Elsevier

Journal of Hand Therapy

Volume 34, Issue 2, April–June 2021, Pages 263-297
Journal of Hand Therapy

Scientific/Clinical Article
Lateral epicondylosis: A literature review to link pathology and tendon function to tissue-level treatment and ergonomic interventions

https://doi.org/10.1016/j.jht.2021.05.005Get rights and content

Highlights

  • Integrative review linking biomechanics and ergonomics of lateral epicondylosis

  • Recommend hazard reducing by patients during watchful waiting

  • Biomechanical parameters suggested for ergonomic recommendations and studies

  • More research needed on kinetic chain exercises and ergonomic interventions

Abstract

Background

Common treatments for lateral epicondylosis (LE) focus on tissue healing. Ergonomic advice is suggested broadly, but recommendations based on biomechanical motion parameters associated with functional activities are rarely made. This review analyzes the role of body functions and activities in LE and integrates the findings to suggest motion parameters applicable to education and interventions relevant to activities and life roles for patients.

Purpose

This study examines LE pathology, tendon and muscle biomechanics, and population exposure outlining potentially hazardous activities and integrates those to provide motion parameters for ergonomic interventions to treat or prevent LE. A disease model is discussed to align treatment approaches to the stage of LE tendinopathy.

Study Design

Integrative review

Methods

We conducted in-depth searches using PubMed, Medline, and government websites. All levels of evidence were included, and the framework for behavioral research from the National Institutes of Health was used to synthesize ergonomic research.

Results

The review broadened the diagnosis of LE from a tendon ailment to one affecting the enthesis of the capitellum. It reinforced the continuum of severity to encompass degeneration as well as regeneration. Systematic reviews confirmed the availability of evidence for tissue-based treatments, but evidence of well-defined harm reducing occupational interventions was scattered amongst evidence levels. Integration of biomechanical studies and population information gave insight into types of potentially hazardous activities and provided a theoretical basis for limiting hazardous exposures to wrist extensor tendons by reducing force, compression, and shearing during functional activities.

Conclusions

These findings may broaden the first treatment approach from a passive, watchful waiting into an active exploration and reduction of at-risk activities and motions. Including the findings into education modules may provide patients with the knowledge to lastingly reduce potentially hazardous motions during their daily activities, and researchers to define parameters of ergonomic interventions.

Introduction

Lateral epicondylosis (LE) decreases the capacity to participate in activities essential to daily life. Based on a long career of caring for patients with LE, Nirschl1 eloquently stated that “LE does not threaten the quantity of life, but it is a major impediment to the quality of life.”

Many authors indicate that LE may be a self-limiting problem, that often resolves with time and limitation of painful activities, but 13% to 34% of patients treated in general practice still reported pain after 3 months or longer.2 The Centers for Disease Control and Prevention (CDC) states that upper extremity musculoskeletal disorders, common in almost all sectors of the United States economy, are increasing in numbers along with associated costs to the worker and industry alike.3 LE is no exception, with both the costs of care and surgical rates increasing as well.4, 5, 6 Therefore, the search for cost-effective care of patients with LE remains great.

In many occupations higher prevalence rates are found than the reported rate in the general population of 0.7% to 4.0%.7 In a review of 22 occupations, the highest prevalence was found in assembly line workers (20%). Other professions, also report high prevalence and incidence rates. Prevalence reached 13.5% in plastic surgeons7,8 and 14% among reconstructive orthopedic surgeons, with the highest rate in those who regularly perform total hip replacements.9 In sports, LE is most associated with tennis players,10 but the condition is also listed as the most prevalent elbow injury in the leading arms of golfers11, 12, 13, 14, 15 and in rock climbers.16 Among musicians in general, LE prevalence has been reported to range from 39% to 87%.17 Results from the University of North Texas Musician Health Survey (UNT-MHS) data set reported that pianists and organists were found most frequently to have problems with LE, followed by harpists.18 There are also populations of athletes without LE as a primary diagnosis, where intuitively this might have been expected, such as throwing athletes and rowers.19,20

Abundant literature exists on various methods to enhance healing of the affected lateral elbow tissues.21 Less abundantly, but increasing in frequency, are investigations into the painful and potentially harmful activities associated with lateral elbow pathology.22 These studies typically focus on which types of activities are associated with the presence of LE; however, they rarely connect these activities to the structure and biomechanical function of lateral elbow tissues. Surveys show that ergonomic patient education for LE continues to be a key intervention used by hand therapists, occupational as well as physical therapists.23,24 However, a scarcity of specifics to guide these educational and activity modification interventions was noted.23

The goal of this literature review is to explore, identify and integrate connections between tissue structures and function and activities, participation, environmental, and personal factors for the management of patients with LE, using the framework provided by the International Classification of Functioning, Disability and Health (ICF) by the World Health Organization. The ICF framework is suitable in its comprehensive approach to health problems.24

Connecting the biomechanics and pathology to specific motions during work, sports, and common daily activities will allow therapists, ergonomists, engineers in human factors, and medical personnel to educate patients on how to adapt activities to reduce the intensity, frequency, and duration of exposure to those activities.

Section snippets

Methods

An explorative literature search was performed to justify the need for the study, identify and formulate the problem. Key constructs and keywords to serve the literature search were formulated. When a sparsity of systematic reviews was encountered to summarize the wide variation of ergonomic approaches, it was decided to use the framework for behavioral intervention development by the National Institutes of Health25 to synthesize salient topics of ergonomic interventions for patients with LE.

An anatomical landscape of the lateral elbow

An in-depth description of elbow anatomy is provided by Morrey,29 who describes the architecture of the osteology, elbow joint structures including their joint capsules and ligaments, bursae, vessels, nerves, and muscles in relation to topical anatomy. Figure 1 gives an overview of the elbow anatomy. The radial nerve is depicted as it traverses the elbow, including its innervated musculature surrounding the lateral epicondyle. The radial recurrent artery originates distally from the brachial

Discussion

The goal of this literature review was to build bridges, connecting pathological lateral elbow structures and wrist extensor function with activities, participation in life roles, environmental factors, and personal contexts in management of tennis elbow. The format of the review, an integrative review, was used to present the status of science for each study component and integrate the components into a theoretical framework. An integrative review stands out from other reviews, in that it may

Conclusions

All components of the ICF, from pathology, tissue structures, and tendon function through activities and participation in life roles, and contextual and personal characteristics, were intimately connected in the care of patients with LE. A full ergonomic inventory is suggested as an important first approach due to the potential to benefit patients in all stages of severity and recovery of LE. Future studies may address if or how repetitive motion injuries of LE are cumulative in nature.

Acknowledgments

The editorial contribution of Jennifer Edwards to this voluminous work is appreciated and recognized. Marsha Lawrence, PT, DPT, CHT is thanked for her review of the manuscript, whenever we needed a fresh pair of eyes on this work.

Quiz: # 762

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.

  • # 1.

    The study design was

    • a.

      RCTs

    • b.

      case series

    • c.

      integrative review

    • d.

      qualitative

  • # 2.

    In addition to tissue-specific interventions, the authors strongly recommend

    • a.

      activity analysis and modification

    • b.

      mobilization with movement

    • c.

      pulsed ultrasound

    • d.

      enforced rest from function

  • # 3.

    Tendinosis has been shown to be

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      Previous studies found a moderate association between the occupational risk factors of forceful and repetitive hand and arm use and development of LET, suggesting that workload modification could reduce the risk and improve the prognosis.15,16 Recent literature supports the idea of actively exploring and reducing at-risk motions contributing to symptoms of LET and suggests that practitioners should include work-related factors as an important consideration for treatment of this common condition.17,18 Education and modification of physical factors in the workplace were previously suggested for inclusion in LET management programs.14,15,19,20

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      Lateral epicondylitis (LE), also known as "Tennis Elbow," is degenerative tendinosis of the extensor carpi radialis brevis. The least mechanical advantage position for the ECRB is wrist flexion in a fully stretched position and less commonly ulnar deviation.1 LE presents with significant pain in the lateral of the elbow, disability, and loss of labor.2

    Funding: None

    Conflict of interest: All named authors hereby declare that they have no conflicts of interest to disclose

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