Role of Therapy and Rehabilitation

Stage 1

Characterized by peritendinous inflammation and crepitus may be palpable over the common extensor origin

Stage 2

Inflammatory response ends, as angiofibrotic changes beginning to occur, leading to degradation of the origin of the ECRB tendon

Stage 3

Pathologic changes leading to a structural failure and rupture along with tear of ECRB tendon

Stage 4

Continued tendon degradation and structural failure, but also with other changes such as fibrosis, soft matrix calcifications, and hard osseous calcification

The repetitive overuse that results in LE is also due in part to the underlying anatomy. The deep surface of the ECRB is in close contact with the capitellum, and repetitive wear and abrasion at this site of contact is felt to play a role in the development of LE [17]. It is felt that repeated undersurface abrasion against the capitellum with elbow extension puts the tendon at risk for microtears and degeneration. These continued repetitive forces lead to further degeneration because of the poor underlying vascular anatomy. Studies have shown that the undersurface of the extensor tendon origin is macroscopically avascular [17, 29], reducing the healing potential, making this area more vulnerable to injury. There are two main hypovascular zones, at the lateral epicondyle and 2–3 cm distal to the extensor insertion [5, 29]. It has also been shown that there may be an imbalance between vasoconstrictor and vasodilator innervation in this area, further contributing to LE and exacerbating the healing difficulty already present in this watershed area [29, 51, 81]. Some feel that the abnormal vascularity contributes to pain mediation in chronic tendinopathies [30].

Neurogenic Inflammation

Pain is a chief complaint of this condition despite the absence of inflammation. The presence of neurochemicals within the involved tissue has been identified. It is believed that these neurochemicals, such as glutamate, substance P, and calcitonin gene-related peptide may be responsible for pain mediation [30]. These substances have been identified in cases of chronic tennis elbow and provide a possible mechanism for pain mediation in this and other chronic tendinopathies [30].

Therapeutic Rehabilitation

Evidence-based medicine is the use of current best evidence in making treatment decisions about the care of individual patients. Both research and clinician expertise are important components of evidence-based practice. Evidence suggests that LE is one of the most commonly seen upper extremity conditions. However, gaps exist between common treatment approaches, clinical practice guidelines, and available evidence. Recent systematic reviews related to LE indicate that the results of therapeutic interventions vary, there is a lack of scientific evidence to draw conclusions about optimal therapeutic interventions, and conservative management is multimodal [6, 12, 47, 80]. Many studies have found that conservative treatment is effective in the treatment of LE [24, 55, 63, 70, ] and many authors have indicated that only about 10 % of patients with LE undergo operative management. Fedorczyk [31] suggests that therapeutic intervention is effective, however, therapists have failed to report their outcomes in peer-reviewed literature. We feel that satisfactory outcomes are to be expected if quality rehabilitation is instituted which incorporates therapeutic interventions that promote the modulation of pain, tissue healing and regeneration, muscular conditioning, patient education, and worksite and sporting modifications.

Phases of Rehabilitation

Three phases of rehabilitation have been proposed for LE. The acute phase is commonly characterized by moderate pain at rest, which can be easily provoked with light functional activity. Typical interventions in this phase are aimed at pain control and activity modification. The restorative phase begins when minimal resting pain is present and minimal provocation of symptoms with active range of motion (ROM) or light functional activity. The third phase, maintenance phase, involves the workplace, equipment, and technique modification for work and sport and continued conditioning to prevent recurrence.

Over 40 different treatment techniques have been reported in the literature with varying levels of scientific evidence [76]. MacDermid et al. [54] conducted a survey of expert opinion and practice patterns of the management of LE by hand therapists. These authors found that hand therapists consider the most essential components of rehabilitation to include patient education, stretching, activity modification, strengthening, pain management, and use of orthoses/splints. However, it is imperative when implementing the various treatment techniques that they are applied based on the current phase of rehabilitation and stage of tendon healing.

The acute phase of rehabilitation is characterized by symptoms that include tenderness over the lateral aspect of the elbow with moderate pain at rest which can be easily provoked with ROM and light functional activity. Patients often report discomfort with elbow extension, forearm pronation, and upon resisted wrist extension or firm gripping [78]. There may be swelling and/or crepitus over the lateral elbow; however, in clinical practice this is most often not present unless the patient has sought medical attention within the first 6 weeks of onset [45]. If swelling is present, the patient would be categorized as a Stage 1 based on the Kraushaar and Nirschl classification system. Therapy during the acute stage is directed at controlling pain and activity modification. Furthermore, therapists attempt to minimize the progression of LE into the latter stages of the Kraushaar and Nirschl classification system.

Patient Education

In order to progress through the phases of rehabilitation, efforts must be taken to modify behaviors and activities as well as to refrain from aggravating activities. Clinicians should provide the patient with education regarding how to apply ergonomic principles during aggravating activities as well as to decrease load and repetition during activity. Emphasis should be placed on avoiding prolonged or repetitive wrist flexion, extension, and radial deviation as these positions increase tension on the muscle–tendon unit [56, 94]. Also, forceful gripping, repetitive finger use, and repetitive pronation and supination can similarly lead to pain and microtrauma of the common extensor tendon. For the computer-based worker, education in optimal hand, wrist, and elbow positions while seated as well as changes to the angle of tilt of the keyboard and position of the keys relative to the worker can be beneficial. (i.e., split keyboard, negative tilt, gel wrist support bar, elbow at approximately 90°, forearms supported). For others, such as factory workers or sports-minded individuals, larger handled tools that allow a wider grip, soft-handled tools that reduce grip effort, and ergonomically designed tools that are lighter and place the wrist in neutral to slight extension during use have been suggested as effective strategies to begin controlling LE symptoms. The literature indicates that ergonomic interventions are subjectively effective, but that minimal change occurs in overall symptom severity [34].

Pain Control Techniques

Rest

The term rest is a misnomer, because cessation from the offending activity is the goal. However, we do not want complete inactivity or immobilization as this can lead to disuse atrophy and compromise the later stages of rehabilitation [20]. Rest with intermittent graded activity should assist with reducing pain. Intermittent graded activity allows for intermittent loading of the involved structures preventing atrophy while promoting gradual, progressive vascularization of the tendon during the initial stages of healing. Thus, activity restriction opposed to complete rest is recommended with restriction from repetitive lifting, gripping, and pronation/supination of the affected arm [18].

Ice

Cryotherapy is a modality that should be introduced at the onset of LE symptoms. It can be applied after activity with the intent to minimize post-activity soreness and to reduce inflammation if present. It is generally applied for 5–15 min a few times per day [76]. Cryotherapy will provide short-term symptom relief [55].

Medication

Medication taken orally (such as antiinflammatories, NSAIDS, etc) or injected (cortisone, lidocaine) does not directly promote recovery [12, 35, 79, 88]. However, it may provide pain control allowing the patient to progress through the phases of rehabilitation. During the acute phase, oral medication may provide symptom control if taken during the first 10–14 days from the onset of injury [20]. If symptoms have been present for many weeks, oral medications will likely provide minimal effect. For a detailed review of medical management and steroid injections, we refer you to Chaps. 4 and 7, respectively.

Orthosis Application

Two popular methods of orthotic intervention to provide pain control include a forearm counterforce strap and a wrist extension orthosis. The forearm counterforce strap is placed around the muscle bellies of the wrist extensors just distal to the elbow joint (Fig. 6.1). During the acute phase of rehabilitation, a wrist extension orthosis may be helpful to allow the wrist extensors to rest. These orthoses can be custom fabricated or prefabricated (Fig. 6.2). Jensen et al. [43] investigated the amount of electrical activity in the wrist extensors by electromyography during activity with and without the wrist orthosis. These authors found that the application of a wrist orthosis in 15° extension reduces muscle activity during lifting activities, and therefore, assumed that there was decreased tension placed on the tendon. In the acute phase of rehabilitation, our preference is to use a custom-made wrist extension orthosis positioning the wrist in approximately 30–40° of extension to adequately unload the wrist extensors. This position has been shown to optimize grip strength [66], therefore, splinting the wrist in this position should allow for optimal hand function while providing rest to the wrist extensors.

Fig. 6.1

Forearm counterforce bracing is the application of a nonelastic strap to prevent full muscular expansion of the proximal forearm. This acts to reduce force transmission across the proximal portion of the muscle–tendon unit which may diminish pain with gripping activities

Fig. 6.2

a Custom fabricated wrist extension orthosis positioning the wrist in approximately 30–40° of wrist extension to adequately unload the wrist extensors. Five degrees of wrist extension

Counterforce bracing is the application of a nonelastic strap to prevent full muscular expansion of the proximal forearm [42, 60]. The therapeutic effect of this form of orthotic application lies in the compressive force applied just distal to the origin of the ECRB. This acts to reduce force transmission across the proximal portion of the muscle–tendon unit which may diminish pain with gripping activities. This form of bracing may also promote rest to the injured structures. Counterforce bracing may be used during the acute, restorative, or maintenance phase of rehabilitation [59, 62, 71]. Snyder-Macker and Epler [82] found a decrease in ECRB and EDC muscle force recruitment with counterforce brace application when compared to no counterforce brace applied as measured by electromyography. It is hypothesized that by inhibiting muscle expansion, the counterforce strap decreases the magnitude of the muscle contraction reducing tension placed to the common extensor origin.

Orthotic application has been the subject of a Cochrane Review [87].

Only five studies met the inclusion criteria for the review and no definitive conclusion could be drawn regarding the effectiveness of orthotic interventions. However, a recent prospective randomized study comparing counterforce bracing to a prefabricated wrist extension orthosis concluded that the orthotic application provides for greater pain relief [33]. These authors postulated that this improvement in pain may be a result of the greater immobilization provided to the wrist extensor muscles in the orthosis. In clinical practice, our approach is to conduct a trial for both orthotic applications and have the patient continue with the device that provides the greatest pain relief.

Exercise: Stretching

Progressive stretching exercises are one of the most commonly used treatments in the management of LE [36]. The purpose is to allow elongation of the muscle–tendon unit in an effort to reduce pain and stiffness. The patient is instructed to perform passive wrist flexion exercises with variable amounts of elbow extension to maintain length of the musculotendinous unit (Fig. 6.3). The stretch is enhanced by progressing to full elbow extension with the forearm pronated and combined with passive wrist flexion. The patient should be instructed to hold this stretch gently for 15–30 s to prevent forceful vigorous stretching which may contribute to worsening of their symptomology. This form of stretching assists with pain reduction [70].

Fig. 6.3

Prefabricated wrist extension orthosis positioning the wrist in approximately 10–15° of wrist extension

Ultrasound

Therapeutic ultrasound is a high frequency sound wave used to stimulate tissue beneath the skin’s surface. Ultrasound is performed to deliver heat to deep musculoskeletal tissues such as tendon, muscle, and joint structures [40]. Essentially, the theorized mechanism of clinical utility with this modality is a stimulation of blood flow and soft tissue extensibility which may have a positive effect of tendon healing as well as decreasing pain. Ultrasound can be performed at different frequencies for various durations. The clinician has the option to select continuous or pulsed-wave treatments. With pulsed-wave treatments, there is a periodical interruption in the intensity applied to the targeted tissue so that no ultrasound energy is produced during the off time within the application. This will produce nonthermal effects of ultrasound. Continuous wave ultrasound can be applied which will produce thermal as well as nonthermal effects.

Ultrasound may be useful during the acute stages of rehabilitation to assist with pain reduction. However, long-term application during the various phases of rehabilitation is likely of minimal benefit. Various authors have recommended that ultrasound be applied along with various other therapeutic interventions such as stretching, activity modification, orthotic application, and progressive resistance exercise. [10, 38, 53].

Phonophoresis and lontophoresis

Iontophoresis and phonophoresis are used to deliver analgesics and/or antiinflammatory agents transdermally. Iontophoresis is the delivery of ionizable substances through the skin driven by an electric field by using a direct current application. Phonophoresis is the use of ultrasound to enhance the delivery of topically applied medications.

The hypothesized benefit of such applications is to provide patients with a higher concentration of medication within the target tissue without exposing the patient to the risks associated with injections. Although injections will provide a higher concentration of medication to the target tissue, these are invasive procedures. The literature reports that phonophoresis does not appear to be superior to ultrasound [41, 46]. However, iontophoresis with dexamethasone sodium phosphate may assist with short-term pain relief during the acute stage of rehabilitation [65].

Low Level Laser Therapy

Low Level Laser Therapy (LLLT) is believed to reduce pain by modulating tissue neuronal activity and inflammation by suppressing inflammatory enzymes that create swelling, redness, pain, and heat [11, 89]. The effect depends on the application of the correct wavelength and density of light delivered to the target tissues for an appropriate period of time (typically between 30 and 60 s). Pulsed treatment can improve tissue repair and antiinflammatory effect; analgesia is best achieved with a continuous beam.

The literature is inconclusive on the effects of LLLT and LE. Some authors report that LLLT provides pain control, however, other papers found no evidence of long-term relief when compared with placebo [13, 19, 37, 49, 52, 84, 92].

Extracorporeal Shock Wave Therapy

Extracorporeal Shock Wave Therapy (ESWT) is reported to encourage tendon healing by disrupting avascular tissue, promoting vascularization, and the release of local growth factors. The literature indicates that ESWT as a treatment for LE provides little or no benefit with regards to pain relief, thus, there is no evidence to support its use [16, 74].

Restorative Phase

The restorative phase should begin when minimal resting pain is present and symptoms cannot be provoked with ROM or light functional activity. During this phase components of treatment used in the acute phase will persist, though the emphasis will move toward resistance exercise, progression to a home exercise program, and continued activity modification.

Progressive Resistance Exercise

Isometric and Concentric Contractions

Once the patient is nearly pain-free at rest and has only minimal pain with light functional activity, they should begin a progressive resistance exercise program. This program should begin with multiangle isometric strengthening of the wrist extensors, wrist flexors, forearm rotators, and digital flexors and extensors [27]. Once tolerance is exhibited with such exercises with minimal increase in symptomology, the patient is progressed to concentric wrist extension as well as isotonic contractions beginning with low weight and low repetitions. The patient should be instructed to begin with five repetitions gradually increasing to 20–30 repetitions for 1–3 sets, 2–3 times per day.

Eccentric Exercise

Eccentric exercise has been advocated to resolve pain associated with chronic tendinopathies. Eccentric strengthening loads the musculotendinous unit to induce hypertrophy and increased tensile strength, reducing the strain on the tendon during movement [2, 83]. Eccentric loading may provide a greater stimulus for collagen produced within the tendon to withstand greater force than encountered during aggravating and provocative activity [26, 83]. It is theorized that eccentric exercise reduces neovascularization within the affected tendon which is believed to be a causative factor in painful tendinopathies [1, 67].

Eccentric strength training has been shown to be effective for treating Achilles [2, 28, 44, 77], patellar [69, 72], and shoulder tendinopathies [95]. More recently, eccentric training has been applied to LE. Crossier et al. [23] demonstrated improvement in pain after eccentric exercise performed on an isokinetic dynamometer which necessitated patients going to a clinic for treatments. Isokinetic dynamometers are expensive and not widely available, therefore it is not a viable treatment option for most patients with lateral epicondlyosis. Tyler et al. [91] conducted a prospective randomized, controlled trial which compared standard treatment (stretching, ultrasound, cross-friction massage, heat and ice) to standard treatment plus eccentric loading. These authors used an inexpensive rubber bar (FlexBar, Thera-Band; Hydenic Corporation, Akron, OH) to perform eccentric exercises performing 3 sets of 15 repetitions daily for approximately 6 weeks. They found an improvement in the eccentric resistance group in all outcome measures utilized (including visual analog scale, Disability of the Arm, Shoulder, and Hand (DASH) Score, and strength) compared to the traditional group. Although further study is needed on the long-term effectiveness of eccentric loading to LE, evidence exists for the short-term benefits of this form of exercise. At our center, we advocate that chronic cases follow a home exercise program which includes a combination of isotonic contractions performed in stages and stretching exercises. This program is a modification of an exercise program advocated by Nirschl and Sobel [64] and consists of three stages of self-progression, which is based on the patient’s response to the program. Please see Fig. 6.4 for program details.

Fig. 6.4

Progressive stretching exercises allow elongation of the muscle–tendon unit in an effort to reduce pain and stiffness. Patients are instructed to perform passive wrist flexion exercises with variable amounts of elbow extension to maintain length of the musculotendinous unit. Figures a–c are demonstrated passive wrist flexion exercises with variable amounts of elbow extension

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Tags: Tennis Elbow

Jun 3, 2017 | Posted by admin in RHEUMATOLOGY | Comments Off

Musculoskeletal Key

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Role of Therapy and Rehabilitation

Neurogenic Inflammation

Therapeutic Rehabilitation