Maudsley's Test

What is lateral epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is a condition that causes pain around the outside of the elbow. It occurs due to inflammation or degeneration of the tendons that attach to the lateral epicondyle, a bony prominence on the outer side of the elbow. These tendons extend the wrist and fingers. 

The condition often results from repetitive wrist and arm motions, such as those used in tennis or other racquet sports, hence the name "tennis elbow." However, any activity involving repetitive arm and elbow joint and wrist movements, like painting, typing, or playing specific musical instruments, can lead to the condition.

Treatment may include rest, physical therapy, pain relief medications, and, in severe cases, injections or surgery.

Symptoms of lateral epicondylitis

Symptoms affect the outer side of the elbow and may include:

• Pain usually starts on the outer side of the elbow and can radiate down the forearm. It often worsens with movement, especially when lifting or gripping objects.
• Reduced grip strength or weakness may be felt, making it challenging to hold or grip items firmly.
• Shaking hands, turning a doorknob, lifting items, or even holding a coffee cup may trigger pain.
• The elbow may feel stiff, particularly after prolonged inactivity or in the morning.
• Some individuals may notice mild swelling around the elbow.

Causes of lateral epicondylitis

This is caused by repetitive stress and overuse of the forearm muscles that attach to the lateral epicondyle (a bony prominence on the outer elbow). This leads to inflammation, micro-tears, or degeneration of the tendons (specifically the extensor carpi radialis brevis tendon). 

Here are common causes:

• Repetitive wrist and arm movements, such as tennis or other racquet sports, can strain the tendons over time.
• Jobs requiring repetitive arm or wrist movements, such as plumbing, painting, typing, or carpentry, increase the risk.
• Using incorrect form during sports or activities can put undue stress on the tendons, increasing the likelihood of injury.
• Tendon degeneration can occur due to aging, weakening the tendon and making it more susceptible to injury.
• Although less common, direct injury to the lateral epicondyle region can lead to inflammation and pain.

Complications that may lead to

While lateral epicondylitis typically doesn't result in severe complications, prolonged or untreated cases can cause issues that may impact daily activities and quality of life. Some potential complications are the following:

• If the condition is not managed effectively, persistent or worsening pain can develop, interfering with daily activities like gripping or lifting.
• Long-term pain and inflammation may cause stiffness and limit the ability to move the elbow or wrist fully.
• Chronic lateral epicondylitis can significantly weaken grip strength, affecting the ability to perform manual tasks.
• Returning to strenuous activities too soon without proper rehabilitation may increase the risk of re-injury.
• If occupational tasks are impacted by pain and reduced strength, productivity at work may decrease.
• Overcompensating for the affected arm could cause strain or injury to the opposite arm, shoulder, or neck.

What is Maudsley's Test?

Maudsley's Test, also known as the elbow flexed the resisted middle finger extension test, is a specific diagnostic maneuver used to identify lateral epicondylitis, commonly called tennis elbow. This condition primarily affects the tendons attached to the lateral epicondyle of the elbow, particularly the extensor carpi radialis brevis and the extensor digitorum communis.

The test explicitly targets the the extensor digitorum communis slip muscle group, which shares the common extensor tendon with other wrist and finger extensors. A positive result is indicated by the elicitation of sudden pain at the lateral elbow, particularly over the lateral epicondyle, when the middle finger is extended against resistance. This pain suggests explicit involvement of the extensor digitorum communis and related extensor muscle slips, which are stressed during the test.

The test is valued for its diagnostic accuracy in confirming lateral elbow tendinopathy. It's one of several examination tests used to diagnose tennis and elbow pain, contributing to a comprehensive physical examination to differentiate lateral epicondylitis from other conditions, such as radial nerve entrapment. The test's ability to isolate specific muscle actions and pinpoint pain helps affirm the diagnosis and guide treatment evaluation.

Positive results from Maudsley's Test can lead to more targeted treatments for patients diagnosed with tennis elbow. Understanding the specific tendons and muscle slips can enhance conservative and surgical management, improving patient outcomes. Further research into the anatomical and clinical findings associated with the test could refine its utility, ensuring high sensitivity and specificity in diagnosing chronic tennis elbow and similar conditions.

How is this conducted?

The test is conducted as follows:

1. The patient is seated or standing, with their affected arm resting on a table or comfortably positioned in front. The elbow is flexed or extended as appropriate, and the forearm is pronated (palm facing downward).
2. The examiner stands facing the patient and stabilizes the patient's elbow with one hand.
3. The patient is instructed to extend their middle finger against resistance.
4. The examiner places their other hand over the middle finger and applies downward pressure while the patient tries to raise their finger upwards, creating a resisted extension.
5. The examiner notes any sudden pain localized at or around the lateral epicondyle of the elbow, specifically where the extensor carpi radialis brevis and the extensor digitorum communis attach.

How are the results interpreted?

The results of Maudsley's Test are interpreted based on the patient's pain response during resisted middle finger extension:

• Positive: If the patient experiences sudden, sharp pain over the lateral epicondyle or surrounding region during the test, it suggests a positive result. This pain is indicative of lateral epicondylitis (tennis elbow), explicitly implicating the involvement of the extensor carpi radialis brevis or extensor digitorum communis tendons, which are part of the common extensor tendon attaching at the lateral epicondyle.
• Negative: The result is negative if the patient does not feel pain or only experiences mild discomfort not explicitly localized to the lateral elbow. This suggests that lateral epicondylitis may not be present, or at least not the primary source of pain.

The Maudsley's Test helps to rule out or confirm lateral epicondylitis but may not fully differentiate it from other conditions like radial nerve entrapment. A positive test is usually interpreted alongside other clinical findings, such as patient history, additional physical examination tests, and imaging if necessary. Combine it with other provocative tests to improve specificity.

The next steps after conducting the test

After conducting Maudsley's Test and obtaining the results, the following steps include:

Further assessment

When diagnosing lateral epicondylitis, if the test is positive, the examiner may do additional tests, such as Cozen's or Mill's, to confirm the diagnosis. The examiner will examine the patient's history, pain characteristics, and activities contributing to the injury to evaluate the patient's condition.

Imaging and diagnostic confirmation

If you are experiencing tendon pain or discomfort, your doctor may recommend imaging tests like ultrasound or MRI. These tests can provide a detailed evaluation of your tendons and help rule out other conditions. They can also confirm if there is tendon degeneration, inflammation, or tears.

Treatment plan

Use a comprehensive, patient-focused approach to manage discomfort from conditions like lateral epicondylalgia. Here are the essential steps for an effective treatment plan:

• Evaluate severity: Perform wrist extension tests, focusing on the extensor digitorum communis, with the elbow extended and flexed. Use isometric middle finger resistance tests to identify pain. Consider patient complaints of pain during forearm pronation and wrist extension. Refer to studies in reputable journals for prevalence and outcomes.
• Set clear goals: Set short-term goals to reduce pain and improve elbow and upper extremity range of motion. Define long-term goals to restore full function and strength, allowing the patient to resume daily activities without discomfort.
• Customize the treatment: Create a treatment plan with rest, physical therapy, and possibly medications to manage pain and inflammation. Include exercises for the wrist and elbow, such as isometric finger resistance and wrist extensions, to strengthen extensor muscles. Regularly monitor pain and adjust the plan as needed for optimal recovery. Educate the patient on techniques to prevent overuse and reinjury.
• Monitor and adjust: Schedule regular follow-ups to assess progress and adjust the treatment plan. Encourage patient feedback on pain and functionality to address changes promptly. Use the latest research, like the findings of the Journal of Hand Surgery, to refine and optimize treatments.

Monitoring and follow-up

Monitor the patient regularly to see how they're doing and change their treatment if needed. It is also essential to know if they're sticking to their physical therapy and changing their activities.

How to use our Maudsley's Test template

To effectively use the Maudsley's Test template in a clinical setting, follow these steps:

1. Fill in the patient’s full name, age, gender, and the examination date. This information is crucial for record-keeping and future reference.
2. Note the examiner's name, position (such as a physical therapist or orthopedic specialist), and the facility where the test is conducted. This helps maintain the professionalism and traceability of the test process.
3. Recognize that the test's purpose is to assess for lateral epicondylitis (tennis elbow), which informs the context in which the test results will be interpreted.
4. Follow the step-by-step procedure included in the template. Make sure to observe and record the patient's response to the resistance, particularly noting any pain around the lateral epicondyle
5. Mark the test as positive or negative based on the patient's pain response. Utilize the checkboxes to indicate the result, which helps in quick visual assessment and record referencing.  Ensure to document:
   • Affected side: Indicate whether the left or right elbow was tested.
   • Pain location: Describe the precise area of pain to aid in diagnosis and treatment planning.
6. Note any additional relevant observations, such as patient discomfort levels during the test or other symptoms noted.
7. Based on the test outcome, suggest further steps such as additional diagnostic tests, physical therapy, or a follow-up appointment.
8. The examiner should sign the document to validate the test results. This formalizes the examination process and confirms the accuracy of the recorded information.

Benefits of conducting this test

Conducting the test provides several benefits for both the clinician and the patient:

• The test targets the extensor muscles in the tennis elbow, making it a reliable tool for diagnosing lateral epicondylitis by eliciting specific pain responses.
• Identifying the condition early allows for timely intervention, preventing further damage to the tendons and reducing the risk of chronic pain.
• A positive test helps clinicians tailor treatment plans effectively, whether through physical therapy, bracing, or medication. This leads to more targeted and efficient patient care.
• The test is non-invasive, making it a low-risk assessment tool that provides valuable diagnostic insights without imaging or more invasive procedures.
• It offers a quick and affordable way to screen for tennis elbow, especially useful in primary care settings, reducing the need for costly tests if the diagnosis is precise.
• The standardized procedure ensures consistency in testing, allowing for comparative assessments over time and across different patients.
• By conducting the test and discussing results with patients, practitioners can help them understand their condition better and engage them more actively in their treatment plans.

Treatments for lateral epicondylitis

Treatment often focuses on reducing pain and inflammation while promoting tendon healing. Common treatment options include:

• Avoid activities that worsen the pain. Adjust daily tasks and ergonomics to reduce tendon stress. Using an elbow strap or brace can help relieve strain and promote healing.
• Applying ice or a cold compress to the elbow can reduce inflammation and numb the area to relieve pain.
• Use OTC pain relievers like ibuprofen or naproxen. Apply NSAID creams or gels. Corticosteroids and PRP injections can ease severe pain and aid healing.
• Exercises restore flexibility and strength. Therapists may use ultrasound, massage, or eccentric exercises. Acupuncture and dry needling can relieve pain and improve function.
• High-energy shock waves stimulate healing and reduce pain in chronic cases.
• In severe or persistent cases, surgery may be required to remove damaged tissue or to release the affected tendon. This is considered when other treatments fail after 6-12 months.