Elbow, Wrist, and Hand Tendinopathies

Cynthia Cooper

Clients with tendinitis/tendinosis experience pain that can significantly limit their daily activities. Simply picking up a coffee cup may be a task that is too painful. Stirring food, putting away groceries, or using a computer keyboard may provoke pain, and exercise routines can be interrupted. These clients may put off going to the physician, hoping that the symptoms will pass. Unfortunately, those who wait may develop chronic changes, which can be more difficult to treat.

Symptoms associated with tendinitis/tendinosis include pain with active range of motion (AROM), resistance, or passive stretching of the involved structures. It is very important to identify the activities contributing to the problem and to make as many ergonomic changes as possible. These often can be accomplished with clever improvising and do not necessarily require expensive purchases. For example, simply placing large pillows in the lap to provide forearm and wrist support while reading or knitting can be very helpful. Many clients recover well by improving their posture and upper extremity (UE) biomechanics and by participating in an ongoing exercise program.

General Anatomy

Tendons are viscoelastic structures with unique mechanical properties. They are composed of connective tissues made of collagen, tenocytes, and ground substance, and they are poorly vascularized. Tendons allow muscle to transmit forces that create motion.¹

The strength of a muscle depends on its cross-sectional area. A larger cross-sectional area provides greater contraction force with transmission of greater tensile loads through the tendon. Tendons with a larger cross-sectional area also are able to bear higher loads.²

The factors that most affect tendons’ biomechanical properties are aging, pregnancy, mobilization (or immobilization), and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Up to the age of 20, the collagen cross-links in tendons increase in number and improve in quality, which equates with increased tensile strength. With aging, tensile strength decreases.²

Clinical Pearl

Tendons remodel in response to the stresses or mechanical demands imposed on them. They become stronger by being exposed to increased stress (e.g., movement). They become weaker when stress is reduced or eliminated (e.g., immobilization, such as orthoses).²

Tendinitis is defined as an acute inflammatory response to injury of a tendon that produces the classical signs of heat, swelling, and pain.³ Physicians and therapists historically have treated tendinitis as a phenomenon of tendon inflammation. However, recent, compelling histologic evidence has resulted in a change of terminology. The term angiofibroblastic hyperplasia or angiofibroblastic tendinosis (hereafter referred to as tendinosis) describes the pathologic alterations seen in the tissue of clients diagnosed as having tendonitis. A visible change occurs in the gross appearance of the tissue. Microscopically, normal tendon fibers are arranged in an orderly fashion. With tendinosis, the tendon fibers are invaded by fibroblasts and atypical vascular granulation tissue, and the adjacent tissue becomes degenerative, hypercellular, and microfragmented. Typically, only a few, if any, inflammatory cells are seen histologically. Tendinosis now is thought to be a degenerative pathologic condition, not an inflammatory one. Experts currently believe that true tendinitis is rare and that the condition hand therapists see in clients is tendinosis.

This histologic evidence has some intriguing implications for therapists: 1) we should question traditional approaches to the treatment of tendonitis as an inflammatory condition, and 2) we should alter our hand therapy treatments to fit the evidence of a tendinosis pathology.⁴

Individuals most likely to have tendinosis 1) are over age 35; 2) engage in a high-intensity occupational or sports activity three or more times a week for at least 30 minutes per session; 3) use a demanding technique for the activity; and 4) have an inadequate level of physical fitness. Symptoms occur when the tissue is worked beyond its tolerance (i.e., overused).¹

General Timelines and Healing

The key to promoting healing is to help your clients avoid pain. Timelines and healing vary. Symptoms may persist or recur over years but do not always do so; some clients recover completely. In therapy, some clients may be able to start pain-free isometric or AROM exercises immediately, whereas others may find this too painful initially. Generally speaking, if your client is following therapy guidelines but has not made progress after a few weeks, suggest a return visit to the physician.

General Treatment Suggestions

General treatment suggestions are presented in the following sections. Lateral epicondylitis, medial epicondylitis, de Quervain’s tenosynovitis, and digital stenosing tenosynovitis are addressed individually because they are common tendinitis/tendinosis diagnoses. The chapter ends with a table designed to promote structure-specific clinical reasoning and treatment for these and other diagnoses of UE tendinitis/tendinosis.

Lateral Epicondylosis (Tennis Elbow)

Anatomy

The lateral epicondyle of the humerus is the origin of the symptomatic muscle-tendon units in lateral epicondylitis, commonly known as tennis elbow (Fig. 28-1). The extensor carpi radialis brevis (ECRB) is most often involved, followed by the extensor digitorum communis (EDC).

FIGURE 28-1 Muscles that attach at the lateral epicondyle of the distal humerus. (From Trumble TE: Tendinitis and epicondylitis. In Trumble TE, editor: *Principles of hand surgery,* Philadelphia, 2000, WB Saunders.)

Diagnosis and Pathology

Clients usually have point tenderness at the lateral epicondyle, possibly anterior or distal to it. Point tenderness at the supracondylar ridge may indicate involvement of the extensor carpi radialis longus (ECRL). Clients with lateral epicondylitis complain of nighttime aching and morning stiffness of the elbow. Gripping provokes pain, as does resisted wrist extension, supination, digital extension, and wrist radial deviation. Grip strength is reduced when the elbow is extended, and pain may be worse with this position (e.g., when carrying a briefcase). Tightness of the extrinsic extensors is common, and stretching of these muscles causes pain (Fig. 28-2).

FIGURE 28-2 Stretching of extrinsic extensors. (From Wadsworth TG: Elbow tendinitis. In Mackin EJ, Callahan AD, Skirven TM et al, editors: *Rehabilitation of the hand and upper extremity,* ed 5, St Louis, 2002, Mosby.)

The test for tennis elbow is called Cozen’s test (Fig. 28-3). The examiner’s thumb stabilizes the client’s elbow at the lateral epicondyle. With the forearm pronated, the client makes a fist and then actively extends and radially deviates the wrist with the examiner resisting the motion. Severe, sudden pain in the area of the lateral epicondyle is a positive test result.⁵

FIGURE 28-3 Cozen’s test. (From Fedorczyk JM: Therapist’s management of elbow tendinitis. In Mackin EJ, Callahan AD, Skirven TM et al, editors: *Rehabilitation of the hand and upper extremity,* ed 5, St Louis, 2002, Mosby.)

Mill’s tennis elbow test originally was described as a manipulation maneuver, but it can be used as a clinical test. The client’s shoulder is in neutral. The examiner palpates the most tender area at or near the lateral epicondyle, then pronates the forearm and fully flexes the wrist while moving the elbow from flexion to extension. Pain at the lateral epicondyle is a positive test result. (For more information on this topic and other provocative tests, see Fedorczyk’s work.)1,5

Differential diagnoses include cervical radiculopathy, proximal neurovascular entrapment, radiocapitellar joint pain, and radial tunnel syndrome. X-ray films can rule out osseous or articular conditions such as calcification or arthritis. When the triceps is most symptomatic, the condition is called posterior tennis elbow.

Radial tunnel syndrome differs from lateral epicondylitis in that the pain is more diffuse and occurs within the muscle mass of the extensor wad rather than at the lateral epicondyle (Fig. 28-4). The middle finger test can be used to detect radial tunnel syndrome (Fig. 28-5). Another test for this syndrome is to tap (percuss) over the superficial radial nerve in a distal to proximal direction. The test result is positive if paresthesias are elicited.⁵

FIGURE 28-4 Radial tunnel syndrome differs from lateral epicondylitis in that the pain is more diffuse and occurs within the muscle mass of the extensor wad rather than at the lateral epicondyle. (From Fedorczyk JM: Therapist’s management of elbow tendinitis. In Mackin EJ, Callahan AD, Skirven TM et al, editors: *Rehabilitation of the hand and upper extremity,* ed 5, St Louis, 2002, Mosby.)

Nonoperative Treatment

Treatment can be divided into two phases, acute and restorative. In the acute phase, the client reports pain at rest that is worsened by daily functional use of the extremity or by range of motion (ROM). The emphasis in this phase is on reducing pain and promoting healing.

Clinical Pearl

Because lateral epicondylitis is not an inflammatory condition, the traditional use of treatments intended to reduce inflammation (e.g., iontophoresis, phonophoresis, corticosteroid injections, nonsteroidal antiinflammatory drugs) should be questioned.

The application of superficial heat may be beneficial for managing pain and improving tissue extensibility.

Precaution. Do not use heat if the injury site is inflamed or swollen.

Ice also may be used for pain relief. The vasoconstrictive effect of ice may help normalize the neovascularization associated with the condition.⁶ Continuous-wave ultrasound and high-voltage pulse current (HVPC) have been reported to reduce pain.¹ Although friction massage has been recommended for healing and pain relief, many clients find this technique too painful to tolerate. Fedorczyk¹ notes that more research is needed on the use of soft tissue mobilization to treat tendinosis.

Orthoses are provided in the acute phase to support the wrist extensors. Either a prefabricated or a custom-made volar wrist cock-up orthosis can be used. The wrist should be positioned in 35 degrees of extension. A counterforce brace is worn over the extensor muscle mass, but this should not be used until the client is able to tolerate it comfortably. Most experts suggest removing it at night to avoid nerve compression problems. The counterforce brace is thought to disperse forces and to promote rest of the involved tendon.

Precaution. Be very careful not to apply a counterforce brace tightly, because this can cause nerve compression. If the client develops sensory symptoms of the superficial radial nerve distribution (dorsal forearm and hand), discontinue use of the counterforce brace.

In the acute phase, AROM should be within pain-free ranges. Gentle isometric exercises (muscle contraction with no movement) in varying positions are done at the elbow, forearm, and wrist. Make sure that these exercises can be performed without pain. Isolated AROM of the ECRB can begin in short arcs of motion, with gravity eliminated if necessary, to stimulate and nourish tissue in a pain-free manner. Be sure the client gently contracts the ECRB with a soft fist, to prevent substitution with the EDC. Also make sure the client relaxes the contraction as the motion is released (wrist flexion with digital extension) so that an eccentric ECRB exercise does not occur at this stage, because it most likely would be painful. Proximal ROM and light strengthening of periscapular and hand intrinsic muscles may begin. Functional activities should be included wherever possible with attention given to posture and pacing.

In the restorative phase, the client’s pain has improved. AROM and light functional activity are no longer painful. The emphasis in this phase is on helping the extensor mass recover flexibility, strength, and endurance. Periscapular and hand strengthening exercises should be continued, and graded conditioning exercises for the common extensors should be added. Assess ergonomic needs and sports participation with biomechanical modifications as needed.

Isometric exercises are advanced with the use of stronger contractions. As muscle contracts more, the tendon is subjected to greater stress. Progressive resistive exercises with isotonic contraction (contraction with muscle shortening) are started with low weight. Gradually, eccentric contraction (contraction with muscle lengthening) may be added.

Precaution. Eccentric exercises should be performed with caution because they are more forceful.

Eccentric exercise helps restore tissue tolerance of the eccentric loads associated with sports and other functional activities. Eccentric exercise is believed to stimulate collagen production, which is considered the key to recovery from tendinosis. However, favorable responses of eccentric exercise for tennis elbow have not been supported by research to date.¹

Operative Treatment

Various surgical procedures can be performed for lateral epicondylitis.⁷ Orthotic use may be ordered after surgery to support the wrist or elbow or both. ROM guidelines and upgrades for strengthening are determined by the surgeon.

Questions to Discuss with the Physician