New Tennis Elbow Test: The Free Test
Reading time: 5 minutes
The ChiroUp Clinical Outcomes and Patient Satisfaction Synopsis (COPS) analyzed more than 630,000 presentations to find that lateral epicondylopathy, aka tennis elbow, is the most common elbow diagnosis.
So, to ensure you’re the go-to provider for tennis elbow, this blog will outline some essential skills for managing lateral epicondylopathy (LE), including:
A review of three time-tested lateral epicondylitis tests
A tutorial of the new Free Test that may help differentiate tendinosis vs tendonitis
Three manipulations and mobilizations that have “compelling evidence” for their effectiveness
1. What are the most useful lateral epicondylitis tests?
A 2018 BMJ systematic review (142) found the most widely used tests for lateral epicondylitis included:
Cozen’s test for lateral epicondylitis
Mills test lateral epicondylitis
Maudsley’s (aka Long finger extension) test
Cozen’s test
Mills test
Long finger extension test
2. Are existing lateral epicondylitis tests adequate?
A new Orthopedic Research and Reviews study (140) highlighted the potential deficiency of existing orthopedic tests for lateral epicondylitis:
“All of these physical maneuvers are positive in the presence of [any] lateral epicondylar pain. Nevertheless, cannot detect degenerative tendon changes, such as bone irregularities, calcific deposits, neovascularization, thickening, thinning, and tears.”
Essentially, these tests can identify if there is a problem with the wrist extensor tendon at the lateral epicondyle but cannot help to qualify the problem as inflammatory vs. degenerative.
3. Understanding tendinosis vs tendonitis
In recent years, lateral epicondylar pain has been subdivided into two categories:
Lateral epicondylitis or wrist extensor tendonitis develops from acute stress to the common extensor tendon, leading to painful inflammation. The main injury site is the extensor carpi radialis brevis tendon, located 1-2 cm below its attachment to the lateral epicondyle. (5,7,8)
Lateral epicondylosis or wrist extensor tendinosis (aka tendinopathy) is caused by chronic, repetitive micro-tearing of the common extensor tendon, resulting in failed healing, degeneration, and potential disruption. (5,6) Chronic cases show no histologic signs of inflammation. (9-12)
Researchers now understand that repetitive microtrauma interferes with the natural healing process, and instead of causing healthy inflammation, the result is a disorganized pathological degeneration of the tendon. (9,19, 12-16,144-146 ) The following chart outlines the progressive phases of chronic tendinopathy.
4. Why tendinopathy vs tendinitis matters
Differentiating tendonitis vs tendinopathy defines whether your management should focus on suppressing inflammation for acute elbow tendonitis presentations or, instead, generating a controlled inflammatory reaction for chronic elbow tendinopathy.
5. The new Free Test for lateral epicondylosis
Historically, MRI or diagnostic ultrasound were the only reliable options for defining the later stages of tendinopathy, including intrasubstance tears. Unfortunately, these advanced diagnostic tests are not cost-effective and time-efficient for many patients or providers.
However, a promising new maneuver, called the Free Test has been shown to “identify a specific intrasubstance tear of the common extensor tendon in patients with lateral epicondylopathy.” (140)
Free Test for Lateral Epicondylopathy
Begin with the seated patient’s shoulder slightly abducted, elbow flexed to 90 degrees, and fist facing down. The patient then performs maximal wrist extension against the clinician’s attempt to force an eccentric movement. Failure to resist extension due to painful weakness suggests intrasubstance tear of the common extensor tendon, aka lateral epicondylopathy.
ChiroUp subscribers can review the Free test tutorial here:
Free test
The Free Test showed 86% sensitivity and 64% specificity for intrasubstance tendon tears. Overall, the test’s accuracy was superior to a positive Cozen’s test or the presence of nocturnal pain. (140)
Editors note- Intrasubstance tendon tears were confirmed by diagnostic ultrasound; however, sensitivity and specificity statistics were based on a small study size of 41 patients.
6. Chronic tennis elbow treatment
So now that we can identify when someone is in the latter stages of tendinopathy, what can we do about it?
A hands-on FAKTR class would be an excellent first step for honing your tendinopathy management skills. Dr. Riddle and his crew are masters in teaching the most potent multimodal tools for musculoskeletal pain and injury management.
The essentials of chronic elbow tendinopathy treatment include:
Controlling stress load and limiting chronic compression
Progressive eccentric loading
Ergonomic, work, play, and sleep modifications
IASTM
Dry needling
Modalities like laser, galvanic, or shockwave therapy (ESWT)
Nutritional recommendations (including Tendisulfur ®) (148)
And, of course, elbow manipulation and mobilization
A 2019 systematic review in the Journal of Hand Therapy found “compelling evidence” that elbow mobilization and manipulation can significantly improve pain, grip strength, and functional outcomes in lateral epicondylopathy patients. (141)
The authors compared elbow Mobilization with Movement, Mill's Manipulation, and Regional Mobilizations for lateral elbow tendinosis treatment. The study found a mean effect of:
47% for Mill's manipulation on improving pain rating
Mill's manipulation did not improve pain-free grip strength
43% for Mobilization with Movement on improving pain rating
31% for Mobilization with Movement on improving grip strength
Need a refresher? Watch the following video that demonstrates three potent tennis elbow mobilization and tennis elbow manipulation skills.
“The healing time for tendinitis is several days to 6 weeks…Treatment for tendinosis recognized at an early stage can be as brief as 6–10 weeks; however, treatment once the tendinosis has become chronic can take 3–6 months.” (147)
7. How do you prescribe the best lateral epicondylosis exercises & ADL recommendations?
We made this one crazy simple. Watch this 1-minute video to learn how to make completely customizable reports like this in 4 clicks for more than 100 diagnoses.
Like what you see? You can create reports like these for your patients in less than four clicks!
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