Introduction
- Michael Levinson, PT, CSCS
- David Altchek, MD
Epidemiology
Age/Sex
- •
Age: Those 35 to 50 years of age are at the highest risk
- •
Females and males
Sport
- •
Tennis
- •
Golf
- •
Occupations or hobbies with repetitive activities
- •
1% to 3% of the general population affected
- •
Adult players: 35% to 50%
- •
Elite players: 11% to 12%
- •
Pathophysiology
Intrinsic Factors
- •
Proximal strength deficits at the scapula and glenohumeral joint
- •
Glenohumeral flexibility deficits such as loss of posterior shoulder flexibility
- •
Poor weightshifting during backhand, late backswing, and hitting with the front shoulder up
- •
Increased wrist extension at ball impact
- •
Poor general condition
- •
Poor upper-limb posture
- •
Inadequate rest and recovery
- •
Inadequate warmup
Extrinsic Factors
- •
Improper racquet grip size
- •
Racquet string tension too high
- •
Strings not resilient or soft enough
- •
Improper handle size of racquet or other sporting equipment that requires grip
Traumatic Factors
- •
Gradual increased load-related pain with increased activity
- •
Repetitive microtrauma
- •
Vascular compromise
- •
High eccentric and concentric stresses on the common extensor tendon (especially during the tennis backhand)
Classic Pathological Findings
- •
Angiofibroblastic hyperplasia, tendinosis
- •
Excessive vascular granulation
- •
Disorganized or degenerative collagen
- •
Degeneration, tendonopathy, tendinosis, and microtears of the extensor carpi radialis brevis (ECRB) and EDU tendon
Clinical Presentation
History
- •
Gradual onset of pain at the origin of the common extensor tendon ( Figure 9-1 )
FIGURE 9-1
Lateral and medial epicondylitis. A , In lateral epicondylitis, or “tennis elbow,” inflammation and pain occur in the outer side of the elbow, where muscles and tendons attach to the bone. The structures involved are the muscles or tendons of the forearm that bring the wrist back or extend the wrist, which is why this condition occurs not only in tennis players but also in anyone who performs repeated resisted motions of the wrist. In medial epicondylitis, or “golfer’s elbow,” inflammation and pain occur in the inner side of the elbow, where muscles and tendons attach to the bone. The structures involved are the muscles and tendons of the forearm that bring the wrist down and flex the wrist. This occurs not only in golfers but in anyone who performs repeated resisted motions of the wrist. B, Origin of the common extensor tendon.
- •
Often related to the backhand, especially in the novice and the recreational tennis player
- •
Other complaints may be related to repetitive labor activities, excessive computer work, or carrying bags with the elbow in extension.
- •
Symptoms often progress from pain after athletic or work-related activities to simple activities of daily living, such as shaking hands or holding an object with the elbow in extension.
- •
The elbow becomes painful at rest and disturbs sleep.
Physical Examination
Abnormal Findings
- •
Loss of wrist flexion range of motion
- •
Tenderness to palpation of the extensor origin at the lateral epicondyle (see Figure 9-1 B )
- •
Localized edema, erythema
- •
Grip weakness
- •
Pain with passive wrist flexion
- •
Pain with resistive wrist and third-finger extension
Imaging
- •
Radiographs: tendinous calcific changes
- •
Magnetic resonance imaging (MRI): tears of the extensor tendon, abnormal tendinous tissue
Differential Diagnosis
- •
C6 to C7 nerve root compression: symptoms more radicular in nature
- •
Posterior interosseous nerve syndrome: may be differentiated by pain with wrist extension and radial deviation, weakness of finger extensors, and pain with thumb extension at the lateral epicondyle
- •
Lateral antebrachial cutaneous nerve irritation (the terminal sensory branch of the musculocutaneous nerve)
Treatment
Nonoperative Management
- •
Activity modification to avoid the aggravating behaviors
- •
Corticosteroid injections
- •
Nonsteroidal antiinflammatory drugs
- •
Counterforce bracing, wrist cockup splint
- •
Shock-wave therapy
- •
Physical therapy: strength, flexibility, conditioning, manipulation, and mobilization
- •
Physical therapy modalities: cryotherapy, transcutaneous electrical nerve stimulation, iontophoresis, ultrasound, and low-level laser
- •
- •
Improvement of sport mechanics
- •
Plasma-rich platelet injections
Guidelines for Choosing Nonoperative Treatments
- •
Diagnosis of tendinitis versus tendonopathy
- •
Severity and history of symptoms
- •
Clinical findings, such as strength, flexibility, postural, and conditioning deficits
Surgical Indications
- •
Failure of injections
- •
Associated intraarticular pathology
- •
Failure of conservative treatment for a minimum of 6 months
Aspects of History, Demographics, or Examination Findings that Affect Choice of Treatment
- •
Persistent pain that interferes with activities of daily living and disturbs sleep
- •
Pain that prevents return to sport such as tennis
- •
Persistent pain localized to the origins of the ECRB and extensor digitorum communis (EDC)
- •
Tear of the extensor demonstrated on MRI evaluation
Aspects of Clinical Decision-Making When Surgery Is Indicated
- •
Surgeon’s experience and the efficiency of the procedure
- •
Other intraarticular pathology may dictate an arthroscopic procedure.
- •
Lateral epicondyle drilling can increase pain and potentially damage the EDC.
- •
Release techniques have potential for complications, such as damage to the lateral ligament complex, instability, and loss of grip strength.
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is not an intrinsic factor that may predispose the patient to lateral epicondylitis while playing tennis?
- A.
Proximal strength or flexibility deficits
- B.
Increased wrist extension at ball impact
- C.
Increased wrist flexion at ball impact
- D.
Inadequate rest and recovery
- A.
- QUESTION 2.
Which of the following is not an extrinsic factor that contributes to lateral epicondylitis?
- A.
Improper racquet grip size
- B.
Racquet string tension that is too high
- C.
Improper footwear
- D.
Racquet string that is not resilient or soft enough
- A.
- QUESTION 3.
Which of the following conditions can easily be confused with, and needs to be differentiated from, lateral epicondylitis?
- A.
Posterolateral instability
- B.
Posterior interosseous nerve syndrome
- C.
Ulnar collateral ligament tear
- D.
C4 to C5 radiculopathy
- A.
- QUESTION 4.
Which of the following would not be a finding in a clinical examination for lateral epicondylitis?
- A.
Decreased grip strength
- B.
Loss of passive wrist extension
- C.
Pain with passive wrist and third-finger extension
- D.
Tenderness to palpation at the lateral epicondyle
- A.
- QUESTION 5.
Which of the following activities of daily living can exacerbate symptoms of lateral epicondylitis?
- A.
Handshaking
- B.
Excessive computer use
- C.
Carrying bags with the elbow in extension
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: C (see Extrinsic Factors )
- QUESTION 3.
Correct answer: B (see Differential Diagnosis )
- QUESTION 4.
Correct answer: D (see Clinical Examination)
- QUESTION 5.
Correct answer: D (see Clinical Presentation )
Nonoperative Rehabilitation of Lateral Epicondylitis (Tennis Elbow)
- Michael Levinson, PT, CSCS
- David Altchek, MD
- •
Understand the pathology: tendinitis versus tendonopathy
- •
Reduction of pain and inflammation and promotion of healing are the primary goals
- •
Control excessive loads to the injured area
- •
Pathologic tissue needs to be repaired and revitalized
- •
Reproduce the functional demands throughout the entire kinetic chain
- •
The patient’s general fitness is critical to recovery and avoiding reinjury
Phase I (Guidelines are evaluation-based)
Protection
- •
Counterforce bracing or a wrist-cockup splint may be used for activities of daily living ( Figure 9-2 ).
FIGURE 9-2
Counterforce brace.
- •
Wrist splints should not be used during sleep, as they may cause shortening of the extensor tendons.
- •
Activity modification should be a significant factor in the treatment plan. The amount of incidental activities performed at home or at work (e.g., computer work, hand-shaking, carrying bags) should be taken into account.
| PHASE I | PHASE II | PHASE III | PHASE IV |
|---|---|---|---|
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Management of Pain and Swelling
- •
Modalities include cryotherapy, iontophoresis, ultrasound, TENS, and low-level laser.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Joint mobilization may be used for pain control or if any capsular restrictions are present. Manipulations (Mill’s manipulation) may also be utilized. Mill’s manipulation is a small-amplitude, high-velocity thrust performed at the end of elbow extension while the wrist and hand are held flexed.
Soft-Tissue Techniques
- •
It is the authors’ opinion that deep-tissue massage often exacerbates symptoms and has little therapeutic value.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Stretching of the wrist and finger extensors should be initiated in a pain-free range of motion (ROM) ( Figure 9-3 ).
FIGURE 9-3
Stretching of the wrist and finger extensors.
Other Therapeutic Exercises
- •
Multijoint, upper-extremity exercises should be initiated to restore total arm strength (TAS) and proximal stability. These should include scapula, deltoid, and rotator cuff strengthening.
- •
Often, the tennis player has a proximal muscle deficit.
- •
Biceps and triceps strengthening should be initiated in a pain-free ROM, avoiding full elbow extension.
- •
For the tennis player, core and lower-extremity strengthening may be initiated without holding weights in the hands.
- •
Upper-extremity posture should be addressed.
Open and Closed Kinetic Chain Exercises
- •
Closed kinetic chain exercises generally are performed with the wrist in extension and the elbow moving into full extension. This is contraindicated in Phase I.
Milestones for Progression to the Next Phase
- •
Reduction of symptoms (pain, edema, inflammation)
- •
Restoration of proximal stability (scapula function, rotator cuff strength)
- •
Normal wrist flexion ROM
Phase II (Guidelines are evaluation-based)
Protection
- •
Counterforce bracing or wrist-cockup splint as needed.
Management of Pain and Swelling
- •
Cryotherapy, iontophoresis, ultrasound, TENS, low-level laser as needed
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Joint mobilization and manipulation if any capsular restrictions are needed
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue pain-free stretching of the wrist and finger extensors. Begin to address any shoulder flexibility deficits. For example, many tennis players have a loss of posterior shoulder flexibility.
Other Therapeutic Exercises
- •
Continue to progress general upper-extremity, multijoint exercises to normalize shoulder and scapula strength. For the tennis player, emphasize the scapula and posterior rotator cuff.
- •
Continue biceps- and triceps-strengthening to include concentric and eccentric activity.
- •
Initiate forearm-strengthening to include wrist flexion.
- •
Core and lower-extremity strengthening may be progressed, but the patient should still avoid holding heavy weights in the hands.
Activation of Primary Muscles Involved
- •
Initiate wrist extension and forearm pronation and supination. Exercises should be initiated with the elbow supported and in flexion to reduce the amount of bone-to-tendon contact at the origin of the common extensor tendon ( Figure 9-4 ).
FIGURE 9-4
Forearm pronation ( A ) and supination ( B ) with the elbow in flexion.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
If proximal strength is adequate, the upper-body ergometer can be used to begin to restore power and endurance.
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization should be initiated proximal to the elbow.
Functional Exercises
- •
Proprioceptive neuromuscular facilitation (PNF) patterns should be initiated.
Milestones for Progression to the Next Phase
- •
Normal upper-extremity flexibility
- •
Normal proximal upper-extremity strength
- •
Minimal pain with wrist extension exercises
Phase III (Guidelines are evaluation-based)
Management of Pain and Swelling
- •
Continue with prior modalities as needed as forearm-strengthening is progressed, symptoms may increase.
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
A full upper-extremity flexibility program should be continued. Overstretching of the wrist and finger extensors should be avoided.
Other Therapeutic Exercises
- •
Continue to progress a full upper-extremity strengthening program, including overhead activities.
- •
Progress core and lower-extremity strengthening and flexibility program.
- •
Sport-specific general conditioning exercises
Activation of Primary Muscles Involved
- •
Eccentric wrist extension should be emphasized if tolerated. This should be initiated with the elbow in flexion and progressed to extension ( Figure 9-5 ). All muscle groups of the forearm should be addressed to restore normal functional movement patterns.
FIGURE 9-5
Resistive eccentric wrist extension.
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization may be progressed to a longer-lever arm (distal to the elbow).
- •
Exercises may be progressed to more challenging positions for the shoulder and elbow ( Figure 9-6 ).
FIGURE 9-6
Rhythmic stabilization in the overhead position with distal resistance.
- •
The patient may then progress to the Bodyblade from a neutral position to positions throughout the tennis stroke.
Plyometrics
- •
A plyometric program should be initiated if the patient is asymptomatic and has a normal strength base and normal upper-extremity flexibility.
- •
A functional progression for a tennis player would follow: two-handed chest pass, side-to-side wood chops, overhead soccer pass, one-handed external rotation, one-handed backhand, one-handed 90° internal and 90° external position.
- •
Deceleration exercises by catching the plyo ball and slowing it down should be included.
- •
Wrist flexion flips and wrist flexion snaps may be incorporated ( Figure 9-7 ).
FIGURE 9-7
Wrist flips and snaps.
Sport-Specific Exercises
- •
Resistive forehand and backhand exercises using elastic resistance or a cable system should be initiated.
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Completion of a plyometric program without symptoms
- •
Full forearm strengthening without residual symptoms
- •
Upper-extremity strength and endurance that is equal or greater than the contralateral side
Phase IV (Guidelines are evaluation-based)
Management of Pain and Swelling
- •
Cryotherapy should be utilized throughout the return.
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue full upper-extremity flexibility program.
- •
Avoid overstretching the extensor tendons.
- •
Stretching should always be pain-free.
Other Therapeutic Exercises
- •
Continue a full upper-extremity strengthening program to include the scapula, shoulder, elbow, forearm, and wrist.
- •
Continue core stability with emphasis on trunk rotation and posture.
- •
Continue full lower-extremity strengthening program with emphasis on closed-chain activities, hip rotation, and unilateral activities. These may include leg press, squats, forward stepups, lunges, side lunges, back lunges, split squats, and lunges with trunk rotation.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Isokinetics for wrist flexion–extension and pronation–supination once a strength base has been established. This can be used to reproduce sport-specific speeds and train for endurance.
Plyometrics
- •
As an interval tennis program is initiated, plyometrics should be phased out.
Sport-Specific Exercises
- •
An interval tennis program should be initiated if criteria are met.
- •
The program should entail a progression of volume and intensity. The program should be progressed individually.
- •
Each phase should be completed without significant symptoms or fatigue prior to advancing to the next phase.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Unable to perform sport-specific activities or return to preinjury activity level
- •
Continued pain with activities of daily living
- •
Failure to restore normal grip strength
Milestones for Progression to Sport-Specific Training and Conditioning
- •
Able to complete interval tennis program without symptoms
- •
Maintain normal upper-extremity strength and flexibility
Tips and Guidelines for Transitioning to Performance Enhancement
- •
When resuming tennis activities, the patient should not try to work through pain or fatigue.
- •
Use of low-compression tennis balls has been advocated when initiating an interval tennis program. These decrease the amount of stress on the elbow at ball impact.
- •
The patient’s racquet should be evaluated for string tension and grip size. These can also be valuable in avoiding reinjury.
- •
Adequate rest and recovery are important to avoiding and minimizing fatigue and reducing the chances of reinjury.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
When returning to tennis activities, supervision by a professional to improve mechanics can enhance performance and prevent reinjury.
- •
Learning to weight-shift properly, use the core and lower extremities, and avoid hitting too late with the leading elbow posture can be very valuable.
- •
Upon returning to tennis, a program for full-body strength, flexibility, and endurance should be maintained. This will also reduce the risk of reinjury.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Normal grip strength on dynamometer
- •
Shoulder strength greater than contralateral side
- •
Normal upper-extremity flexibility
- •
Completion of full-interval tennis program
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which cannot be utilized for protection and symptom reduction during the initial phase of nonoperative treatment?
- A.
Sling
- B.
Elbow counterforce brace
- C.
Activity modification
- D.
Wrist cockup splint
- A.
- QUESTION 2.
Which would not be considered a criterion for return to sport?
- A.
Normal shoulder forearm and shoulder flexibility
- B.
Completion of a sport-specific plyometric program
- C.
Interval tennis program with only minimal to moderate symptoms
- D.
Shoulder strength greater than contralateral side
- A.
- QUESTION 3.
Which position allows the most bone-to-tendon contact for the extensor tendons?
- A.
Elbow flexion and forearm supination
- B.
Elbow extension and forearm pronation
- C.
Elbow extension and forearm supination
- D.
Elbow flexion and forearm pronation
- A.
- QUESTION 4.
Which of the following should one do when returning to tennis activities?
- A.
Use tennis balls with high compression
- B.
Hit unsupervised
- C.
Play through fatigue to build endurance
- D.
Learn to weight-shift properly and avoid hitting too late with leading elbow
- A.
- QUESTION 5.
When should isolated strengthening of the wrist and finger extensors be initiated?
- A.
When a proximal strength base has been established
- B.
When forearm flexibility is restored
- C.
When the patient is asymptomatic
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Phase I: Protection )
- QUESTION 2.
Correct answer: C (see Specific Criteria for Return to Sports Participation )
- QUESTION 3.
Correct answer: B (see Evidence )
- QUESTION 4.
Correct answer: D (see Performance Enhancement and Beyond )
- QUESTION 5.
Correct answer: D (see Phase II )
Postoperative Rehabilitation after Open or Arthroscopic Surgery for Lateral Epicondylitis
- Michael Levinson, PT, CSCS
- David Altchek, MD
Indications for Surgical Treatment
- •
Failure of conservative treatment, which may include nonsteroidal antiinflammatory drugs, cortisone injections, splinting, and physical therapy and activity modification for a minimum of 6 months
- •
Persistent pain that interferes with activities of daily living
- •
Pain that prevents an athlete from returning to sport
- •
Clear localization of pain at the anatomic areas of the extensor carpi radialis brevis (ECRB) and extensor digitorum communis
- •
Tear of the extensor tendon diagnosed
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Supine position on the operating table
- •
Extensor carpi radialis longus (ECRL) is split longitudinally and retracted medially and laterally.
- •
The ECRB is exposed.
- •
Fibrinous material is debrided.
- •
Mini-Mitek suture anchor (De Puy Synthes, West Chester, Pennsylvania) is inserted into the lateral epicondyle.
- •
Two limbs of suture are passed through the ECRL and ECRB and reattached to the lateral epicondyle.
- •
Placed in posterior splint
Other Surgical Techniques and Options
- •
Major differences in other surgical techniques (if not covered in other sections)
- •
The ECRB can be debrided and released arthroscopically.
- •
The arthroscope is used to identify the location of the ECRB tendon and identify any other elbow joint pathologies, such as loose bodies.
- •
Any variance from rehabilitation guidelines would result from any postoperative joint effusion that might interfere with restoring range of motion (ROM) and strength.
- •
The clinician should be cognizant of any posterolateral instability that may result from this procedure.
Before Surgery: Overview of Goals, Milestones, and Guidelines 1
1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.
- •
Understand the surgical procedure performed and healing rates of the tissues involved
- •
Understand the positions and activities that stress the wrist and finger extensors and their attachment at the lateral epicondyle
- •
Minimize active wrist and finger extension during the early phases of rehabilitation
- •
Avoid painful ROM and strengthening
- •
Understand the criteria for returning to functional and athletic activities
Phase I : Immediate Postoperative Period (days 0 to 14)
- •
Early range of motion is important. It should be performed actively or actively with assistance.
- •
Aggressive passive range motion should be avoided to allow optimal soft-tissue healing.
- •
A brace is generally not required. However, it may be indicated if patient activity modification is a concern.
| PHASE I (weeks 1 to 2) | PHASE II (weeks 3 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 14) | PHASE V (weeks 14 to 24) | PHASE VI (weeks 24 to 52) |
|---|---|---|---|---|---|
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Goals
- •
Patient education
- •
Activity modification to avoid stressing the repair
- •
Protect the surgical repair
- •
Minimize swelling, pain, and inflammation
- •
Avoid contracture
Protection
- •
A posterior splint is used for 1 week. As mentioned above, a brace is generally not indicated.
Management of Pain and Swelling
- •
Oral pain medications are prescribed.
- •
Cryotherapy is used for pain and inflammation.
- •
Activity modification to avoid pain is also critical. Minimizing activities that stress the wrist and finger extensors will help to reduce postoperative pain.
- •
For swelling, cryotherapy and activity modification
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Codman exercises are used to increase blood flow into the entire upper extremity and maintain flexibility of the glenohumeral joint.
- •
Scapular retraction exercises are used to maintain posture and begin to restore proximal strength.
- •
Elbow active range of motion (AROM) and active assisted range of motion (AAROM) exercises are initiated. The therapist should not engage the patient with passive range of motion (PROM).
Other Therapeutic Exercises
- •
Once the sutures are removed, the patient may begin to use a stationary bicycle, but should avoid gripping the handle with the surgically treated hand.
Milestones for Progression to the Next Phase
- •
Minimal pain and swelling
Phase II (weeks 2 to 6)
- •
The therapist should continue to avoid engaging the patient with aggressive PROM to allow optimal soft-tissue healing.
- •
Elbow extension should be restored by a low-intensity/long-duration stretch in supine.
- •
Patients should be advised to perform activities with their surgically treated arm with the elbow in flexion to reduce stress to the repair.
Goals
- •
Protect surgical repair
- •
Minimize pain, swelling, and inflammation
- •
Continue to modify activities of daily living (computer use, handshaking, carrying, and lifting)
- •
Avoid painful exercises.
Protection
- •
No protection is needed if the patient is compliant.
Management of Pain and Swelling
- •
Continue cryotherapy and oral pain medications as indicated.
- •
Continue cryotherapy and activity modification to control swelling.
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue AROM and AAROM of the elbow.
- •
Low-intensity/long-duration stretch for elbow extension if needed; performed while supine with a towel roll under the humerus
- •
Gentle wrist ROM is initiated to avoid forearm stiffness and promote healing. This should be performed with the elbow in flexion.
- •
AROM of the shoulder is performed to maintain glenohumeral ROM and flexibility.
Other Therapeutic Exercises
- •
Continue stationary bicycle while avoiding gripping with the surgically treated hand.
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Begin manual sidelying scapular stabilization exercise with resistance proximal to the elbow to continue to establish proximal strength ( Figure 9-8 ).
FIGURE 9-8
Manual sidelying scapular stabilization exercises with proximal resistance.
Milestones for Progression to the Next Phase
- •
Minimal pain or swelling
Phase III (weeks 6 to 10)
- •
When initiating isotonic exercises for the shoulder, scapula, and elbow, the patient should avoid end ranges of elbow extension. This will avoid excessive stress to the surgically repaired extensor tendon.
- •
Strengthening of the wrist and finger extensors should begin with the elbow supported and flexed. This will decrease bone-to-tendon contact pressure at the origin of the common extensor tendon at the lateral epicondyle.
Goals
- •
Continue to avoid excessive stress to the surgical repair.
- •
No pain with exercise or activities of daily living
- •
Full elbow ROM
- •
Begin to restore shoulder and scapular strength/flexibility.
- •
Begin to restore elbow and forearm strength.
Management of Pain and Swelling
- •
Cryotherapy is continued, and oral pain medication should be discontinued.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
In cases where extension is not full by 6 to 10 weeks, joint mobilization, such as joint distraction and posterior gliding of the ulna on the humerus, should be utilized.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
If full extension has not been restored, a low-intensity/long-duration stretch should continue to be used. A weight or elastic resistance may be added.
Other Therapeutic Exercises
- •
Sport-specific core and lower-extremity strengthening may be introduced. However, holding heavy weights in the hands while performing these exercises should be avoided.
- •
Proximal strengthening should be introduced for the shoulder and scapula, including the rhomboids; serratus; upper, middle, and lower trapezius; and latissimus dorsi and rotator cuffs.
- •
All exercises should be performed while avoiding the end range of elbow extension ( Figures 9-9 to 9-11 ).
FIGURE 9-9
Scapula retraction with elastic resistance.
FIGURE 9-10
Serratus punch.
FIGURE 9-11
Latissimus dorsi pull-down.
- •
Begin biceps and triceps strengthening while avoiding the end stage of elbow extension.
Activation of Primary Muscles Involved in Injury Area or Surgical Structure
- •
Isotonic exercises for the wrist and finger extensors are initiated with the elbow supported and in flexion.
Open and Closed Kinetic Chain Exercises
- •
Most closed kinetic chain exercises put significant stress on the lateral epicondyle and common extensor tendon.
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization exercises for the shoulder can be initiated with resistance proximal to the elbow ( Figure 9-12 ).
FIGURE 9-12
Rhythmic stabilization with proximal resistance.
Milestones for Progression to the Next Phase
- •
Full elbow ROM. Using standard goniometry, average elbow ROM is 0° internal and 140° external. However, it should be compared with the nonoperative side.
- •
Pain free with exercises and activities of daily living
- •
Good proximal strength base. All shoulder strength should be 5/5 using standard manual muscle testing. Scapulothoracic function should be within normal limits based on observation and comparison to the nonoperative side.
- •
Good shoulder flexibility determined using standard goniometry and compared with the nonoperative side. For shoulder internal rotation, vertebral level may be used.
Phase IV (weeks 10 to 14)
- •
Elbow pathology in the athletic population is often associated with a selective loss of shoulder flexibility.
- •
In preparing for athletic activities, begin to restore proximal flexibility, especially in the posterior structures of the shoulder.
- •
The common extensor tendon often undergoes significant eccentric stresses. Eccentric training should begin to be incorporated into the program.
Goals
- •
Restore normal shoulder and scapular strength
- •
Restore normal shoulder flexibility
- •
Begin to restore forearm flexibility
- •
Progress to overhead activities
Management of Pain and Swelling
- •
Cryotherapy is continued to prevent any muscle soreness.
- •
Any significant pain in this phase indicates that the patient’s activity level should be reduced.
- •
The surgeon should address any significant swelling in this phase.
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Forearm stretching for both the lateral and medial side should be performed. Posterior shoulder flexibility exercises should be initiated ( Figure 9-13 ).
FIGURE 9-13
Posterior shoulder stretch.
Other Therapeutic Exercises
- •
Scapula, shoulder, and elbow strengthening should be progressed as tolerated.
- •
Rotator cuff strengthening should be progressed to the 90° internal and 90° external position ( Figure 9-14 ).
FIGURE 9-14
Rotator cuff strengthening in the 90° internal and 90° external position.
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Wrist and finger extension strengthening should begin to emphasize the eccentric activity of muscle contraction.
Sensorimotor Exercises
- •
Proprioceptive neuromuscular facilitation patterns are initiated.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Upper-body ergometry may be initiated to improve general upper-extremity endurance ( Figure 9-15 ).
FIGURE 9-15
Upper-body ergometry
Neuromuscular Dynamic Stability Exercises
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Rhythmic stabilization exercise should be progressed to resistance distal to the elbow and to the overhead position.
Phase V (weeks 14 to 24)
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Sport- or work-specific programs should be initiated only after the patient has demonstrated normal strength, flexibility, and endurance.
- •
The patient should have tolerated all neuromuscular drills, including plyometrics, prior to beginning a sport- or work-specific program.
- •
For the tennis player, problems are often initiated by strength and flexibility deficits at more proximal points in the chain, such as the trunk and hips.
Goals
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Restore normal neuromuscular function
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Begin sport- or work-specific activities without pain
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Restore full-body strength, ROM, flexibility, and endurance
Management of Pain and Swelling
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Cryotherapy
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
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A full upper-extremity flexibility program should be continued for the shoulder, elbow, wrist, and forearm.
Other Therapeutic Exercises
- •
For the athlete, a full core and lower-extremity strengthening and flexibility program should be incorporated.
- •
For the tennis player, emphasis on hip and trunk flexibility and strength is critical.
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Wrist and finger extensor strengthening should be performed with the elbow in extension if tolerated.
- •
Forearm pronation and supination exercises should be incorporated to improve total forearm function. Heavy resistance is not required and, in most cases, is contraindicated.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
When available, isokinetics can be utilized to build endurance and simulate the speeds and loading rates of functional activities, such as tennis.
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization may be progressed to all functional positions.
- •
The patient may be progressed to the Bodyblade if one is available.
- •
A functional progression should be followed from the patient’s side to external rotation, then to the 90° internal and 90° external position, and then to follow-through ( Figure 9-16 ).
FIGURE 9-16
Bodyblade.
Plyometrics
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When the patient is asymptomatic and with a normal strength base and upper-extremity flexibility within normal limits, a plyometric program should be initiated.
- •
Progression: Chest pass, side-to-side wood chops, overhead soccer pass, one-handed external rotation with arm at side, one-arm external rotation in 90° internal and 90° external position.
Functional Exercises
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Deceleration exercises are performed first in a kneeling position. Tossing a Plyoball over the shoulder and catching it and decelerating the arm.
- •
This should be progressed to a standing position where the patient trains the larger body parts to absorb stress from the upper extremity during a serve ( Figure 9-17 ).
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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