Lateral Epicondylalgia (Tennis Elbow)

Case Study:

A 50-year-old school secretary has been diagnosed with right sided lateral epicondylalgia following an insidious onset of intermittent elbow pain three months ago. This coincided with taking up badminton to improve her fitness levels. Elbow pain, measured by the Numerical Rating Scale, ranges from 0/10 to 7/10. Her pain is aggravated after playing badminton. Pain is also starting to occur during typing; an activity that is required to achieve many of her occupational tasks. The patient feels that the problem is getting progressively worse and is concerned about the impact upon her ability to work.

The patient has a history of recurrent exacerbations of right-sided elbow pain over the last two years, which commonly last for two to three weeks. However, this current episode has failed to resolve, and she has been referred to physiotherapy by her doctor. On examination by the physiotherapist, the salient objective findings were as follows:

1) Reduced muscle length of the right wrist extensors (tested with elbow extension and wrist flexion)

2) Pain on isometric right wrist extension

3) Reduced and painful grip strength on the right side, measured using a Jaymar hand held dynamometer; Right-hand 16kg and left-hand 40kg

Review of the literature and formulation of treatment plan

Lateral epicondylalgia (LE) is prevalent in about 1-3% of individuals in the United Kingdom (UK), with approximately 40% of people experiencing this condition (Ahmad et al., 2013). This condition is commonly seen in individuals between the ages of 35-55 years old and affects both sexes equally (Bisset and Vicenzino, 2015). LE is characterised as a degenerative tendinopathy and pain at the tendon of the lateral epicondyle (Luk et al., 2014). A healthy tendon is able to dissipate and withstand repetitive release and compression (Bhabra et al., 2016). However, excessive load or overuse may lead to reactive tendinopathy, tendon disrepair, or degenerative tendinopathy (Cook and Purdam, 2009).

This patient is diagnosed with right sided LE and is suffering from reduced muscle length, reduced grip strength, and pain. The research illustrates that individuals that work in an office and of older age are significantly associated with LE (Bisset and Vicenzino, 2015). Also, she has recently started to play badminton to increase her physical activity. As her elbow is unaccustomed to physical activity, repetitive contractions and extension of her elbow has led her into the reactive tendinopathy phase (Kahlenberg et al., 2015). This has led to thickening of her tendon and has limited the tendon’s adaption to tensile load (Cook & Purham 2009). Thickening of the tendon is the body’s adaption to minimise the overload and thereby, increasing stiffness of the tendon (Bass, 2012). Due to the stiffening of the tendon and onset of pain, this has limited her range of motion (ROM) and muscle length. She is fearful of aggravating her arm and wrist because pain will prevent her from doing her job as a secretary and may leave her housebound. This in turn will affect her psychosocial well being, as she is secluding herself with the fear that her recurrent elbow pain will limit her activities of daily living (ADLs).

To aid in her recovery, an individualised treatment plan will target three main problems, which are reduced muscle strength, reduced ROM, and pain. A study by Musumeci (2015) found that patients who complained about pain led to a reduction in physical activity and deconditioning. After addressing the painful symptoms, there was a higher adherence to exercise and thus, an improvement in muscle strength and ROM (Musumeci, 2015). According to the principles of treatment, the aim of treating LE should prioritise the maintenance of pain first, then preserving movement, improving grip strength and endurance, returning to normal function, and lastly controlling clinical deterioration (Ahmad et al., 2013).

The patient's LE is caused by overuse of her extensor muscles, specifically her extensor carpi radialis brevis (ECRB), which has led to microtears at origin of the muscle at the lateral epicondyle of the humerus (De Smedt et al., 2007). The literature found that there was no significant increase in inflammatory markers and suggests that the pathology of LE is not an inflammatory response (Kahlenberg et al., 2015). In a healthy tendon, tightly packed type I collagen fibres are arranged along the axis of tendon, but under stress, the microtears cause hypertrophy of fibroblasts, misaligned collagen, stiffness, and decreased tensile strength (Bhabra et al., 2016). An increase of immature type III collagen fibres and loss of collagen continuity may lead to failure and inability to adequately load-bear (Bass, 2012). 

Her pain is caused by the presence of substance P and due to pain, she is unable to participate in physical activity, leading to reduced muscle bulk and strength. As her recurrent elbow pain has not healed properly, central sensitisation is a condition that causes the nervous system to be in a heightened sense of high reactivity (Lluch et al., 2014). LE is associated with hyperalgesia and increased response to noxious stimuli, which means that the patient may have a hyper-sensitised pain reaction to a stimulus that should be bearable, but the nervous system perceives it as a strong pain (Bisset and Vicenzino, 2015). Another component of central sensitisation is allodynia, which means that the patient experience pain even where there should not be pain (Lluch et al., 2014). This could lead to psychosocial problems as she is withdrawing from activities as she fears any contact with her elbow could lead to intense pain. Furthermore, if she is not able to return to work as a secretary or engage in regular activity, the literature has shown that this can lead to decreased self-esteem and self-worth (Zamani Sani et al., 2016). 

Currently, there are many modalities to treat LE, ranging from electrotherapy to exercise to manual therapy. There is no clear consensus in the literature that advocates for one treatment over another treatment (Dimitrios, 2016). The acute treatment for LE has been traditionally corticosteroid injections and the research has shown that it provides short-term benefits, but the evidence supporting long-term efficacy is conflicting (Gautam et al., 2015). Some evidence supports the use of electrotherapy for short term benefits, but there is a lack of high-quality research advocating for its usage for long-term benefits (Ediz and Alpayci 2012). A randomised controlled trial by D’Vaz et al. (2006) evaluated the effects of ultrasound therapy in tendon repair. It found that ultrasound therapy was no more effective for a large treatment effect than a placebo. However, a limitation was the small sample size of 59 participants, as inadequate sample would lead to a possibility of a Type II error. The study determined that 200 participants were required to detect a moderate treatment effect. Another limitation was using grip strength as an outcome measure because it is reliant on patient effort. Despite this, grip strength is a valid and reliable indicator of quality of life and will be utilised in her treatment (Gum et al., 2017). Lastly, the study found that ultrasound requires high patient motivation due to the length of the therapy and was expensive for patients to administer at home.

Therefore, exercise and deep transverse friction massage (DTFM) will be explored. In the literature, exercise as a sole treatment approach has not shown to have a positive effect on patients with LE (Dimitrios, 2016). Exercise alleviates pain due to the release of endorphins, a natural analgesia and movement aids in lubricating the joint and synovial sweeping (McArdle et al., 2015). Recent research has favoured the usage of eccentric training to restore function, decrease pain, and improve performance (Kenas et al., 2015). The research has shown that maintaining ROM with eccentric strengthening exercises were superior to conservative management, such as wait and see approach (Ahmad et al. 2013). In a study by Tyler et al. (2010), 21 participants with chronic unilateral LE were randomised into an eccentric training group and a comparator group. The control group performed isotonic wrist extensor strengthening exercises, whereas the intervention group performed isolated eccentric strengthening exercises. It found that eccentric exercises produced greater pain relief and functional improvement. However, a limitation was the small sample size of 21 participants. A power calculation was conducted to achieve a P < 0.5 at 80% power and 15 participants per group or 30 participants total was necessary. The physiotherapist conducting the experiment justified the cessation of recruitment because the participants in the standard group consistently scored poor results, whereas the eccentric group consistently scored good results. However, this was just an assumption made and if the sample size had been larger, the results may have been different.

In another study by S?derberg et al., (2012), 42 patients were randomised into an eccentric training group and control group. It found that a 6-week daily home eccentric exercise program was effective at increasing functional pain-free grip and strength. A strength of this study was the inclusion criteria of a history of pain around the lateral epicondyle for at least one month and a diagnosis of LE. This is important for the findings to be external valid for the patient The mean age of the participants was 49 years old, which is approximately the patient's age as well. However, the study group was heterogeneous, with a wide range of perceived pain, age, and ADLs. This could be a limitation as a range in these factors could have affected the effects of the intervention. Furthermore, another limitation of this study was that it was a single-blinded randomised control trial as the participants were blinded to allocation of the intervention groups, but the researchers were not. This could lead to bias and skewed data. Lastly, 5 participants dropped out of the study prior to completion and reduced the sample size from 42 to 37. A reduction in sample size could lead to a Type II error and a clinical effect to be found, even if it does not exist. However, the authors believed that the results were consistent and any observed effects were underestimated rather than overestimated.

In a systematic review by Raman et al. (2012), it evaluated the literature regarding concentric, isometric, eccentric, and isokinetic exercises in patients with LE. It found that all forms of exercise showed positive changes in pain, strength, and disability over time, but nine of the twelve studies utilised eccentric training as an intervention. The dosage of exercise varied between studies and there was no consistence in types of exercises, intensity, repetitions, sets, frequency, and number of weeks. The primary limitation of this study is the lack of high-quality trials as many studies had methodological limitations, such as inadequate follow-up, lack of blinding, lack of power calculation, or lack of sample size. All these factors could contribute to bias and affect the internal and external validity of the study. Furthermore, while most of the studies support eccentric training, this does not constitute proof that it is more effective. It is just the most studied.

Given the findings from the literature, the patient’s physiotherapy management plan will include an eccentric strengthening program. A baseline will be established at the clinic and the physiotherapist shall prescribe a progressive overload program based on the initial assessment (Schoenfeld et al., 2015). The exercise prescribed will equate to 30% of the user’s 1 repetition maximum (RM) and progress until patient is able to tolerance 80% of 1RM (Kenas et al., 2015). The literature with the best supporting evidence advocates for eccentric exercises 3 times per week with 24-48 hours rest in between and at least 2-3 sets of 10-15 repetition with each eccentric contraction approximately 4-6 seconds (Raman et al., 2012).

In conjunction with eccentric training, DTFM targets and mobilises the scarring in the chronic lesions (Loew et al., 2014). The therapeutic effect of this modality is to induce pain relief, produce a traumatic hyperaemia in chronic lesions, and improve function (Joseph et al., 2012). This will aid in the remodelling and reorientation of collagen fibres, as well as increase blood flow to the area to assist in healing (Loew et al., 2014). Furthermore, DTFM stimulates the A-beta fibre, which are myelinated and can disturb the sensation of pain by inhibiting the firing rate of the A delta and C fibres (Mendell, 2014). The periaqueductal grey matter releases opioid like chemicals, such as endorphins, down the descending corticospinal tract to modulate the pain and produce an analgesia effect (Mendell, 2014). The evidence for this intervention is controversial as a Cochrane review by Loew et al. (2014) found that there was no conclusive evidence to determine the effects of DTFM on pain, improvement in grip strength, and functional status. It is worth nothing that this review had only two randomised control trials (RCT) with small sample and this limits the external validity. Furthermore, the quality of the studies selected were of low quality due to the difficulties or inabilities to blind the participants and personnel, which would contribute to a high level of bias.

Another systematic review by Joseph et al. (2012) found that DTFM was effective in treatment of LE. In this study, 9 RCTs of excellent quality were used, which strengthens the systematic review and reduces the amount of bias. However, the varied design methods, locations, and outcome measures used in each RCT were different and a definitive conclusion was not drawn. It was found that in some cases, there was evidence to support DTFM in conjunction with joint mobilisation and stretching that showed benefits at the elbow.

Given the patient’s lifestyle, exercise intervention and DTFM would be appropriate because of its cost-effectiveness and ease of access. Factoring in her psychosocial and socioeconomic status, the management of pain will allow her to return to socialising with her friends and increase her self-esteem. In a study by Zamani et al. (2016), it found that physical activity was linked to an increased self-esteem. As individuals were able to return to work or physical activity pain-free, not only were their confidence levels increased, but social interactions with peers lead to greater self-worth. Her exercises can be performed at home, at a physiotherapist clinic, or at work. This is important because ease of access to exercise will lead to greater adherence (Hannink et al., 2017). To monitor the patient's pain during her treatment, the Numeric Rating Scale (NRS) will be utilised. The NRS is a reliable and valid outcome measure for measuring pain (Hawker et al., 2011). It has high test-retest reliability in both literate and illiterate patients, with r=0.96 and r=0.95 respectively, and high construct validity when compared to visual analogue scale (VAS), with a correlation range from 0.86 – 0.95 (Hawker et al. 2011).

To assess grip strength, a hand held Jaymar dynamometer will be used. In a seminal paper by Hamilton et al. (1992), it was found that the dynamometer exhibited good within-instrument reliability and valid as a grip measurement device in comparison to a sphygmomanometer. In additional research, this dynamometer has been shown to have criterion-related validity with other widely used dynamometer (Espa?a-Romero et al., 2010). A short-term goal would be to increase right-hand grip strength from 16kg to 25kg within 3 weeks. This is a realistic goal as her baseline in her left-hand is 40kg. A long-term goal would be to increase right-hand grip strength back to 40kg within 6 weeks. This can be achieved by performing isometric holds with various equipment, ranging from dumbbells to milk jugs at home. This is important to her occupation as she will need to be able to grip a pen, stapler, or office equipment to perform her daily tasks.

This patient has LE and a history of recurrent exacerbation of right-sided elbow pain. With an individualised exercise rehabilitation protocol and DTFM, she can return to her hobbies and occupation without pain. While there is no consensus in the literature to choose one intervention over another, using clinical reasoning, exercise and DTFM has been chosen due to its simplicity and cost-effectiveness. As there are various modalities, there is not one correct approach and her physiotherapy management plan should fluid and subject to change depending on her pain, preference, and progression. 

References:

Ahmad, Z., Siddiqui, N., Malik, S. S., Abdus-Samee, M., Tytherleigh-Strong, G. and Rushton, N. (2013) 'Lateral epicondylitis A REVIEW OF PATHOLOGY AND MANAGEMENT.' BONE & JOINT JOURNAL, 95B(9) pp. 1158-1164.

Bass, E. (2012) 'Tendinopathy: Why the difference between tendinitis and tendinosis matters.' International Journal of Therapeutic Massage and Bodywork: Research, Education, and Practice, 5(1) pp. 14-17.

Bhabra, G., Wang, A., Ebert, J. R., Edwards, P., Zheng, M. and Zheng, M. H. (2016) Lateral Elbow Tendinopathy: Development of a Pathophysiology-Based Treatment Algorithm. Vol. 4. Los Angeles, CA: SAGE Publications.

Bisset, L. M. and Vicenzino, B. (2015) 'Physiotherapy management of lateral epicondylalgia.' Journal of Physiotherapy, 61(4) pp. 174-181.

Cook, J. L. and Purdam, C. R. (2009) 'Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.' British Journal of Sports Medicine, 43(6) pp. 409-416.

De Smedt, T., De Jong, A., Van Leemput, W., Lieven, D. and Van Glabbeek, F. (2007) 'Lateral epicondylitis in tennis: Update on aetiology, biomechanics and treatment.' British Journal of Sports Medicine, 41(11) pp. 816-819.

Dimitrios, S. (2016) 'Lateral elbow tendinopathy: Evidence of physiotherapy management.' World Journal of Orthopaedics, 7(8) pp. 463-466.

Espa?a-Romero, V., Ortega, F. B., Vicente-Rodríguez, G., Artero, E. G., Rey, J. P. and Ruiz, J. R. (2010) 'Elbow Position Affects Handgrip Strength in Adolescents: Validity and Reliability of Jamar, DynEx, and TKK Dynamometers.' Journal of Strength and Conditioning Research, 24(1) pp. 272-277.

Gautam, V. K., Verma, S., Batra, S., Bhatnagar, N. and Arora, S. (2015) 'Platelet-Rich Plasma versus Corticosteroid Injection for Recalcitrant Lateral Epicondylitis: Clinical and Ultrasonographic Evaluation.' Journal of Orthopaedic Surgery, 23(1) pp. 1-5.

Gum, A. M., Segal-Karpas, D., Avidor, S., Ayalon, L., Bodner, E. and Palgi, Y. (2017) 'Grip strength and quality of life in the second half of life: hope as a moderator.' Aging and Mental Health, pp. 1-6.

Hannink, E., Dawes, H. and Barker, K. (2017) 'What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review.' BMJ Open, 7(12) p. e019221.

Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011) 'Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain)' Arthritis Care & Research, 63(S11) pp. S240-S252.

Joseph, M. F., Taft, K., Moskwa, M. and Denegar, C. R. (2012) 'Deep friction massage to treat tendinopathy: A systematic review of a classic treatment in the face of a new paradigm of understanding.' Journal of Sport Rehabilitation, 21(4) pp. 343-353.

Kahlenberg, C. A., Knesek, M. and Terry, M. A. (2015) 'New developments in the use of biologics and other modalities in the management of lateral epicondylitis.' BioMed Research International, 2015 pp. 439309-439310.

Kenas, A., Masi, M. and Kuntz, C. (2015) 'Eccentric Interventions for Lateral Epicondylalgia.' STRENGTH AND CONDITIONING JOURNAL, 37(5) pp. 47-52.

Lluch, E., Torres, R., Nijs, J. and Van Oosterwijck, J. (2014) 'Evidence for central sensitization in patients with osteoarthritis pain: A systematic literature review.' European Journal of Pain, 18(10) pp. 1367-1375.

Loew, L. M., Brosseau, L., Tugwell, P., Wells, G. A., Welch, V., Shea, B., Poitras, S., De Angelis, G. and Rahman, P. (2014) 'Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis.' The Cochrane database of systematic reviews, 11;2014;(11) p. CD003528.

Luk, J. K. H., Tsang, R. C. C., Leung, H. B. and Department of Medicine and Geriatrics, F. Y. K. H. S. B. R. P. H. K. (2014) 'Lateral epicondylalgia: Midlife crisis of a tendon.' Hong Kong Medical Journal, 20(2) pp. 145-151.

McArdle, W. D., Katch, F. I. and Katch, V. L. (2015) Exercise physiology: nutrition, energy, and human performance. 8th, international ed., Philadelphia: Wolters Kluwer Health.

Mendell, L. M. (2014) 'Constructing and deconstructing the gate theory of pain.' Pain, 155(2) pp. 210-216.

Musumeci, G. (2015) 'Effects of exercise on physical limitations and fatigue in rheumatic diseases.' World Journal of Orthopaedics, 6(10) pp. 762-769.

Raman, J. M. P. T. P., MacDermid, J. C. M. P. and Grewal, R. M. D. M. F. (2012) 'Effectiveness of Different Methods of Resistance Exercises in Lateral Epicondylosis—A Systematic Review.' Journal of Hand Therapy, 25(1) pp. 5-26.

Schoenfeld, B., Brad, J. S., Mark, D. P., Dan, O. and Bret, C. (2015) 'Effects of Low- vs. High-Load Resistance Training on Muscle Strength and Hypertrophy in Well-Trained Men.' Journal of strength and conditioning research, 29(10)

Smart, K. and Doody, C. (2007) 'The clinical reasoning of pain by experienced musculoskeletal physiotherapists.' Manual Therapy, 12(1), 2007/02/01/, pp. 40-49.

Zamani Sani, S. H., Fathirezaie, Z., Brand, S., Pühse, U., Holsboer-Trachsler, E., Gerber, M. and Talepasand, S. (2016) 'Physical activity and self-esteem: Testing direct and indirect relationships associated with psychological and physical mechanisms.' Neuropsychiatric Disease and Treatment, 12 pp. 2617-2625.