Swodeam Consulting Inc. - Manual Therapy Online Quiz

MTO QUIZ #19

Tennis Elbow

Tennis elbow can be one of the more difficult pathologies to treat. Often this difficulty is due to the therapist's failure to locate and deal with the etiology. Simple overuse, the way it is usually thought of, is unlikely to be a major cause of the condition. More likely, unfamiliar overuse, or changes to the internal or external environment result in tennis elbow. Unfortunately the internal changes are often difficult to detect and require a detailed examination of the areas that could cause or contribute to tennis elbow. This question concerns the etiology of tennis elbow.

List the possible etiologies of tennis elbow (lateral epicondylitis)

ANSWERS

Direct blunt trauma

Direct blows may cause inflammation of the tendon or the myotendonous junction. These are perhaps the easiest of the etiologies to treat. Unfortunately it is also probably the least common.

True overuse

Unfamiliar or non-routine overuse, routine overuse after time off, change of tool, change of working position etc. are all possible causes of tennis elbow. To determine this etiology takes careful questioning and a skeptical attitude, as there is a real urge to take the easy solution. Again treatment is relatively easy. The patient changes what they are doing or how they are doing it and the therapist treats the local pathology.

C5/6 biomechanical dysfunction

This has been postulated to cause tennis elbow or tennis elbow type pain in a variety of ways. These include:

Pain referral: A careful scanning examination may reveal the presence of a small palsy. Sensation testing in particular may help, demonstrating hypoesthesia in the C5 or 6 dermatome.
Interruption of axoplasmic flow and consequent tropic malnutrition and increased vulnerability to otherwise innocuous stresses: Much more difficult to demonstrate and it may be possible only by excluding other possibilities. There should be a biomechanical dysfunction at C5/6 and there may be evidence of segmental facilitation.
A minimal palsy resulting in either weakness and/or neuromuscular incoordination and subsequent tendon injury: See a.
Segmental facilitation with hypersensitivity of the tenoperiosteal attachment: There will be a biomechanical dysfunction at C5/6. There should also be hypertonicity in the local spinal muscles and possibly in those muscles derived from this segment particularly the wrist extensors. Also look for hyperesthesia in the dermatome. A quick test is to retest the positive isometric wrist extension with the head held in varying positions. If there is a complete relief of pain when the head position is altered, there is no local pathology and segmental facilitation is the sole cause of the pain. More usually however, there is partial relief of pain indicating segmental facilitation combined with local pathology.

Combined cervical dysfunctions (C2/3, C5/6, T2/3)

Often an isolated C5/6 dysfunction will not cause tennis elbow as the changes are subclinical, however, the same level of change when combined with other dysfunctions will produce a problem.

Abduction subluxation of the ulnohumeral joint

The subluxation tends to push the radius distally, shifting the carpals ulnarly and limiting their ability to extend. The theory is that the proprioceptive feedback telling of a failure to extend and radially deviate caused increased activity in the extensor muscles and subsequent tendonitis. Examine the elbow for loss of the normal abduction end feel in both the osteokinematic and arthrokinematic. Treatment involves reducing the pathomechanical problem and treating the local pathology.

Flexion carpal subluxation

This is basically the same mechanism as the ulnar subluxation but the dysfunction is in the wrist. Examine the wrist for the subluxation and treat it by manipulation.

Disclaimer:
The assessment and treatment techniques depicted or described in this site are not intended to replace formal instruction in orthopedic manual or any other type of physical therapy. They are intended to review, augment and facilitate the knowledge and skills previously gained on manual therapy or other course and to stimulate the untrained or trainee physical therapist to increase the bounds of his or her knowledge and skill base.