Summary
Lateral Epicondylitis (LE), tennis elbow, is one of the most commonly seen overuse syndrome that can cause long term disability in working and non-working adults. Main characteristics are pain and tenderness over the lateral epicondyle of the humerus at the origin of the common extensor tendon.1,2 There are many theories to the exact cause, but it is commonly believed that LE is caused by degeneration of the extensor carpi radilias brevis tendon, specifically. 3 Symptoms are reproduced with resisted supination and wrist doriflexion.1 More than 70% of LE cases are occupational related, and individuals over 40 are more often affected. 1,3
Guide To PT Practice4
The Guide to Physical Therapy Practice is a tool for clinicians to help give general guidelines to help with diagnosis, prognosis, and interventions for a given disorder or syndrome. Based on the controversy
of the true classification of lateral epidcondylitis, the guide provides the two patterns listed below:
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation
Based on these two patterns, expected number of visits range from 6-24 for pattern 4-D and 3- 36 for pattern 4E.
Intervention techniques that are similar across patterns are the following:
- Flexibility exercises:
- Range of Motion exercises
- Stretching
- Strength, Power, and endurance training:
- Active assistive, active & resistive exercises
- Pain reduction
- Task –specific performance training
- Body mechanics training
Anticipated Goals/ Expected Outcome of Physical therapy sessions are:
- Pain is decreased
- Joint swelling, inflammation or restriction is reduced
- Range of Motion is improved
- Muscle Performance (strength, power, & endurance) is increased
- Ability to perform physical actions, tasks, or activities is improved
- Disability associated with acute or chronic illnesses is reduced
- Tolerance of positions and activities is increased
- Risk factors are reduced
- Safety is improved
For more information refer to the Guide:
http://guidetoptpractice.apta.org/
Relieving Pain
One of the main symptoms of lateral epicondylitis is pain at the location of the common extensor tendon on the lateral epicondyle of the humerus. The source of pain generators in LE is multifactorial, consisting of intra- and extra-articular structures, which can produce symptoms.5 In the acute phases of LE research has suggested rest, limiting activities, corticosteroid injections, and use of nonsteroidal anti-inflammatory drugs (NSAIDS).1,5,6 These interventions are used to reduce tendinous inflammation, relieve of tendon strains, and to allow time for healing.5
Current research has investigated the effectiveness of these interventions strategies. For the use of topical NSAIDS, diclofenac, possible short-term pain relief has been documented.1 As for oral NSAIDS use, the evidence is conflicting. Studies have shown benefits with reduction of pain up to four weeks.1,5 Only one study has compared different types of NSAIDS yet findings were insiginificant.5 Studies have shown local corticosteroids injections pain relief exceeded NSAIDS up to six weeks yet long term benefits has not been documented.1,3,5,6
Physical Therapy For Lateral Epicondylitis
The goal of physical therapy for the management of lateral epicondylitis is to reduce pain by increase strength and stretching of the forearm and wrist.1,3,5,7 No current standard protocols have been documented in the literature. Strengthening and stretching programs should be based on the patient’s symptoms. The following sections are to discuss current research and theories behind physical therapy treatment of LE.
Increasing Strength
Programs have focused on increasing forearm strength and endurance. Current research is starting to support the use of eccentric strengthening programs.1,3,5,8 The theory behind eccentric strengthening is to load the musculotendinous unit inducing hypertrophy and increasing tensile strength. This in turn reduces the strain on the tendon during activities.3,8 Eccentric contraction can create a greater stimulus for the cells of the tendon, producing collagen and resulting in the tendon being able to withstand greater forces. Decreasesing neovascularization has been recently documented as another benefit of eccentric strengthening. It is believed that neovascularization is a causing factor of pain in LE and other tendionpathies.3,5
Improving Range of Motion
Stretching should performed in combination with strengthening programs.1-3,5,7,9 Stretching programs for lateral epicondylitis focuses on the wrist extensors musculature. Two studies discuss how stretching programs should be performed. Stretching should be performed by bring the wrist into flexion with the elbow in full extension, forearm pronated and placeing overpressure with the other hand allowing a stretch to be felt at the common extensor tendon.3,5 Martinez-Silevestrini et al suggests patient should perform stretching with shoulder at 90 degrees flexion and should be performed twice a day, three repetitions with a 30 second hold followed by a 30 second rest before next repetition.3
Example of a Stretching/Strengthening Program2
Home Exercise
Home Exercise programs should be based on strengthening and stretching programs performed in the clinic setting. Progression and sets should be based on patient tolerance to exercise and relief of symptoms.
Post-Surgical Intervention Physical Therapy10
Most cases of lateral epicondylitis can be treated conservatively. Surgical interventions are recommended when symptoms persist 6 to 12 months with non-surgical intervention.1,5
Below is an example of a physical therapy protocol post-surgical intervention:
(Note this is only one therapist’s treatment plan and variations can occur)
Phase I: Days 1-7
• Movement of the wrist and fingers for 2 minutes, 3-5x/day
• Ice and NSAIDs are utilized for pain control
• The patient is also educated on the signs of wound infection; including excessive
swelling, redness, excessive heat, oozing from the incision, a dramatic increase in pain or
a fever greater than 100° for more than one day
• Day 3: Showering is allowed, with bandages off, and gentle pain-free elbow, wrist and
shoulder ROM is started. At this point the immobilizer is optional.
Phase I: Days 7-17
• More aggressive ROM is encouraged in and out of the shower
• Goals for day 17 are 80% of normal elbow ROM
• The arm can be used for light activity only
• Ultrasound
• High Volt Galvanic Stimulation
Phase I: Days 18-21
• Sub maximal Isometrics are started
• The patient begins antigravity wrist flexion, extension, supination and pronation without
pain
• If painful the patient is instructed to utilize a counterforce brace during exercising
• Once the patient can perform 30 repetitions, without pain, they can progress to a 1-pound
weight or light resistance band. All exercises are performed with the elbow bent to 90°
and resting on a table or the lower extremity
Phase II: Weeks 3 – 6
Goals: Pain level less than pre-surgery level
Full ROM.
• Therapeutic exercises:
Rotator cuff, elbow and scapular stabilization training with light
resistance
Aerobic conditioning on a stationary bike or treadmill
Light stretching is encouraged at this stage with emphasis on end range and passive
overpressure
Progressive resistive exercises – strengthening wrist flexion, extension,
supination/pronation, ulnar and radial deviation. Progress the patient from a flexed and
elbow supported elbow to a fully extended and unsupported elbow
Pain free grip strengthening with putty or ball
Utilize counterforce brace during exercise if pain continues
• Gentle soft tissue mobilization/massage along and against fiber orientation
• Consider use of ice after exercise.
Phase III: Weeks 8 – 12
• Begin task specific functional activities
• Return to sport activities
• Continue counterforce bracing if needed
• Continue wrist, elbow, shoulder and scapular strengthening
• Patient is allowed to return to athletics once their grip strength is normal.
For More information: http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/14Elbow-LateralEpicondylectomy.pdf
Modalities
In the reviewing the literature the following modalities are the used in treatment of lateral epicondylitis and brief information on the current evidence on the efficiency of each are listed below:
Ultrasound therapy (US):
Current research has found limited evidence to support the use of US. Some studies have found short-term benefits (> 3 months) in reducing pain when in combination with other treatments. There has been no evidence to support long-term benefit from the use of US.1-3,5,9 One systematic review found evidence that exercise therapy is more beneficial than US in the treatment of acute or chronic lateral epicondylitis. 9
Acupuncture:
Evidence has shown short-term benefits (three days to two months) in pain reduction following acupuncture treatment.9,1 Deep acupuncture treatment has shown greater pain reduction results compared to more superficial treatments.9 Evidence is conflicting on use for treatment of LE at this current date.1
Electrotherapy:
Modalities include electromagnetic field therapy and iontophoresis.1 Inotrophpersis has been documented to significantly reduce pain and improve function when used as part of LE treatment.8 Benefits occur after two to four weeks.1 Evidence at this time is conflicting in the use of electromagnetic field therapy.1,9
Autologous Blood Injection: Hypothesized that injections will initiate the inflammatory cascade and initiate healing of degenerative tissue. Studies are lacking; therefore, autologous blood injection cannot be recommended at this time.1 (Not use by Physical Therapists)
Laser:
Evidence for the use Low-level laser therapy (LLLT) in LE treatment is conflicting. One study on the short term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis found LLLT increased grip strength but had no effect on pain reduction compared to bracing and ultrasound treatments.2 Another review on the treatment options for LE has found no significant evidence to support the use of LLLT in treatment of LE increase grip strength or pain reduction.1,5,7,9
Deep Tendon Friction Massage (DTF): Evidence shows little clinical benefit. One systematic review states DTF combined with other physical therapy modalities may reduce symptoms.7
Cryotherapy: Research discusses the use of ice to reduce inflammation, but there is no information here to discuss in detail.
Orthoses(Bracing):
Bracing or orthoses has been widely used in the treatment of lateral epicondylitis. Goal of using these devices is to reduce tension at the extensor origin allowing time for healing to occur.1,2,5 Multiple studies and reviews have been unable to provide evidence for the benefits of using orthoses.1-2 One study on short term efficacy of laser, brace and ultrasound treatment in Lateral Epicondylitis found that bracing was less effective than both US and laser therapy in reducing pain.2 There are many types of splinting or bracing devices available but the debate continues on which devices are the best.5
Table:1
Treatment of Lateral Epicondylitis( Example of a way on how to decide which treatment to use for LE): 1
Considerations:
Based on literature there are over 40 different treatments techniques for lateral epicondylitits.3 Yet, even with so many different interventions strategies being used to fight this condition, there has been non consensus in the literature on the most efficient intervention.1,3 The above sections are addressing the most commonly use interventions strategies seen currently. Treatment of lateral epicondylitis should consist of rest, strengthening, and stretching techniques to reduce pain and disabilities. Treatments strategies should be decided based on the patient’s symptoms and complains.
References
1. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physicia. 200; 76:843-848,849-50;853
2. Öken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu RZ, Öken OF. The Short-term Efficacy of Laser, Brace, and Ultrasound Treatment in Lateral Epicondylitis: A Prospective, Randomized, Controlled Trial, J Hand Ther.2008;21:63-8
3. Martinez-Silvestrini J, Newcomer K, Gay R, Schaefer MP, Kortebein P, Arendt KW. Chronic Lateral Epicondylitis: Comparative Effectiveness of a Home Exercise Program Including Stretching Alone versus Stretching Supplemented with Eccentric or Concentric Strengthening, J of Hand Ther.2005;18:411-420
4. American Physical Therapy Association. Guide to physical therapist practice. Second edition. American physical therapy association. Phys Ther. 2001;81(1)
5.Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg. 2008;16(1):19-29
6.Nynke S, Assendelft WJ, van der Windt D, Hay E, Buchbinder R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain.96(2002):40-23
7.Bohr PC. Systematic review and analysis of work-related injuries to and conditions of the elbow. Am J Occup Ther. 2011;65(1):24-8
8.Page P. A new exercise for tennis elbow that works. N Am J Sports Phy Ther.2010;5(3):189-193.
9.Trudel D, Duley J, Zastrow I, Kerr EW. Rehabilitation for patients with lateral epicondylitis: A systematic review. J Hand Ther. 2004;17(2):243-66
10. http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/14Elbow-LateralEpicondylectomy.pdf
Images References
1.http://guidetoptpractice.apta.org/local/img/home_cover.gif
2.http://adkblog.s3.amazonaws.com/wp-content/uploads/2011/12/topical-pain-reliever-122111-300x238.jpg
3.http://www.gpb.org/files/imagecache/newsArticle/news/images/body/pill_bottle_0.jpg
4.http://cfile227.uf.daum.net/image/147ADF524DC92F4723644F
5.http://www.pamf.org/sports/king/images/lateral_1.jpg
6.http://img03.static-nextag.com/image/Intelect-Legend-Ultrasound-5cm/10/000/010/243/937/1024393700.jpg
7.http://home-remedy-network.com/wp-content/uploads/2011/03/Rheumatoid-Arthritis-And-Treatment-With-The-Help-Of-Alternative-Medicine-03-10-2011.jpeg
8.https://www.medco-athletics.com/images/products/55001.JPG
9.http://sccofutah.com/clients/2390/images/klaser_s.jpg
10.http://www.aafp.org/afp/2007/0915/afp20070915p843-f1.jpg
