Fig. 14.1
Many physical therapy programs treating lateral epicondylitis include static stretching of the extensor mechanism (a) as well as eccentric stretching (b–d). Eccentric stretching involves contracting the extensor mechanism against resistance as the muscle is lengthened by moving from extension to flexion
Croisier et al. compared age, sex, and activity matched groups who underwent either passive rehabilitation or an active eccentric strengthening program. The passive rehabilitation protocol included use of analgesics, ice, ultrasound, deep friction massage, and stretching. The eccentric program included a progressive eccentric strengthening regimen [33]. They found that the eccentric group had a more rapid reduction in pain, significant improvement in strength and less disability compared to the passive group at 9 weeks postinitiation. Another study comparing stretching only, an eccentric strengthening program, and a concentric strengthening program demonstrated no difference between the groups at 6 weeks; however, a recent systematic review concluded that there is moderate evidence supporting the use of eccentric exercise [28, 34].
Ellenbecker et al. propose additional activity specific strengthening that focuses on the scapula and rotator cuff in addition to the forearm and wrist [32]. In addition to strengthening, proper mechanics should be addressed to reduce stress on the arm and possibly reduce recurrence. Once patients are pain-free and have the affected extremity strength equal to the contralateral side, they may return to sport. A gradual increase in play is recommended until the athlete can resume their preinjury activity level without discomfort.
Conclusions
There is limited evidence for when a patient can return to full activity after conservative or operative treatment. Additionally, there is no evidence examining the effect of early return to activities on the severity or duration of symptoms. The evidence for treatment outcomes favors conservative management.
The authors’ preferred treatment begins with a discussion with the patient about the often self-limited nature of the disease and the treatment options. After ruling out other pathology, we typically recommend that patients take a common sense approach to initially managing their symptoms. This includes self-limiting their activities and taking oral NSAIDs as needed. Patients are instructed to return to full activities as they are able. If the pain is severe enough to eliminate a patient from an important event or competition, we would consider 1–2 corticosteroid injections for short term pain relief.
Patients with persistent symptoms after conservative management may undergo surgical treatment. The decision to proceed to surgery is based on symptom persistence despite extensive conservative care, symptom severity, and patient preference. Our approach emphasizes educating patients about the relapsing and remitting nature of their symptoms as well as the possibility for a long duration of symptoms. A thorough discussion about other treatment options including risks, benefits, and the limitations of our evidence is important in order to arrive at a treatment plan that suits each individual.
References
1.
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6A):832–9.PubMed
2.
3.
Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br. 1992;74(5):646–51.PubMed
4.
5.
Leach RE, Miller JK. Lateral and medial epicondylitis of the elbow. Clin Sports Med. 1987;6(2):259–72.PubMed
6.
Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br. 1991;73(3):409–11.PubMed
7.
8.
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.CrossRefPubMedCentralPubMed
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
