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History
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A thorough but focused history and physical examination
are critical to a timely and accurate diagnosis. e main objective is to collect sucient clinical data to establish a diagnostic
hypothesis that will focus the examination while conrming
that no signs and symptoms are present that would require immediate medical referral. Important areas to discuss include the
mode of onset, the location, quality, nature, and behavior of the
symptoms, and the patient’s goals. A body chart can help collect
information on the specic location and nature of the patient’s
symptoms. Information should be sought on factors such as
tobacco use, occupation, hand dominance, recreational activities, duration of symptoms, and prior episodes and attempted
treatments.
16
With few exceptions, pain in a specic area of the elbow is
caused by underlying physical structures. For example,
• Anterior elbow symptoms suggest an anterior capsular sprain,
distal biceps tendon rupture or tendinopathy, elbow dislocation, or pronator syndrome (particularly in throwers).
Medial elbow symptoms suggest medial elbow tendinopathy
•
(MET), ulnar collateral ligament (UCL) sprain, ulnar nerve
injury, exor-pronator muscle injury, fracture, Little League
elbow (in skeletally immature throwers), or valgus extension
overload.
• Posteromedial elbow symptoms suggest an olecranon tip
stress fracture, posterior impingement (in throwers), or trochlea chondromalacia.
• Posterior elbow symptoms suggest olecranon bursitis, olecra-
non process stress fracture, or triceps tendinopathy.
• Lateral elbow symptoms suggest a capitulum fracture, lat-
eral elbow tendinopathy (LET), a radial collateral ligament
(RCL) complex sprain, osteochondral degenerative changes,
osteochondritis dissecans (Panner’s disease), posterior interosseous nerve syndrome, radial head fracture, radial tunnel
syndrome, or synovitis.
Forearm symptoms with a gradual onset can result from sev-
•
eral causes including a radius or ulna stress fracture, radial
tunnel syndrome, cubital tunnel syndrome, and brachialis
tendinopathy.
Symptoms from neuromusculoskeletal sources other than
the elbow that should be included in the dierential diagnosis
include nerve root conditions (cervical radiculopathy at the C6
or C7 level or both may cause referral of pain into the lateral elbow area), shoulder pathology, thoracic outlet or brachial
plexus pathology, primary nerve pathology, peripheral nerve
17
entrapment syndrome, and diabetes mellitus.
Lower motor neurons transmit impulses via peripheral spinal nerves or
cranial nerves from the anterior horn of the spinal cord to the
associated skeletal muscle(s); consequently, a lower motor neuron lesion presents with muscle atrophy, fasciculations (muscle
twitching), decreased reexes, decreased tone, negative Babinski
sign, and accid paralysis.
Asking the patient how the following activities aect their
symptoms may assist in the dierential diagnosis:
18
• Lifting
• Activities of daily living (ADLs)
• Gripping (small vs large objects; pronated vs supinated position)
Cervical and thoracic movements or sustained postures
•
• Shoulder position
•
Sustained or repeated activities.
e majority of patients seek physical therapy services for
pain relief. Although pain may feel like it is coming from the
patient’s body, it is an emotional experience that is highly individualized and extremely dicult to quantify. Attempts to
quantify pain should endeavor to be objective, but pain is a
subjective phenomenon. Medicine is currently moving toward
the biopsychosocial management of pain and other symptoms
due to the realization that health status and concomitant conditions, such as psychological, intrinsic (discriminative, aective,
and cognitive components), and biological factors (genetics,
19-21
age, and sex) can inuence a patient’s experience.
While peripheral sensitization is a local phenomenon that is important
for protecting damaged tissue during the early phases post-injury, another phenomenon called central sensitization, dened
as “amplication of neural signaling within the central nervous
system (CNS) eliciting pain hypersensitivity” and considered a
form of maladaptive plasticity within the CNS can also occur.
22
is imbalance can cause muscle pain through a combination
of altered pain perception and abnormal nerve conduction.
23
is is important to remember when rehabilitating some elbow
complex conditions, especially the medial and lateral elbow tendinopathies.
Systems Review
Symptoms involving the elbow may result from a pathology remote to the elbow. Further investigation is warranted for
any insidious onset of symptoms and complaints of numbness
or paresthesia in the upper extremity. Non-neuromusculoskeletal causes may include an acute myocardial infarction (a cardiac referral can occur to the left, right, or both arms or in the
shoulders, elbows, back, neck, throat, lower jaw, or stomach),
Pancoast syndrome (malignant neoplasm of the superior sulcus
of the lung), or abnormalities in esophageal motility (eg, achalasia and diuse esophageal spasm).
Observation and Palpation
Observational ndings form the basis of the early clinical
impression, and observation begins as soon as the patient enters
the clinic. Much can be learned from this early inspection, such
as how the patient holds the extremity and how much discomfort appears to be present. For an accurate and thorough observation and palpation of the elbow, the clinician must be able to
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9
see both arms. Any asymmetry in size or positioning between
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the 2 extremities should be noted, as well as the presence of any
scars, deformities, or swelling. Even minor swelling or eusion
may prevent full extension of the elbow. e clinician should
look for normal soft-tissue and bony contours and compare
them to the other side. Contours include the angle formed between the arm and the forearm when the forearm is supinated
and extended - the carrying angle - of the involved elbow. e
elbow has a normal carrying angle between 11° and 14° in men
and between 13° and 16° in women, although a recent study did
24
not show any signicant dierence.
e most common causes
of an altered carrying angle are a history of trauma or an epiphyseal growth disturbance. For example, a cubitus valgus can be
caused by a lateral epicondylar fracture, whereas a cubitus varus
may result from a supracondylar fracture. Although a normal
carrying angle allows the forearm to clear the hip during gait
and may also be necessary when carrying objects, it is unclear
at what point the size of the carrying angle has a negative impact even though the literature suggests a possible relationship
between an increase in carrying angle and nontrauma-related
25
ulnar neuropathy.
Most elbow structures are easily palpable because they are
supercial, making it easier for the clinician to localize the specic area of pain and potentially making palpation useful in
the dierential diagnosis of some elbow conditions. Slightly
anterior and distal to the medial epicondyle, one can palpate,
from proximal to distal, the muscle origins of the pronator teres,
FCR, PL, exor digitorum supercialis (FDS), and exor carpi
ulnaris (FCU). Overuse of the wrist exors may result in pain
and palpable tenderness at the medial epicondyle, extending
approximately 1–3 cm distal to the epicondyle. Just posterior
to the medial epicondyle, the ulnar groove can be palpated, as
can the ulnar nerve that travels within the groove. e clinician should evaluate for crepitus in the olecranon fossa and for
any subtle elbow extension obstruction suggestive of synovitis
or the presence of intra-articular loose bodies. Several tendons
and muscles can be palpated in the region between the lateral supracondylar ridge and the lateral epicondyle. e muscles
from proximal to distal are the brachioradialis, extensor carpi
radialis longus (ECRL), extensor carpi radialis brevis (ECRB),
and the extensor digitorum (ED). Tenderness over the ECRB is
a common nding in lateral elbow tendinopathy (LET or tennis
elbow). e radial head is in the skin depression immediately
distal to the lateral epicondyle.
Range of Motion
A thorough analysis of posture and movement within
the whole kinetic chain is recommended to identify potential
contributing factors that may be modiable through rehabil-
26
itation.
ere is no elbow position optimal for all activities
and the functional range of motion (ROM) needed for most
activities varies from approximately 140° of exion to reach the
27
occiput to 14° of exion required to tie a shoelace.
However,
some modern-day activities like using a cell phone and typing
on a keyboard may require as much as 149° of elbow exion.
28
Fortunately, a slight loss of motion at the elbow is unlikely to
have a negative functional impact because the majority of ADLs
including bringing food to the mouth, drinking from a cup,
applying underarm deodorant, and perineal care can all be performed with approximately 50° of supination to 50° of prona-
27,29,30
tion, and 100° of elbow exion (from 30° to 130°).
Elbow ROM can be assessed with the patient seated, although extension is better evaluated with the patient standing.
e patient is asked to perform active extension and exion of
the elbow, then pronation and supination of the forearm, and
wrist exion and extension with the elbow exed to 90° and
then fully extended. If any motion restrictions are present, the
nature and location of the motion barrier and any pain related to the motion barrier should be evaluated and noted. Many
factors can aect the outcome of ROM measurements. For example, an apparent loss of normal elbow exion may be caused
by tester error (eg, improper alignment of the goniometer, misidentication of bony landmarks, or inconsistencies in manual
31,32
force).
Common causes of limited elbow motion include
muscle hypertrophy, ulnar nerve neuropathy, osteophytic arthritis, intra-articular loose bodies, posterior capsule tightness,
adhesions, and possibly triceps tendinopathy. e reliability of
goniometric measurements varies according to the joint being
measured. A 2018 systematic review of the literature that aimed
to investigate the reliability and validity of the universal goniometer in measurements of adults’ elbows found several studies
that showed high intra- and inter-rater reliability of the univer-
33
sal goniometer.
Assessing the end feel, an important component of ROM
testing, can provide additional information. For example, a loss
of expected elbow extension may indicate an intrinsic joint
problem in the presence of a springy end feel. Losses of elbow
ROM are also associated with specic injuries. For example,
decreased pronation and supination are frequent ndings following a Colles fracture, advanced degenerative changes, elbow
dislocations, and fractures of the forearm and elbow.
Resistive Testing
Resistive tests are designed to provide information about
the eciency with which the musculotendinous units can act
across a bone-joint lever-arm system to generate motion actively
or to passively resist movement against variable resistance. Evaluations of intra- and inter-examiner reliability have generally
shown that agreement within 1 full grade occurs approximately
34
95% and 90% of the time, respectively.
However, the level of
certainty of the ndings depends on a combination of the muscle’s length when tested, and the amount of force applied. For
example, a study that examined the inuence of the magnitude
and the duration of force application determined that the duration of the tester’s eort multiplied by the average applied force
35
during each test was the biggest inuencer on tester ratings.
10
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It is generally believed, based on the work by Cyriax, that
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pain with a contraction indicates an injury to the contractile
tissue or joint structures, and that weakness (not associated with
pain) indicates an injury to a neural structure (eg, spinal nerve
root or peripheral nerve). e cause of weakness can be corroborated by combining the ndings from other muscles tested
(including the same muscles on the opposite extremity), the
type of symptoms, the symptom duration, and the symptom
distribution.
It is also essential to assess the relationship between the
strength and exibility of a muscle or muscle group and the
kinetic chain’s ability to perform functional tasks smoothly and
eciently.
Passive Joint Mobility Testing
An examination of joint mobility is performed to determine the amount and variability of the arthrokinematic glide
at the joint being tested. However, it is essential to remember
that caution must be used when basing clinical judgments solely
on joint mobility testing results because few studies have examined the validity and reliability of these tests, and little is known
about the validity of any ndings for most inferences.
Special Tests
Multiple special tests for the elbow are targeted to the
unique needs of the examination and structures being tested.
36
A literature review by Valdes and LaStayo
published in 2013
concluded that “a signicant number of provocative tests for
the elbow, wrist, and hand either do not have adequate data
to support their usefulness or their clinical utility has not been
assessed.” Part of the reason for this is that many of these tests
have been propagated by physicians who use them during the
physical examination and correlate the test outcomes with the
intraoperative ndings. us, with a few notable exceptions,
the reliability of most of these tests is either weak or unproven;
thus, it is wise to avoid overreliance on labeling a specic test as
37
positive or negative.
e diagnostic accuracy of selected spe-
cial tests of the elbow that have been researched is provided in
3,36,38-49
Table 1.
When using Table 1, please remember that the
sensitivity or specicity of a clinical test refers to how likely the
test will rule in or rule out the suspected diagnosis with a positive or negative test result. For example, the sensitivity of the
Cozen test is based on the proportion of people who have LET
who also have a positive test result. However, some people who
have LET will not have a positive test result, and some people
who do not have LET will have a positive test result. us, a
test’s sensitivity and specicity values do not provide the clinician with the most useful information when deciding the test’s
usefulness for a particular patient. Also, sensitivity and specicity values do not reect the pretest probability that the disorder
is present, so they cannot calculate the change in probability of
50
the disorder based on the test results.
In contrast, predictive
values can be more useful than specicity and sensitivity val-
ues because the predictive value provides the probability that
the negative or positive test result is correct; however, predictive
values are highly inuenced by the frequency of the disorder in
50
the sample population.
Using LET as an example, the positive
predictive values (PPVs) will be lower and the negative predictive values (NPVs) will be higher if only a small percentage of
the patients in the study have LET, whereas if most of the patients in the sample have LET, then the PPV will be higher and
50
the NPV will be articially lower.
Finally, positive and negative likelihood ratios (LRs) provide more useful and accurate information to the clinician than NPV and PPV, because LRs are
calculated independently from the prevalence of the condition
in the sample population, making the LRs an important statis-
51
tic for summarizing diagnostic accuracy.
Based on the data in
Table 1, it would appear that, at least for the elbow, the only
highly recommended tests are the Tinel and elbow exion tests
for cubital tunnel syndrome.
Decision-making
After completing the examination, the clinician should be
able to integrate all clinical ndings to determine a working
clinical hypothesis or physical therapy diagnosis. Factored into
the diagnosis is the current stage of healing of the structure
or condition. A vast proportion of acute conditions typically
respond well to an initial approach outlined by the acronym
POLICE (protection, optimal loading, ice, compression, and
elevation). During this phase, exercises for the uninvolved areas of the upper extremity (shoulder, wrist, and hand) are encouraged, based on tolerance. As soon as tolerated, the patient
is progressed through the hierarchy of ROM exercises (passive
range of motion [PROM], active-assisted range of motion
[AAROM], and then active range of motion [AROM]) before,
or while simultaneously, beginning the hierarchy of resisted exercises at varying joint angles (submaximal isometrics, maximal
eort isometrics, concentric exercises, eccentric exercises, and
then, if appropriate, isokinetic and plyometrics exercises).
Chronic conditions are usually more challenging because
they often have an underlying cause, such as tissue underloading or overloading that is often associated with a biomechanical
decit. Also, as described in the History section, the phenomenon of central sensitization may need to be considered if the
patient has experienced pain or prolonged limb immobilization
before physical therapy or has begun to move dierently from
52
the expected norm to minimize pain.
Central sensitization
can manifest in disproportionate pain, reports of a large pain
area with a non-segmental distribution, or pain varying in lo-
53
cation and distribution (traveling pain).
Although not wholly
diagnostic, the clinician should look for changes in movement
symmetry, the appearance of compensations, or any aberrant
movements, and correct them at the earliest opportunity.
Whenever possible, the clinician should avoid using gener-
al protocols. Instead, the clinician should design an individual-
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11
Table 1.
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Diagnostic Accuracy of Selected Special Tests for the Elbow
Test and
related
diagnosis
Elbow exion
(cubital tunnel
syndrome)
Pressure
provocation
(cubital tunnel
syndrome)
Tinel sign
(cubital tunnel
syndrome)
Scratch collapse
(cubital tunnel
syndrome)
Crossed nger
(cubital tunnel
syndrome)
Test description Findings
e patient is seated with the glenohumeral joint in a neutral position, the elbow
in maximum exion, the forearm in supination, and the wrist in neutral. is
position is actively sustained for 60 seconds to 3 minutes, depending upon the
author. A positive test is indicated by either patient-reported paresthesias or worsening of preexisting paresthesias in the ulnar nerve distribution.
e patient’s upper extremity is positioned as in the elbow exion test. e clinician applies pressure to the ulnar nerve at the cubital tunnel for 30 seconds. e
test is positive with reproduction of tingling and numbness in the fourth and fth
digits.
e clinician taps lightly at the ulnar nerve around the medial epicondylar
groove. e test is positive if the patient reports tingling or electrical sensations
radiating to the fourth and fth digits.
e patient is seated facing the clinician, with the arms adducted, elbows exed
to 90°, and with both hands outstretched and wrists in a neutral position. e
patient is asked to perform simultaneous resisted bilateral shoulder external rotation while keeping the arms adducted. e clinician gently pushes against both of
the patient’s forearms into internal rotation, asking them to resist against steady
application of force. Using the ngertips, the clinician then scratches or swipes
the skin overlying the course of the potentially compressed nerve (the ulnar nerve
is scratched over the cubital tunnel at the medial elbow). e test is positive if the
patient demonstrates a momentary loss of external resistance tone on the aected
side after “scratching” over the cubital tunnel.
e patient is seated with both forearms in pronation. e clinician instructs the
patient to cross the middle nger over the index nger for both hands. A positive
test is recorded if the patient cannot fully cross the ngers on the involved side.
Beekman et al
39
LR+: 1.0
LR-: 0.99
Cheng et al
38
LR+: 45.99
LR-: 0.54
Novak et al
48
LR+: 45
LR-: 0.11
Cheng et al
38
LR+: 53.99
LR-: 0.46
Beekman et al
39
LR+: 1.3
LR-: 0.72
Cheng et al
38
LR+: 68.99
LR-: 0.31
Earle and Vlastou
LR+: ∞
LR-: 0.36
40
Shoulder internal rotation
(cubital tunnel
syndrome)
Chair sign
(posterolateral
rotary instability [PLRI ]of
the elbow)
e patient’s upper extremity is maintained in 90° of abduction and maximum
internal rotation of the shoulder, and 10° of shoulder exion, with 90° elbow
exion and neutral position of the forearm and wrist, with nger extension. e
test is considered positive if any slight symptom attributable to cubital tunnel
syndrome occurs within 10 seconds.
With the patient seated, the elbows are exed to 90°, and the forearms are
supinated. e patient then pushes up on the arms of the chair and extends the
elbows. Elbow extension creates an axial and valgus load to the supinated elbow
while the patient rises. A positive test indicating PLRI will cause apprehension
with terminal extension of the involved elbow or reluctance to push through the
arms.
12
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Ochi et al
41
LR+: ∞
LR-: 0.19
Regan and Lapner
43
LR+: 0.87
LR-: Unable to
calculate
Academy of Orthopaedic Physical erapy, APTA.
Table 1.
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Continued
Test and
related
diagnosis
Push-up sign
(PLRI)
Test description Findings
e patient assumes a push-up position with the forearm supinated. From this
position, the patient pushes up from 90° elbow exion. A positive test in a patient
with PLRI will cause radial head subluxation or pain.
Regan and Lapner
LR+: 0.87
LR-: Unable to
calculate
43
Table-top relocation (PLRI)
Valgus stress
(ulnar collateral ligament
[UCL])
Milking
maneuver
(anterior band
of ulnar collateral ligament
[AUCL])
Moving valgus
stress (chronic
UCL tear of
the elbow)
e test is started with the patient’s forearm in supination and with their hand
placed around the edge of a table. ere are 3 parts to this test: (1) the patient
applies an axial load through the elbow while exing the elbow, which causes
apprehension at approximately 40° of exion; (2) the patient repeats the rst maneuver while the clinician applies pressure on the patient’s radial head, attempting
to prevent any subluxation and symptoms; and (3) the clinician removes his or
her thumb from the partially exed elbow, and any subsequent radial head subluxation reproduces the symptoms.
e patient is seated or supine. e clinician exes the patient’s elbow to 25° and
while holding the distal forearm with one hand stabilizes the distal humerus and
applies a lateral force to stress the UCL.
e humerus is extended and externally rotated to neutralize glenohumeral joint
motion. e forearm is then supinated and the elbow is exed to 90°. e clinician then applies valgus stress to the elbow by extending the patient’s thumb (Figure 13). e AUCL is then palpated along its course. A positive test is recorded if
there is any apprehension, reproduction of pain, or symptoms along the course of
the UCL complex, especially between 30° and 60° of elbow exion.
e patient is seated and the clinician applies and maintains a constant moderate valgus torque to the patient’s fully exed elbow and then quickly extends the
elbow. A positive test is recorded if medial elbow pain is reproduced at the UCL
and is at a maximum between 120° and 70° of elbow exion (Figure 14), which
is evocative of the elbow position between the late cocking and the early acceleration phases of throwing (referred to as the shear range). Pain with extension
beyond 70° suggests condyle injury to the humeroulnar joint.
Arvind and
Hargreaves
44
LR+: 1.0
LR-: Unable to
calculate
Callaway et al
45
LR+: 1.3 for pain;
laxity undetermined
LR-: 0.7 for pain;
0.81 for laxity
Diagnostic accuracy
has not been determined
O’Driscoll et al
42
LR+: ∞
LR-: 0.05
Passive medial
elbow tendinopathy
(MET)
Active wrist
exion against
resistance
(MET)
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e examiner palpates the medial epicondyle and supports the patient’s elbow
with one hand while the other hand passively supinates the patient’s forearm and
extends the wrist. Pain at the medial epicondyle is a positive sign.
e patient is seated with the forearm supinated, and the elbow exed to 90°.
Using one hand, the clinician palpates the medial epicondyle while supporting
the patient’s forearm. e patient is asked to make a st and to ex the wrist
while the clinician applies resistance. A positive test is indicated if this maneuver
reproduces the medial elbow pain.
13
is test was found
to lack adequate
diagnostic accuracy
to rule in or rule out
MET
is test was found
to lack adequate
diagnostic accuracy
to rule in or rule out
MET
Table 1.
https://t.me/med1917
Continued
Test and
related
diagnosis
Cozen (lateral elbow
tendinopathy
[LET])
Test description Findings
e seated patient makes a st while the clinician supports the elbow with one
hand (thumb over the lateral epicondyle). e patient is then asked to extend the
wrist against resistance with the forearm pronated and the wrist radially deviated.
e test is considered positive if there is any reproduction of pain over the lateral
epicondyle region.
Saroja et al
LR+: 0.84
LR-: ∞
46
Maudsley
(LET)
e patient’s forearm and hand are positioned on a at surface with the elbow extended. e patient is asked to extend their middle nger, and the clinician then
provides pressure over the extended digit. e test is considered positive if there is
any reproduction of pain over the lateral epicondyle region.
Mill (LET) e patient is seated with the upper arm in a neutral position, the elbow exed
at 90°, and the forearm parallel to the oor in pronation. e clinician supports
the patient’s elbow with one hand, while using the other hand to ex the patient’s
wrist. e test is considered positive if there is any reproduction of pain over the
lateral epicondyle region.
Biceps squeeze
(distal biceps
tendon rupture)
e patient is seated with the elbow exed approximately 60°-80° and with a
slightly pronated forearm resting in their lap. e clinician stands on the side of
the extremity being tested and squeezes the biceps brachii rmly with both hands;
one hand at the myotendinous junction and the other hand around the muscle
belly. A positive test is a lack of forearm supination indicating a biceps brachii
rupture.
Abbreviations: LR+, positive likelihood ratio; LR-, negative likelihood ratio
ized plan for each patient based on the symptoms, the presenting impairments, and any movement dysfunction, rather than
relying on a predetermined plan designed for a generic patient
or condition. It also may be appropriate to divide intervention goals between those designed to improve functional and
work-related abilities and those aimed at enhancing a patient’s
ability to perform athletic or recreational pursuits.
nation of intervention strategies, sequence of therapeutic procedures, and establishment of discharge criteria.
must also weigh all examination ndings while considering relevant environmental, social, cultural, psychological, medical, and
physical ndings, to cluster the information into recognizable,
understandable, and identiable diagnoses, dysfunctions, or
classication syndromes.
whether following injury or surgery, must follow a progressive
Conclusion
A specic diagnosis can be ascertained only when all po-
and sequential order, each step building on the previous phase,
to ensure that healing tissues are not compromised.
tential causes for the signs and symptoms have been considered,
including a thorough examination of the cervical and thoracic
spine, shoulder, and wrist joints. Ideally, all impairments are
highlighted, and a determination is made as to the reason for
those impairments. Any decision-making must encompass the
selection of tests during the examination process, interpretation
of the data from the detailed history and examination, establishment of the diagnosis, estimation of the prognosis, determi-
COMMONLY ENCOUNTERED CONDITIONS
OF THE ELBOW AND FOREARM
e following sections describe the more common examination ndings and the recommended evidence-based intervention approaches for selected elbow conditions, including
postoperative rehabilitation principles for selected surgical procedures.
Saroja et al
46
LR+: 0.88
LR-: ∞
Saroja et al
46
LR+: ∞
LR-: 0.47
Ruland et al
47
LR+: N/A
LR-: 0.04
54
e clinician
55
Finally, all rehabilitation approaches,
14
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Elbow Tendon Pathologies
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Although the term epicondylitis has traditionally been used
to describe lateral elbow pain (tennis elbow) and medial elbow
pain (golfer elbow), histopathologic studies have demonstrated
that these conditions often are not inammatory conditions in
that they demonstrate an absence of prostaglandin-mediated
inammation; instead, they are degenerative conditions that
likely involve both peripheral and CNS pathways, resulting in
hyperalgesia or allodynia.
have been described:
56
In fact, 3 etiologies of tendinopathy
57
• Vascular - tendon degeneration occurs because of focal areas
of vascular compromise
Mechanical – repetitive loading of the tendon results in mi-
•
croscopic degeneration, broplasia, and eventual scar tissue
•
Neural modulation – tendinopathy results from neurally-mediated mast cell degranulation and the release of substance P
us, the terms tendinopathy or angioblastic tendinosis
are more contemporary, and the rehabilitation focus has shifted
away from absolute rest, ice, and anti-inammatory medica-
58
tions.
Similarly, the terms tennis elbow and golfer elbow, named
due to the apparent high incidence in the respective sport, are
being used less frequently because both conditions appear to be
aggravated by a rotation of the arm with exion and extension,
irrespective of any sporting activity.
e exact level of mechanical and biological stimulation required to maintain normal tendon homeostasis is not currently
known, but it is widely believed that an abnormal level of stimulation (too little or excessive loading) may play a role in the
pathogenesis of tendinopathy.
59
Indeed, despite the wealth of
knowledge about tendon structure and function, there remains
a surprising scarcity of knowledge concerning tendon pathophysiology. is is likely because despite tendinopathies being
common conditions with common features of pain during
tendon loading, diuse or localized swelling, and limitations
in activity-potential or performance, they present dierently,
depending on the site and the nature of the injury process.
60
It does appear, though, that a process involving pathologic
change in the tendon can result in a structural breakdown and
irreparable brosis or calcication because the involved tendon
attempts to speed up tissue production to compensate for the
increased rate of microdamage caused by increased use and a
decreased recovery time.
In terms of function, tendons can be classied as either
positional (responsible for exact movements) or energy-storing
(responsible for locomotion and ballistic performance) based on
their ability to tolerate stress.
In general, the prevalence of tendinopathy, particularly in
tendons that transmit large loads under eccentric and elastic
conditions, increases with age as the tendons become weaker,
stier, and less yielding due to the vascular, cellular, and collagen-related alterations that occur with aging.
61
Also, tendons
that wrap around a convex surface or the apex of a concavity,
and those that cross 2 joints, are particularly vulnerable to over-
62
use injuries, as are those with areas of scant vascular supply.
Although sports activity remains the most common source
of tendinopathy, the cause can be work-related, drug-related
(eg, cortisone, cyclosporine, statins, and quinolone antibiotics),
or due to a metabolic disorder such as disturbed glucose metab-
63
olism or atherosclerosis.
In terms of trauma to the tendon, it
would appear that the combination of tension and compression
results in shearing and friction forces that cause degradation
64
of the collagen proteins at a rate that exceeds collagen repair.
Consequently, some causes of tendinopathy include increasing age; excessive volume, magnitude, or speed of loading; any
abrupt or acute changes in the amount or type of load; and less
than optimal biomechanics (structural malalignments, muscle weaknesses or imbalances, decreased exibility, and poor
64
form).
It is well established that a correctly prescribed exercise program has a positive eect on both skeletal muscles and tendons.
Unfortunately, tendinopathies are dicult in terms of guiding
treatment or prognosis. However, it is generally agreed that tendinopathy management should include an appropriate and op-
65
timal loading of the tendon,
with any therapeutic load being
administered carefully and in a graduated and controlled fash-
58
Initially, isometric contractions (24 repetitions of 10 sec-
ion.
onds duration, or 6 repetitions of 40 seconds duration) should
be used, because this type of muscle contraction appears to re-
66-68
duce tendon-related pain.
e isometrics may be followed
by heavy, slow-motion resistance training while considering all
58
relevant muscles within the kinetic chain.
Endurance training
and the ability to sustain compression loads (eg, friction over
the tendon and heavy stretching) should be included as tolerated, but usually not in the initial stages of management because
58,69
they can be provocative.
e next stage involves increasing
load on the tendon by incrementally introducing speed rst and
58
then energy-storage (plyometric) loads.
In summary, treatment of tendinopathy involves a multifaceted approach, which includes identication and removal of
all negative internal or external forces and factors, establishing a
stable baseline for treatment, determination of the tensile load
starting point, and a progression of the loading program according to the patient’s symptoms.
70
Lateral elbow tendinopathy
e common wrist extensor tendon, which connects the
muscles that control wrist extension and radial deviation, is involved in LET, especially at the origin of the ECRB. Lateral
elbow tendinopathy primarily occurs in individuals who have
jobs that require repetitive grasping, forceful or heavy manual
71,72
tasks, or nonneutral wrist postures.
It is also important to
note that LET may be secondary to (or associated with) dys-
71
function of either the cervical spine or the shoulder.
For exam-
ple, a 2019 study recommended addressing any scapular muscle
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15
weakness in patients with LET.
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71,73
To help eliminate a cervical
or shoulder cause, the clinician can test isometric wrist extension in varying positions of the cervical spine or shoulder. For
example, if involvement of the cervical spine is suspected, the
amount of discomfort on isometric testing can be assessed with
62
the cervical spine extended, then exed, etc.
Pain is the primary symptom of LET; thus, the clinician
should try to provoke discomfort by actively or passively load-
74
ing the tendon.
Palpable tenderness usually is found over the
anterior aspect of the lateral epicondyle. Pain can often be reproduced by performing passive wrist exion with the forearm in a
pronated and the elbow in an extended position, or by resisted
extension of the wrist, index nger, or middle nger. Quantitative measurement of grip strength is an important variable
when assessing and plotting the progress of LET because of its
essential role in the performance of daily activities, work tasks,
and sports. Pain-free grip strength testing using a hand-grip dynamometer has been shown to have good to excellent test-retest
74,75
reliability (intraclass correlation coecients > 0.80).
To determine if a patient’s change in a specic measurement is real
or due to random error, the minimal detectable change with
95% certainty (MDC
size of random errors. us, by knowing the MDC
) is used as a parameter to estimate the
95
of grip
95
strength in patients with upper extremity injuries, clinicians can
determine whether the change in a grip strength score results
from real improvement or random measurement errors. Given the widespread use of hand-grip dynamometry to quantify
grip strength, it is surprising that very few robust studies report
76
MDCs for pain-free grip strength.
77
determined an MDC95 of 5.1 kg (11.2 lbs) and 5.2 kg (11.5
However, a study by Kim et
lbs) for the left and right hands, respectively, with these ndings being similar to a previously published study by Putho
78
and Saskowski.
Obviously, documented grip strength will be
impacted in the presence of injury. For example, a 2007 cohort
79
study by Dorf et al
found that the extremity with LET had a
50% grip strength decit with the elbow in extension compared
to the uninvolved side.
Pain can be assessed using a self-reported measure such as
the Patient-Rated Tennis Elbow Evaluation (PRTEE), a valid,
reliable, and sensitive clinical instrument for individuals with
80
chronic LET (see Outcome Measures and Scales).
ree commonly used special tests for LET are the Cozen test (Figure 3),
Mill test, and Maudsley test. For the Mill test, the patient is
seated, and the clinician palpates the patient’s lateral epicondyle
with one hand while pronating the patient’s forearm, fully exing the wrist, and extending the elbow with the other hand. A
positive test is the reproduction of lateral elbow pain. For the
Maudsley test, the patient is also seated. While palpating the
patient’s lateral epicondyle with one hand, the clinician resists
the extension of the patient’s middle nger with the other hand,
stressing the ED muscle and tendon. A positive test is the reproduction of lateral elbow pain. e diagnostic accuracy for the
above 3 tests for LET is outlined in Table 1.
Figure 3.
Cozen Test
e clinician stabilizes the patient’s elbow with one
hand. With the forearm pronated, the patient is asked
to extend and radially deviate the wrist against the
clinician’s manual resistance.
Finally, other diagnoses that can mimic LET should be
considered, such as radiocapitellar chondromalacia, posterolateral elbow instability, plical irritation, intra-articular loose
bodies, malignancy, cervical radiculopathy (C6 or C7), radial
tunnel syndrome, or compression of the posterior interosseous
15,81
nerve at the arcade of Frohse (supinator syndrome).
Despite advances in elucidating LET causes, the standard
of care remains nonoperative management with nonsteroidal
anti-inammatory drugs (NSAIDs), cross friction massage,
electrical and thermal modalities, therapeutic exercise, and
82
bracing and rest.
Unfortunately, due to the many causes documented, the traditional physical therapy tactic has been to try
to address all potential causes at once using a combination of
interventions. Not surprisingly, most of the studies that have
looked at the nonoperative management of LET have been inconclusive as to the eectiveness of the physical therapy interventions listed below:
25,68,83-87
Joint mobilization and manipulation
A 2004 retrospective review suggest that most patients had
successful outcomes regardless of manual therapy interventions
88
to the cervical spine.
In contrast, a 2019 systematic review and
meta-analysis concluded that there is convincing substantiation
that joint mobilizations of the elbow complex can decrease pain
and increase functional grip scores throughout all time frames
89
compared to control groups in the treatment of LET.
e
techniques used to examine the passive accessory motions of
the elbow complex can be used to mobilize the joints, with the
clinician varying the technique (ie, grade) of the mobilizations
16
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based on the aim of the treatment, the patient’s response, the
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stage of tissue healing, and the irritability of the joint. e potential joint mobilizations for the elbow complex include:
•
Humeroulnar distraction (Figure 4): used for pain control.
• Humeroulnar lateral glide: commonly used as part of the
intervention for LET.
Humeroradial anterior glide: used to improve elbow exion
•
(Figure 5).
Humeroradial posterior glide (Figure 6): used to improve
•
elbow extension.
•
Proximal radioulnar joint glides (Figure 7): an anteromedial
glide can be used to increase supination; a posterior lateral
glide can be used to increase pronation.
Figure 5.
Anterior Glide of the Radius on the
Humerus (Humeroradial Joint)
Mobilization with movement (MWM)
90-92
techniques
have received substantial attention in the management of LET.
A MWM technique may be benecial in the presence of occasional radiating symptoms into the forearm and tenderness over
the lateral epicondyle of the humerus, the radial head, and the
fascia between the origins of extensor muscles.
93
Also, a MWM
technique appears to be helpful if a patient complains of a weak
and painful grasp and pain reproduction when turning a door
handle or carrying groceries. For the MWM, the patient is
asked to perform the identied painful task while the clinician
Figure 4.
Distraction of the Humeroulnar Joint
e clinician stabilizes the patient’s humerus and applies an anterior glide (away from the table) of the radius to produce the accessory glide that accompanies
elbow exion based on the arthrokinematics of the
concave radial head moving on the convex surface of
the capitulum of the humerus (Appendix C).
Figure 6.
Posterior Glide of the Radius on the
Humerus (Humeroradial Joint)
e clinician wraps the ngers around the proximal
third of the patient’s forearm with one hand while
stabilizing the patient’s humerus with the other. e
clinician applies a force through the patient’s proximal forearm at an angle that distracts the humeroulnar joint.
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e patient is positioned supine with the forearm supinated. e clinician uses one hand (right hand in
the photo) to stabilize the patient’s humerus and ulna
(convex surface) while applying a posterior glide of the
radius (concave surface) down toward the table with
the thenar eminence of the other hand (Appendix C).
17
Figure 7.
https://t.me/med1917
Glides of the Radius on the Ulna
(Proximal Radioulnar Joint).
provides a laterally directed glide to the elbow manually (Fig-
ure 8) or using a belt (Figure 9).
90-92
e technique is typically
repeated for 6 to 10 repetitions per visit and then repeated over
several follow-up sessions.
Soft tissue mobilization
Transverse friction massage (TFM), when used in combination with other physical therapy interventions in the later
stages of treatment, has low-level evidence for benets. A Cochrane systematic review that assessed the benets and harms
of TFM for treating LET did not nd sucient evidence to
determine the eects of TFM on pain, grip strength, and functional status, noting that the small sample sizes limited the conclusions derived from the randomized controlled trials.
94
e patient is positioned supine with the forearm supinated. e radial head is located by exing and extending the elbow. Once located, the clinician grasps
the convex radial head between the thumb and index
nger and moves it in an anterior/posterior direction
on the ulna’s concave radial notch. For example, the
radius spins medially and glides anteriorly (away from
the table) on the ulna during supination (Appendix
C).
Figure 8.
Lateral Glide of the Ulna (Movement
with Mobilization)
Eccentric exercises
Limited evidence suggests that eccentric loading of the
involved tendons is an eective intervention for a variety of
tendinopathies, including Achilles, rotator cu, and patellar
tendinopathies. Based on this evidence, eccentric exercise may
provide both a structural and functional benet for tendinopathy rehabilitation. For LET, a daily routine of eccentric exercises
is recommended with 3 sets of 15 repetitions (with each repetition taking 4 seconds to complete and a 30-second rest between
sets) with sucient load to induce discomfort during the exer-
Figure 9.
Lateral Glide of the Ulna with Belt
(Movement with Mobilization)
e patient is in the supine position, with the elbow
in full extension and the forearm in pronation (the
superior portion of the gure). e clinician stabilizes
the upper arm (the inferior portion of the gure) and
applies a sustained lateral glide of the ulna on the humerus. e patient is then asked to make a st while
the clinician maintains the lateral glide.
18
A belt is wrapped around the clinician’s back and the
patient’s forearm so that the belt edge is level with the
elbow joint. Using one hand, the clinician stabilizes
the patient’s humerus while supporting the patient’s
forearm and wrist with the other hand. From this position, the ulna is glided laterally by the belt as the
clinician gently leans backward.
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