Rethinking Elbow Epicondylitis

Chiropractic adjustments and soft tissue techniques such as friction massage, Leahy's active release, strain/counterstrain, and other methods often cure intractable elbow epicondylitis in a few visits. But occasionally we run into stubborn situations which do not seem to get well no matter what therapy we apply. Of course, the first question that must be answered is the validity of our diagnosis; the second question is whether we are properly using the technique? Since this article cannot adequately discuss methods of technique it may be helpful to discuss our evaluation and other considerations regarding the problem.

Lateral epicondylitis is usually related to activities that require resisted wrist extension. The primary muscle involved is the extensor carpi radialis brevis, and secondarily, the extensor digitorum communis.¹ There is usually pain on resisted wrist extension, possible pain or resisted forearm supination, and passive wrist flexion. Maximum tenderness is usually over the anterior portion of the lateral epicondyle. Whatever the actual mechanism by which friction massage affects the pathologic tissue, I have not always been successful in using this method on cases which have been consistently present close to a year with a complaint of continuous rest pain. I feel that one reason may be Nirschl's description of the pathology of the tissue in chronic conditions. Nirschl1 showed that the involved chronic tissue was edematous with granulation-like tissue that he termed angiofibroblastic tendinosis where acute inflammatory cells were absent. He stated that the degree of angiofibroblastic infiltration appeared to correlate with the clinical phases of pain and the duration of symptoms. Other changes associated with the tendinosis were secondary fibrosis, exostosis, tendon calcification, and iatrogenic cortisone changes which caused cellular death and atrophy. Nirschl feels that a surgical solution may be necessary when there is greater than 50 percent tendon cross section of permanent tendinosis with a patient who complains of constant rest pain (dull aching) and pain that disturbs sleep, or pain that is caused by light activities of daily living. Depending on the case, conservative treatment up to one year is recommended before surgery.²

Of course a principle reason why our treatments may not be effective is because our treatment is too localized or our diagnosis is wrong. Although a lateral or medial epicondylitis may be the correct diagnosis, it is often necessary to address not only the local painful origin but also the belly of the muscle and insertion, or wherever an adhesion or "tendinosis" may be located anywhere in the involved muscle or tendon or even in associated muscle areas. The function of the whole area must be considered for the benefit of the local lesion.

A condition that may mimic lateral epicondylitis is the radial tunnel syndrome.³ Functional testing may create similar responses as in epicondylitis. The main differentiation may be pain located between the radial head and the supinator muscle. The patient may complain of a vague, diffuse aching feeling radiating distally into the forearm rather than the more localized pain at the lateral epicondyle.² Electrodiagnostic studies are often equivocal. Another cause of lateral elbow pain may be degenerative changes at the radiocaptielar joint with associated calcific deposits and radial head or distal humerous osteophytes. Standard radiographs of the elbow should be taken to rule out these problems.² Field and Altchek² devised a functional test to distinguish between a lateral epicondylitis and degenerative changes in the radiocapitellar joint. To stress the radiocapitellar joint without aggravating the lateral tendons, they apply an axial load on the forearm (compression of the radiocapitellar joint) and apply gentle passive supination and pronation. As long as the wrist is maintained in a neutral position (not flexed or extended) during this test, the lateral epicondylitis will not be exacerbated unless of course it is in an acute stage.

Medial epicondylitis primarily involves the pronator teres, flexor carpi radialis and palmaris longus, and secondarily involves the flexor carpi ulnaris and flexor sublimis.¹ Sometimes it is difficult to distinguish between a chronic medial epicondylitis and a chronic medial collateral ligament insufficiency, since valgus testing might also aggravate the muscular component. Leach and Miller⁴ devised a test to eliminate the pain of medial epicondylitis while performing the valgus test. They applied a valgus stress to a slightly flexed elbow with a flexed wrist and pronated forearm, which allows ligamentous tension while reducing the muscular tension. The medial collateral ligament would considered normal if this type of valgus test was painless.

References

1. Nirschl RP. Elbow tendinosis/tennis elbow. Clin in Sports Med. 1992;11:851-870.

    

2. Field LD, Altchek DW. Elbow injuries. Clin Sports Med. 1995; 14:59-78.

    

3. Moss SH, Switzer HE. Radial tunnel syndrome: A spectrum of clinical presentations. J Hand Surg. 1983;8:414.

    

4. Leach RE, Miller JK. Lateral and medial epicondylitis of the elbow. Clin Sports Med. 1987;6:259.

Editor's note: Dr. Hammer will be conducting his next Subluxation Myopathology (SM) seminar April 29-30 in Toronto, Canada and May 20-21 in Seattle, Washington. You may call 1-800-359-2289 to register.