Tennis Elbow Management
Original Editor - Mariam Hashem
Top Contributors - Mariam Hashem, Kim Jackson, Tarina van der Stockt, Robin Tacchetti, Tony Lowe and Jorge Rodríguez Palomino
Framework For Rehabilitation[edit | edit source]
Management of tennis elbow (Lateral Epicondyle Tendinopathy) is similar in concept and approach to tendon rehabilitation. For the benefit of achieving long term goals, rehabilitation should be a multi-modal perspective and also to meet individual needs. We explored the different causes and associations of Tennis Elbow in the assessment course including, central sensitization, muscle and tendon structural changes and mechanical abnormalities. Hence, there is a need to examine all these aspects in the history taking and objective examination and consider them when designing a rehabilitation programme.
The use of multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy[1]. This includes education, exercises, tissue loading management, manual therapy and steroid injection. All of thhese management strategies can be used and tailored depending on the patient's needs, the clinician's clinical reasoning and a shared decision between patient and clinician. It should be centred around exercise based programme- best ,managememnt we have at the moment.
Patient Education[edit | edit source]
Educating patiens on their condition, prognosis, management options and self-management may not be effective on the short term and cannot be used as a stand alone measure. However, it has a good long-term effect if used in cobination with other measures for the management of Tennis Elbow[2].
Patient education is defined as ''a planned learning experience using a combination of methods such as teaching, counselling, and behaviour modification techniques which influence patients’ knowledge and health behaviour''[3]. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improving self-efficacy[4].
Tendon structure is strong, made up of type I collagen.
Health of tendon- thinking in a wide prespective, smoking, food and inactivity, diabetes, obesity- they all determine health in general and also recovery of tendonitis.
Load Management[edit | edit source]
Lateral Epicondyle Tendinopathy is a degenerative condition characterised by increased thickness and tearing in the common extensor tendon[5], and the presence of neuromotor dysfunction- particularly of extensor carpi radialis brevis (ECRB)[6]. Pain with hand grip is the most common presentation with TE. Powerful grip in healthy individuals in observed when the wrist is at 35 degrees extension. The same power is observed they grip with 11 degrees less wrist extension. The muscle activity of the wrist exhibit less reaction time in people with TE[7]. And use different nueromuscular strategies when gripping[6].
Reduction of load on the tendon is an effective pain management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to target load by retraining the mechanical properties of the tendon. A good way of altering the load is to ask patient to work under pain threashold on a numerical scale from 1-10 and loading the tendon under the level of exaggerated pain[8].
Pain and swelling will occur in response to increased load- this phase is known as ''reactive tendinopathy''. Reducing pain is essential in this phase by pain management measures and de-loading. Identifying the contributing factors to pain and tendinopathy can help in modifying the loads on the tendon. These factors include sudden increase in load or it can mean applying changes to the way a player holds a tennis raquet or a person lifting an object. Lifting objects with flexed elbow and supinated forearm is a way of de-loading the extensors at the elbow, particularily ECRB, which is the main. It is a static stabilizer of the wrist. in slight extension when holding your phone for example. Lifting with elbow extended and forearm supinated.
Exercises[edit | edit source]
progresing exercises gradually- to build tendon strength, tolerance adn resilience.
The default was to think about eccentric exercises. This was the standard protocol particularily in Achilis and Patellar Tendinopathyies.
Exercise types, load and programme design are still inconclusive regarding TE exercise management. Loading for a minimum of 12 weeks- studies point to
Role of Isometrics as an option- ECRB as a main tendon involved in TE- the role is static stabilizer of the wrist. makes sense.tasks.
Isomteric exercises for wrist. one of the measures.
To progressively load the tendons, start with elbow flexed and forearm supinated, isometric in this position. then gradually increase elbow extension angle- weight/theraband to add more load.
Bilateral movement- bearing in mind the central effects of TE[9]
task oriented exercise- functional to include shoulder
weight bearing through arm
The aim is to exapnd the view beyind the typical exercises
dominance of long wrist extensors over short extensors- when doing isometrics keep a fist, or avoid pushing fingers into extension/
Should exercises painfree pr painful is debated in litrature- exercising into pain in MSK disorders
Pain free exercises are most common. Exercise helps, loading is good and ex is the best treatemtn available. weighting in the long term benefits to the current pain. education of patient- exercises are damaging your joint- tackling myths. To build efficacy they have to go through pain sometimes.
If atient is not responding-
c
Isometric exercises were found to have hypoalgesic effect both locally and away from exercised part during and after contraction[10].
MWM[edit | edit source]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633771/
Steroid injection[edit | edit source]
long term outcomes are poor-
98% get better with physio
worse prognosis, high recurence rate and development of chronicity. there is a big move away.
Clinical reasoning skills- weight out the benefit and the current symptoms.
Discussion- shared decision
If there is a need to reduce pain- this might be a good way to engage patients into exercises by reducing their pain.
Taping[edit | edit source]
References[edit | edit source]
- ↑ Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. doi:10.1136/bmj.38961.584653.AE
- ↑ Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Can Chiropr Assoc. 2015;59(4):349–362.
- ↑ training physiotherapy students to educate patients: a randamized controlled trial
- ↑ Ndosi M, Johnson D, Young T, et al. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Ann Rheum Dis. 2016;75(6):1126–1132. doi:10.1136/annrheumdis-2014-207171
- ↑ Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. J Musculoskelet Neuronal Interact. 2018;18(3):323–332.
- ↑ 6.0 6.1 Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case-control study. Scand J Med Sci Sports. 2016;26(12):1382–1390.
- ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.
- ↑ Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy
- ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Med Sci Sports Exerc. 2016;48(4):599–606.
- ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578581/
