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

Assessment of Tennis Elbow

Framework For Rehabilitation

The management approach of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy, adapts the general principals of tendinopathy rehabilitation. For the benefit of achieving long term goals, rehabilitation should be a multi-modal perspective and also to meet individual's needs. We explored the different causes and effects 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. This includes education, exercises, tissue loading management, manual therapy and steroid injection. All of these management strategies can be used and tailored depending on the patient's needs, clinician's clinical reasoning and a shared decision between patient and clinician. Since exercises are the best management option available to us at the moment, TE management should be centred around exercises.

Patient Education

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 good long-term effects if used in combination with other measures for the management of Tennis Elbow.

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''. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improves self-efficacy.

Since tendinopathy is a degenerative disease and the first stages are condidered inflammatory, recovery and treatemnt will depend on the general health of the body. Smoking, obesity, high consumption of processed and fatty food and obesity can delay the recovery. These factors should be discussed with the patients to ensure optimum engagement with treatment.

Load Management

TE is a degenerative condition characterised by increased thickness in the common extensor tendon, and the presence of different neuromuscular strategies with wrist function particularily when gripping. Pain with hand grip is the most common presentation with TE and as a result people with TE demonestrated their most powerful grip at a reduced wrist extension angle when cpompared with healthy individuals. angle of wrist extension when gripping and less reaction time in wrist muscle activity , particularily ECRB muscle.

Reduction of load on the tendon is an effective 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 their pain threashold and engage them in exercises that load the tendon below the level of exaggerated pain.

Pain and swelling will occur in response to increased load which 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. A sudden increase in load by movements involving repetitive wrist extension from pronated forearm and extended elbow can trigger pain and inflammation on the common extensor origin. To de-load the inflammed tendon, educate your pateint on lifting objects with flexed elbow and supinated forearm.

Exercises

The classical model for exercises in tenidnoopathy rehabilitation is eccentric contraction as a standard protocol, especially with Achilis and Patellar Tendinopathies. Eccentric exercises are considered to be an effective measure for tendon overuse injuries and prevention of re-injuries. They are also better in preparing patients/athletes for return to function or athletic activities when compared to concentric exercises. Tendons response to eccentric exercises in Achillis tendinopathy were observed after twelve weeks of trainig. However, other studies found no difference on tendon response between concentric and eccentric exercises. The evidence on load, speed of movement, number of repetition, duration of contraction and type of exercise remain inconclusive.

Considering the fact that ECRB is the main tendon affected in TE and the role of the muscle in stabilizing the wrist statically support the use of isometric exercies in TE management. Isometric exercises were found to have hypoalgesic effect both locally and in remote sites from exercised part during and after contraction.

Coombes et al compared the immediate effects of isometric exercises performed with different intensities (above and below the pain threshold) on pain perception in patients with chronic TE. Their findings support the use of exercises above pain threshold in incerasing resting pain intensity immediately after exercises compared to the other group. Another intersting finding of this study was that greater fear of movement resulted in greater pain intensity during exercises above pain threshold.

Gradual progression of exercises is essential to increase tendon tolerance to loads. The following are different ways to progress your exercises:

• Elbow and forearm position: begin with flexed elbow and forearm in supination, then progress by increase elbow extension angle.
• Fingers flexion vs extension: begining with fingers in flexion then progressing to extension to load the long extensors.
• Adding weights: wither by an exercise band or dumbells
• Bilateral movement. Many people report bilateral symptoms , supporting the evidence of the association of central senstization with TE.
• Functional training exercises and targeting the whole upper limb.
• Weight bearing exercises

Exercising in the pain-free range and refraining from exercises that aggravate the pain are the common advice given in any MSK management. However, weighing in and explaining the long term benefits of exercises on loading the tendon properly and building tissue tolerance may require some pain initially.

Manual Therapy

Mobilization with movement can be utilized with other measures to reduce pain and facilitate exercises. Rehay et al investigated the effect of Mulligan's mobilization with movement in TE and found significant reduction in night pain and pain on VAS up to 3 months after application of treatement and increase in pain-free grip strength. Another study found the same approach to be superior to wait and see and corticosteriod injection.

Steroid injection

Corticosteriod injection has good outcomes only on short terms( up to six weeks). The long term outcomes are poor and it was found to be linked to high recurrence rates. One study found increased pain, reduced grip strength in an intermediate follow up after corticosteriod injection. However, the short term benefit of pain relief can be sought to encourage patient's engagement with the exercise programme.

Taping

Taping has a good placebo pain relief effect and pain-free grip strength in patients with chronic TE. A study compared the effect of kinesiotaping with exercises to sham tape with exercises and exercise only groups on patient-rated tennis elbow evaluation (PRTEE), Pain visual analogue scale (VAS), grip strength, and the disabilities of the arm, shoulder and hand (QuickDASH) scales. The results of the study support the combination of kinesiotape and exercises.