC Musculoskelet. Disord. 10, 76. Coombes, B., Bisset, L., Vicenzino, B., 2009b. An integrative model of lateral epicondylalgia. Br. J. Sports Med. 43, Dimberg, L., The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics 30, Du Toit, C., Stieler, M., Saunders, R., Bisset, L., Vicenzino, B., Diagnostic accuracy of power- Doppler Ultrasound In Patients With Chronic Tennis Elbow. Br. J. Sports Med. 42, Fernández-Carnero, J., Fernándezde-las-Peñas, C., Cleland, J.A., Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. J. Manipulative Physiol. Ther. 31, Feuerstein, M., Miller, V.L., Burrell, L.M., Berger, R., Occupational upper extremity disorders in the federal workforce: Prevalence, health care expenditures, and patterns of work disability. J. Occup. Environ. Med. 40, Fredberg, U., Bolvig, L., Andersen, N.T., Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am. J. Sports Med. 36, Gunn, C.C., Milbrandt, W.E., Tennis elbow and the cervical spine. Can. Med. Assoc. J. 114, Hay, E.M., Paterson, S.M., Lewis, M., Hosie, G., Croft, P., Pragmatic randomised controlled trial of local 316

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