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LATERAL EPICONDYLITIS​

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Lateral epicondylitis (tennis elbow) is defined as a pathologic condition of the wrist extensor muscles at their origin on the lateral humeral epicondyle. Overuse or repetitive trauma in this area causes fibrosis and microtears in involved tissues. Often history of repetitive flexion-extension or pronation-supination activity is obtained. Symptoms also occur when the annular ligament is stressed.
With lateral epicondylitis, there is pain along the lateral epicondyle and radiohumeral joint with gripping activities. 
The PRTEE i.e. Patient-Rated Tennis Elbow Evaluation Questionnaire is a 15-item questionnaire  designed to measure forearm pain and disability in patients with lateral epicondylitis.
Special tests of provocation include - Cozen’s test, Mill’s test and Maudsley’s test.

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IMPAIRMENTS

 

BODY STRUCTURES

  1. Microdamage and partial tears near musculotendinous junction

  2. Inflammation of periosteum with formation of granulation tissue and adhesions

  3. Inflammation of adventitious bursa

  4. Calcified deposits

  5. Lesion affecting the tendinous origin of common wrist extensors

  6. Hypertrophy of synovial fringe between radial head and capitulum

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BODY FUNCTIONS

  1. Pain in elbow region

  2. Swelling

  3. Tenderness

  4. Muscle spasm

  5. Decreased muscles strength and endurance

  6. Decreased grip strength

  7. Affected basic activities of daily living

  8. Mild limitation of elbow extension

  9. Positive Mill’s test 

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GOALS

 

  • Short term 

  1. Patient and family education

  2. Ergonomic advice

  3. Reduce pain

  4. Reduce swelling

  5. Reduce spasm

  6. Improve muscles strength

  7. Improve endurance

  8. Improve grip strength

  9. Achieve full range of motion

  10. Achieve functional activities

 

  • Long term

  1. Maintain range of motion

  2. Maintain muscle strength

  3. Maintain upper extremity function

  4. Maintain cardiovascular conditioning

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MANAGEMENT​

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Patient education

  • Advice and techniques on prevention of painful activities

  • Elimination of lifting heavy weight

  • Activity modifications as avoid grasping in pronation and controlled supination lifting

  • Use of both upper extremities while lifting

  • Correction of mechanics i.e. if a late or poor backhand causes pain, correction of the mechanics of the stroke is warranted. Avoidance of ball impact that lacks a forward body wt transference is stressed. If typing with unsupported arms, place the elbows on stacked towels for support will help.

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Reduce pain and swelling

  • Rest the muscles by immobilization

    • Splint

  • Counterforce bracing only during aggravating activity

  • Cryotherapy : 

    • Direct Ice : 10 to 15 mins for 6 – 7 times per day

  • Transverse friction massage at site of lesion

  • Ultrasound:

    • Acute dosage:

    • pulsed mode 1:4/3

    • Frequency : 3MHz

    • Intensity : 0.25- 0.4 Wb/m3  for 2 -3

  • Whirlpool:

    • 10 to 15 mins in Extrimity tank

    • Temperature:

      • Acute Inflammation: 55-65 F or 65-80 F

      • Pain, ROM, soft tissue extensibility: 99-104 F 

  • High Voltage Galvanic Stimulator

  • Mobilisation with movement

    • Lateral glide applied to proximal forearm with resistance added to wrist extension.

  • Dry Needling

  • Kinesio-taping

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Improve ROM

  • Stretching

    • elbow in full extension and wrist in flexion with slight ulnar deviation 

    • 5-6 stretches

    • holding for 30 secs

    • 2-3 times a day.

  • Multiple-angle muscle setting(submaximal isometrics)

  • Phonophoresis or Iontophoresis

    • Hydrocortisone or Lidocaine is used.

  • Shoulder and scapular ROM exercises 

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Improve strength

  • Gentle strengthening program

    • Grip strength, Wrist extensors, Wrist flexors, Biceps, Triceps and Rotator cuff strengthening.

  • Isotonic eccentric hand exercises with graduated weights not exceeding 5 pounds

  • Wrist curls

    • 1-2 pounds initially,10 times

    • Increase two sets of 10 daily (with supination and pronation) 

  • Wrist flexion-extension resistive training and elbow flexion-extension resistive training(through painfree ranges)

    • Weights

    • Theraband

  • Dynamic exercises

    • Low intensity resistance for multiple repetitions

    • Progress to more intense resistance.

  • Plyometric exercises if goal include returning to sport activities or require elbow and forearm power.

  • It includes -

    • Bouncing a tennis ball on a short-handled racket

    • Rapid eccentric/concentric elbow and forearm motions with an elastic resistance.

    • Rapid chest passes or overhead passes using a weighted plyometric ball. 

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PROTOCOL AFTER EPICONDYLITIS SURGERY

 

Surgical approach is not used unless the patient has recalcitrant symptoms for more than 1 year despite the conservative treatment.

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ACUTE


Days 1-7

  • Position the extremity in a sling for comfort.

  • Control edema and inflammation : apply ice for 20 min 2-3 times a day

  • Gentle hand, wrist and elbow ROM exercises in pain-free range

  • Active shoulder ROM, lower trapezius setting

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SUBACUTE


Weeks 2-4

  • Remove sling

  • Advance ROM passive motion combined with active assisted motion within pain tolerance

  • Gentle strengthening with active motion and submaximal isometrics 

  • Edema and inflammation control : continue ice application

  • Shoulder and scapular strengthening

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Weeks 5-7

  • Advance strengthening as tolerated to include weights or rubber tubing

  • ROM with continued emphasis on end range and passive overpressure

  • Edema and inflammation control with ice

  • Modifies activities for beginning functional training

  • Gentle massage along and against ms fiber

  • Counterforce bracing

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CHRONIC

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Weeks 8-12

  • Continue counterforce bracing if needed

  • Begin task specific functional training

  • Return to sport or activities.

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Precautions

  • Avoid smoking as it can slow the healing and recovery

  • Be sure not to stress the elbow again

  • If the game caused injury, work with a tennis pro to improve the swing to avoid overwork of elbow

  • Also strengthen the shoulder to support and take pressure off the elbow

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REFERENCES

Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kelvin E. Wilk 2nd Ed.

Therapeutic Exercises by Carolyn Kisner and Lynn Allen Colby 7th Ed.

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