Lateral epicondylalgia, Causes, Symptoms, Treatment

Lateral epicondylalgia








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Lateral epicondylalgia/Tennis elbow is also known as lateral epicondylalgia (LE) and often referred to as epicondylitis or tendinopathy clinically, has complex underlying pathophysiology which is not well understood but is characterized by uncomplicated signs of localized pain over the lateral epicondyle which is made worse with resisted wrist extension and grip. The term epicondylitis has recently been considered a misnomer because of a lack of inflammatory signs.  The pain may also extend into the back of the forearm and grip strength may be weak.[rx][rx] The onset of symptoms is generally gradual.[rx] Golfer’s elbow is a similar condition that affects the inside of the elbow.[rx]

Lateral epicondylitis also is known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. The word epicondylitis suggests inflammation, although histological analysis on the tissue fails to show any inflammatory process. The structure most commonly affected is the origin of the tendon of the extensor carpi radialis brevis and the mechanism of injury is associated with overloading. Nonsurgical treatment is the preferred method, and this includes rest, physiotherapy, cortisone infiltration, platelet-rich plasma injections and use of specific immobilization. Surgical treatment is recommended when functional disability and pain persist. Both the open and the arthroscopic surgical technique with resection of the degenerated tendon tissue present good results in the literature.

Tennis-Elbow-

 

Tennis Elbow 

Obviously, this condition earned its name because whacking tennis balls around a lot was the original main cause, but these days it is much more commonly caused by computer usage. And heavy computer users outnumber serious tennis players at least a thousand to one.

Tennis-Elbow

Today, this condition would be better-called computer elbow.

  • (1) Electrohydraulic – electromagnetic, or piezoelectric devices are used to translate energy into acoustic waves during extracorporeal shock wave treatment (ESWT) for chronic lateral epicondylitis (CLE) of the elbow (elbow tendonitis or tennis elbow). These waves may help to accelerate the healing process via an unknown mechanism.
  • (2) Results from randomized – controlled trials have been conflicting. Half of the studies showed statistically significant improvement in pain in the treatment group, and half of the studies had data showing no benefit over placebo for any measured outcomes.
  • (3) Limited evidence shows that ESWT – is cheaper than arthroscopic surgery, open surgery, and other conservative therapies, such as steroid infiltrations and physiotherapy, that continue for more than six weeks.
  • (4) The lack of convincing evidence – regarding its effectiveness does not support the use of ESWT for CLE.

Causes of Tennis Elbow

Tennis-Elbow-

  • Overuse – This can be both non-work and work-related. Overuse can happen from “repetitive” gripping and grasping activities such as meat cutting, plumbing, painting, auto-mechanic work, etc.
  • Trauma – Although less common, a direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. This can make the elbow more susceptible to an overuse injury.
  • Tennis elbow is a type of repetitive strain injury – resulting from tendon overuse and failed healing of the tendon. In addition, the extensor carpi radialis brevis muscle plays a key role.[rx][rx] Example of repetitive movement that may cause tennis elbow
  • Early experiments suggested that tennis elbow – was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries.[rx] Repeatedly mis-hitting a tennis ball in the early stages of learning the sport causes shock to the elbow joint and may contribute to contracting the condition.[rx]
  • Tendons and joints are made of flexible – string-like tissues that connect muscles to bones. Repeatedly using tendons and joints can lead to strains, tears or inflammation because the tissue forming them becomes degenerated and worn-down over time (meaning the tissue experiences microtears)
  • An injury to a tendon is called “tendinopathy –  In the case of tennis elbow, the tendon that is injured is the extensor carpi radiaslis reavis (or the ECRB). The ECRB tendon controls the movement of the wrists when the elbow is straight. If the elbow is straightened and bent over and over again, the tendon can become overworked. This is why tennis elbow is really a form of injury.
  • Inflammation  – then develops around the outer elbow muscle and tendon as your body’s way of attempting to heal these tiny tissue tears. The damaged tendon sometimes starts leaking fluid and even collagen, increasing inflammation. Sometimes the area forms hardened tissue to fix the damage.
  • Tennis elbow is most common – in people who use their elbows in the same manner day after day, for many weeks or months on end.
  • Adults with professions – that require consistent use of the upper arms and repetitive movements are especially prone to developing tennis elbow. This includes athletes, personal trainers, gardeners, painters, auto workers, landscapers, carpenters, cooks or butchers and plumbers
  • Even if your job – doesn’t require much use of your elbows or arms, if you spend a lot of time typing on the computer, knitting, cooking, painting or playing an instrument, it’s still possible to suffer from tennis elbow.
  • Playing racquet sports – such as tennis, badminton or squash (see below)
  • Throwing sports – such as the javelin or discus
  • Using shears while gardening
  • Using a paintbrush or roller while decorating
  • Manual work such as plumbing or bricklaying
  • Activities that involve fine, repetitive hand and wrist movements – such as using scissors or typing
  • Other activities that involve repeatedly bending the elbow – such as playing the violin
  • Sports like tennis, rowing or strength training
  • Manual labor like painting, carpentry or turning screws
  • Heavy lifting
  • Playing musical instruments, such as the piano
  • Working at a computer or a supermarket cash register
  • Using plumbing tools
  • Painting
  • Driving screws
  • Cutting up cooking ingredients, particularly meat
  • Repetitive computer mouse use.


Symptoms of Tennis Elbow & Diagnosis

A symptom of tennis elbow commonly include

  • Pain, tenderness and swelling – around the elbow. Some people find that pain is the first in the morning after getting up
  • Shooting or intense pain – that carries over to other parts of the forearm, especially when moving the arm
  • Trouble moving the wrist normally and stretching the hand
  • Pain on the outside of your upper forearm, just below your elbow – the pain may also travel down your forearm towards your wrist
  • Pain when lifting or bending your arm
  • Pain when writing or gripping small objects – for example, when holding a pen
  • Pain when twisting your forearm – for example, when turning a door handle or opening a jar
  • Pain and stiffness when fully extending your arm
  • Pain when picking things up – gripping objects, typing on a computer and putting pressure on the lower arms in other ways
  • Tennis elbow will develop slowly – as more micro tears develop in the elbow’s tendon. At first, you might not notice this process happening, but at some point, you’ll feel tenderness, especially when repeatedly moving the elbow.
  • Tennis elbow experience – a weakening in their grip (like when they are holding a tennis racket or golf club); others have trouble picking up everyday things, like a toothbrush or phone.

Diagnosis of Tennis Elbow

Physical examination

  • To diagnose tennis elbow, physicians perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic.
  • For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin), 1 cm distal and slightly anterior to the lateral epicondyle.[rx] There is also pain with passive wrist flexion and resistive wrist extension (Cozen’s test).[rx]

Medical imaging

  • X-rays – These tests provide clear images of dense structures like bone. They may be taken to rule out arthritis of the elbow. X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbows, such as fracture or arthritis. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle.[rx]
  • Medical ultrasonography – are other valuable tools for diagnosis but are frequently avoided due to the high cost.[rx] MRI screening can confirm excess fluid and swell in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis muscle.
  • Magnetic resonance imaging (MRI) scan – If your doctor thinks your symptoms are related to a neck problem, an MRI scan may be ordered. MRIs scans show details of soft tissues and will help your doctor see if you have a possible herniated disk or arthritis in your neck. Both of these conditions often produce arm pain.
  • Electromyography (EMG) – Your doctor may order an EMG to rule out nerve compression. Many nerves travel around the elbow, and the symptoms of nerve compression are similar to those of tennis elbow.

tennis-elbow

  • Cervical radiculopathy with pain in the elbow and forearm.
  • Elbow overuse to compensate for disease in an adjacent joint (frozen shoulder for example).
  • Posterior interosseous nerve (PIN) entrapment (also known as ‘radial tunnel syndrome’). Nerve compression produces neuropathic pain in the lateral forearm. However, pain is not reproduced by wrist extension. Resisted supination can produce pain as the supinator is one of the possible areas of PIN compression.
  • An anesthetic block of the PIN can be diagnostic, but injection should be performed selectively to avoid diffusion of the local anesthetic to the lateral epicondyle area. The middle finger extension test, resisted supination of the forearm and nerve conduction studies have all been described to assist in the diagnosis of radial tunnel syndrome.
  • Degenerative changes and OCD of the capitellum. It has been observed that 59% of cases of lateral elbow pain refractory to conservative treatment have some chondral changes in the radiocapitellar joint. OCD typically affects young individuals involved in sports and physical activities who have mild grinding and pain when performing a moving valgus test.
  • Inflammation and edema of the anconeus muscle. Some studies have reported a relatively high incidence of anconeus edema, shown in MRI of patients complaining of lateral elbow pain.Fasciotomy of the muscle can solve that problem.
  • Posterolateral elbow instability should definitely be ruled out in every patient suffering from lateral elbow pain. The association between instability and epicondylitis has been established, following excessive use of steroids or the local pathogenic insult. The presentation is low-grade and may require examination of the patient under anesthesia to test it properly. The presence of cubitus varus, previous surgery or dislocations of the elbow should be assessed.
  • Other causes of pain include low-grade infection (Propionibacterium acnes) or other inflammatory diseases such as rheumatoid arthritis.

    Treatment of tennis elbow


    In the acute stage

    • Give advice on the self-limiting nature of the pathology if adequate steps to avoid the aggravation of symptoms are taken.
    • Give advice on the modification of aggravating activities: • Avoid lifting, especially heavyweights,
    • Lift objects close to the body, with elbow bent and palm facing upwards
    • Avoid repetitive gripping and twisting activities,
    • Take regular breaks from all activities involving the upper limb,
    • Suggest the patient seek “light duties” which avoid tasks aggravating the condition at work if possible.
    • Offer analgesia or NSAID medication if clinically appropriate. Although evidence for analgesia and NSAID are inconclusive, patients may opt to try pain-relieving medication.

    If symptoms persist beyond 12 weeks but are less than 26 weeks, discuss other options including

    • Referral to physiotherapy for supervised and home exercise programs and manual therapy.
    • Laser therapy (of the correct dose) could be considered.
    • For short-term relief of severe pain consider corticosteroid injections. However, consideration of long-term relapses and the likelihood of adverse effects should be discussed with the patient.

    Non-operative treatment

    Non-operative treatment includes a wide array of possibilities with a rate of improvement in 90% of cases. Several new techniques have been developed in last decade including percutaneous radiofrequency treatment and injections with different preparations of growth factors. It is wise to involve the patient and gain their commitment to the management programme as it may be months before improvement is observed:

    Rest 

    • Rest is your first line of defense against this condition. People find it persistent mainly because they don’t take the problem seriously enough. Even a minor injury like this will not just magically go away if you keep doing whatever irritated the forearm muscles and tendons in the first place. A week of resting the arm as much as possible is often enough to make a significant difference.

    Exercise 

    • Although resting is initially critical, a careful balance of rest and a variety of exercise is the basic formula for recovery from most RSIs. Nothing in biology seems to recover without a little stimulation — you just have to beware of overdoing it. Gradually and progressively train the flexor muscles and tendons to tolerate exercise again.
    • Chances are good that you will need to go more slowly than you think; these conditions rarely change quickly. Mobilizations and stretching (next up) are good examples of easy, intermediate exercises — ways to start exercising without over-stimulating.
    • But eventually, you want to work up to working out with, say, spring-loaded hand grips … and then tennis, of course (even if you’re not a tennis player). At all stages, though, you start with small doses, and the need to give plenty of rest (recovery time) is crucial throughout. It’s never just exercise, and never just rest, but a long term balancing act between them.

    Stretching and mobilizing

    Although stretching is over-rated as a general tonic (see Quite a Stretch), it can be useful for specific therapy like this. Muscle trigger points (muscle knots) occasionally respond well to stretch (see Stretching for Trigger Points), and in my experience, it’s a little more likely to work out in this muscle group.

    • Since trigger points are almost always a factor in tennis elbow, I always recommend stretching for this condition. It is tricky to fully stretch the muscles involved in tennis elbow, but you can do it like this – while standing, with your arm in front of you, place the back of your hand against a wall with the fingers pointed out to the side, straighten your elbow, and then press into the wall so that your wrist is flexed sharply. Hold for a minute. Be cautious: do not stretch too hard, and release the stretch gradually, over several seconds at least.

    www.rxharun.com/tennis-elbow-tests_large-elbow-exer
    Isometric contraction for pain relief

    • A small 2015 test showed a surprisingly robust pain-relief effect from briefly “clenching”:7 tensing the muscles on the back of the forearm without the wrist, basically just putting the tendon under strong tension for about a minute. The pain reduction was substantial and lasted for at least 45 minutes.
    • It may be one of the best pain-control strategies, and a good alternative to medication. For tennis elbow, you want to pull on the common extensor tendon of the forearm. Probably the easiest way to do that is just to hold the hand firmly in a neutral position (with the other hand), and then attempted to extend the hand (bend the wrist backward). Start with moderate intensity for about one minute, and tinker with the intensity and duration to see what works best for you.

    Icing 

    • Tendinitis supposedly hurts because of the “inflammation,” but as explained above inflammation is actually limited or missing entirely in chronic cases. In acute (fresh) cases, or serious flare-ups of a chronic condition, ice might actually control inflammation and potentially retard the progression of the condition — a genuine biological benefit, as opposed to just a bit of pain control — but unfortunately, no one knows if it actually works.

    Contrast Hydrotherapy 

    • Contrasting is the alternating application of heat and cold to the area. This dramatically increases circulation to the entire arm and hand. Like icing, this is stressless tissue stimulation, but with a much greater impact on circulation in particular.
    • Like icing, there’s no direct evidence that this actually works, but it’s a solid theory — and, done right, it is actually extremely pleasant! Obviously, please don’t burn yourself with too-hot water. By far the most convenient method of doing this is in a double-sink: one filled with cold water, the other with hot water. For more information about contrasting, see Contrast Hydrotherapy.

    Self-massage 

    • Your forearm is an easy body part to reach for self-massage! Tennis elbow is probably always aggravated by muscle tension in the forearms, regardless of whether muscle strain is part of the condition or not. It is often helpful to do some simple massage: firm, long, lubricated strokes from hand to elbow on the back of the arm.
    • Be firm but not brutal. Visualize the muscles like a sponge full of dirty water that you are squeezing out! See Massage Therapy for Tennis Elbow and Wrist Pain, which explains exactly where the worst trigger points in the arm usually form.

    Friction Massage

    • Like all tendinitises, tennis elbow may respond well to a specific massage technique called “friction massage.” Rub back and forth over the tendon (across it) gently with your thumb or finger pads until the sensitivity fades, which should take no more than a minute or two, and then increase the intensity slightly and repeat. If the intensity doesn’t ease, discontinue. Deep Friction Massage Therapy for Tendonitis.

    Ergonomic Adjustments 

    • If you use a computer heavily, you may wish to invest in some improvements to your computer workstation to aid in healing from computer elbow. Keyboards are straightforward, as there is really only one important thing to know: don’t lift the back of your keyboard. This is a bizarre anachronism that exists only because early keyboard manufacturers wanted computer keyboards to seem more like typewriter keyboards (i.e. steep). However, the ergonomic problem with this is significant. An elevated keyboard forces you to keep the wrists “cocked” into extension, holding all of the extensor muscles of the forearm in contraction. This is Very, Very Bad, and severely aggravates computer elbow situations. Avoid it at all costs. Mitigate it with a gel wrist pad (to lift the heel of the hand).

    Shock wave Therapy 

    • Extracorporeal shock wave therapy (ESWT) is the more expensive, intense, and high-tech and over-hyped cousin of regular ultrasound. ESWT uses much stronger sound waves — shock waves! Treatment is painfully intense and painfully pricey, though it would probably be worthwhile if it worked.
    • On the one hand, ESWT is just a “more is better” version of standard ultrasound because it is often used with the same imprecise clinical intention to stimulate/provoke tissues. On the other hand, because it was originally developed for smashing gall stones, ESWT is strong enough to actually disrupt tissue, such as, say, calcifications in tendons — which is a nice precise clinical goal and a whole different kettle of fish. And there is evidence that it can be effective in exactly that circumstance: if your tendons are calcifying.

    One woman’s ergonomic mouse is another’s hand torture device!

    • And we even fail to adjust when the cord outright snags! We get focussed on our work and simply put up with the cord being caught under a book or the corner of the keyboard. It’s not that the mouse is necessarily stuck in a “bad” position, but we aren’t free to move it to a better one. By contrast, wireless mice are surprisingly liberating. If your arm is getting uncomfortable using the mouse in one position, you can simply adjust.

    tennis-elbow-tests_large-elbow-exer/taping

    • For the same reason, I recommend basically the best quality mouse, which is laser these days. Mouse shape and button design are pretty trivial factors. Basically, comfort is all you’re looking for, and people’s hand shapes and usage patterns are so different that one woman’s “ergonomic” mouse is another’s hand torture device.

    Physiotherapy

    • It is another alternative. Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favorable results than rest and reduced activity at short-term follow-up. No standard regime has been established as superior to any other method.
    • The fundamental principle is to load the tendon as close as possible to its limit but without surpassing it. Eccentric exercises and partial load-favoring tendon healing are the mainstays of physiotherapy regimes. A stable shoulder and scapula are necessary for correct elbow function; strengthening exercises of the scapular stabilizers including the lower trapezius, serratus anterior and rotator cuff muscles is mandatory.

    Epicondylar Counterforce Braces

    • Work by reducing tension in the wrist extensors. Elbow straps, clasps or sleeve orthoses have been demonstrated as superior for pain relief and grip strength when compared with placebo orthoses. However, no differences between races were shown in a systematic review and we do not use them in our practice. We have seen patients with secondary nerve problems due to prolonged use of a counterforce brace.

    Percutaneous Radiofrequency Thermal Treatment

    • A radiofrequency electrode is introduced percutaneously under ultrasound guidance which produces a thermal injury when activated, inducing a microanatomy and removing all pathological tissue. Good outcomes have been reported, and no reduction of tendon size has been observed.

    Extracorporeal Shock-wave Therapy

    • A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process. (ECSW) has been proposed as an alternative to non-operative management. The mechanism of action is not fully known. A generator of specific frequency sound waves is applied directly onto the overlying skin of the ECRB tendon. It has not been demonstrated to be more beneficial than other treatment modalities.

    The Use of Low-Level Laser Therapy

    • It has been proposed due to the stimulating effect of laser on collagen production in tendons. Although laser was not initially viewed as particularly useful among LE therapies, a recent study has demonstrated some short-term benefits when using an adequate dose and wavelength.

    Acupuncture

    • It has demonstrated good outcomes on short-term follow-up. However, long-term results remain unclear. The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.

    Laser Therapy

    • The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
    Transcutaneous electrical nerve stimulation (TENS)
    • TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.

    Activity Modification

    • Initially, the activity causing the condition should be limited. Modifying grips or techniques, such as use of a different size racket in tennis, may relieve the problem.

    Equipment Check

    • If you participate in a racquet sport, your doctor may encourage you to have your equipment checked for proper fit. Stiffer racquets and looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring.

    Medication

    • Non-steroidal anti-inflammatory drugs  – (NSAIDs) can be useful for the short-term relief of symptoms. Even if their use is superior to a placebo, no differences between oral and topical NSAIDs have been established.
    • Corticosteroid injections – are commonly used to treat LE. The way in which they work is currently unknown; they probably help to control local inflammatory response and pain medication.Corticosteroid injections seem to be superior to NSAIDs at four weeks, but no differences are observed at a later stage. Cortisone injections should be avoided in all cases, unless a short-term good result is advisable (such as a professional tennis player in mid-season), as most patients improve without corticosteroids and better long-term results can be achieved without them.Patients should be advised of potential side-effects including changes in coloration of the skin, fat atrophy and muscle wasting.
    • Hyaluronic acidA substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
    • Autologous blood injections – are thought to work by stimulating an inflammatory response which will bring in the necessary nutrients to promote healing. Short-term good results have been reported recently;, however, no benefit in the long-term follow-up has been found and its use is only recommended for those recalcitrant cases when other modalities of treatment have failed.
    • Platelet-rich plasma injections (PRP) – These preparations are thought to contain high concentrations of growth factors, which could theoretically enhance tendon healing. The general technique involves patient-blood extraction, centrifugation and re-injection of the plasma into the lateral epicondyle. Good outcomes have been reported., However, no differences were seen between PRP and whole blood injections. Moreover, significant differences among available commercial systems and variations in the technique make it difficult to draw clear conclusions about the use of PRP in this pathology. New legal regulations could slow down the adoption of these last techniques.
    • Botulinum toxin A injections – act by diminishing muscle tone. Reducing the tension on the ECRB insertion could be beneficial for pain relief. Good short-term results have been published, but as yet there is no consensus on its use and the effects may be conditioned by the technique, the operator and the dose.

      Randomized controlled trials published subsequent to the latest systematic reviews on injection therapy

      Author Number randomized Interventions Outcome measures Results
      Kazemi et al 60 Methylprednisolone or Autologous blood Quick DASH
      PPT
      At 4 weeks autologous blood superior in: severity of pain, pain in grip, PPT Quick DASH
      Modified Nirschl scores
      At 4 and 8 weeks
      No differences in Nirschl score, grip strength, and limb function
      At 8 weeks autologous blood superior for all outcomes
      Peerbooms et al 100 PRP or Corticosteroid injection VAS
      DASH
      Significant improvement in PRP group over steroid group for pain and DASH.
      Corticosteroid group better initially and then declined
      PRP group progressively improved
      Ozturan et al 60 Corticosteroid injection or Autologous blood injection or ECSWT Thomsen provocative testing
      Upper extremity functional scores, maximal grip strength
      Corticosteroid injection significantly better for all outcomes at 4 weeks
      Autologous blood injection and ECSWT gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 weeks
      The success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for autologous blood injection (83.3%) and ECSWT (89.9%)

      Surgery

      In recalcitrant cases, surgery may be an option. Surgical methods include

      • Lengthening, release, debridement, or repair of the origin of the extrinsic extensor muscles of the hand at the lateral epicondyle
      • Rotation of the anconeus muscle
      • Denervation of the lateral epicondyle
      • Decompression of the posterior interosseous nerve

      Surgical techniques for lateral epicondylitis can be done by open surgery, percutaneous surgery or arthroscopic surgery, with no evidence that any particular type is better or worse than another.[rx] Side effects include infection, damage to nerves and inability to straighten the arm.[rx]

      Exercise Protocol For Rehabilitations

      Eccentric exercises

      • Muscle-strengthening exercises can generally be divided up into concentric and eccentric exercises. In concentric exercises, the muscle contracts (tightens) – and in eccentric exercises, the muscle relaxes. One example of a concentric exercise is holding a weight in your hand and pulling it up towards your body. Gradually lowering the weight again is an eccentric exercise. Slowly working against gravity like this strengthens the muscles.

      Eccentric strengthening exercises

      • Hold a weight in your hand.
      • Rest the affected arm on a table with your palm facing down, allowing your hand to hang off the edge of the table.
      • Use your free hand to bend the affected wrist back as far as you can while lifting the weight.
      • Gradually lower the hand with the weight in it.
      • Repeat about 10 to 15 times.
      • After a short break, repeat this set of exercises two more times.

      Strengthening exercise for tennis elbow. It’s important not to use heavyweights. The weight should be about 30% of the maximum weight you can hold. Slight pain is okay, but you shouldn’t put too much strain on the arm.

      Eccentric strengthening exercises

      • Rest the elbow of the affected arm on a table, with your forearm upright. Turn your forearm so that the palm of your hand is facing away from you.
      • Hold a full bottle in the affected hand.
      • Gradually lower the arm with the bottle, making sure not to bend your wrist.
      • Allow the bottle to fall into your free hand and move the affected arm back to the upright starting position.
      • Pass the bottle from the freehand back up to the affected hand.
      • Repeat about 10 to 15 times.
      • After a short break, repeat this set of exercises two more times.

      It’s best to do strengthening exercises three times a day. Strengthening exercise for tennis elbow

      Stretching

      The aim of stretching exercises is to stretch the wrist extensor muscles in the forearm. These exercises are recommended in order to improve the mobility (range of movement) of the arm and wrist. They can either be done actively or passively. By “actively,” we mean you do them yourself. In passive exercises, a physiotherapist or training partner stretches that part of the body for you.

      Example:

      • Stretch the affected arm out in front of you, with your palm facing downwards.
      • Relax your wrist, allowing your hand to dangle down.
      • Using your other hand, push the affected hand down and pull it towards your body.
      • Hold the stretch for about 30 to 45 seconds.
      • Have a break (about 30 seconds).
      • Repeat three times.

      People are advised to do these stretching exercises about twice a day.

      Lateral epicondylalgia

      Lateral epicondylalgia

      Stretching exercise for tennis elbow

      Wrist turn

      To perform a wrist turn:

      • bend the elbow at a right angle
      • extend the hand outwards, palm facing up
      • twist the wrist around gradually, until the palm is facing down
      • hold the position for 5 seconds
      • repeat nine more times
      • do two more sets of 10 repetitions

      Wrist turn with weight

      The wrist turn with weight is the same as the wrist turn above. But, in this version, the person also grips a light weight, such as a small dumbbell or a tin of food.

      Wrist lift, palm up

      Lateral epicondylalgia

      To perform a wrist lift, palm up:

      • grip a light weight, such as a small dumbbell or a tin of food
      • bend the elbow at a right angle
      • extend the hand outwards, palm facing up
      • bend the wrist up towards the body
      • hold this position for 5 seconds, then release slowly
      • repeat nine more times
      • do two more sets of 10 repetitions

      Elbow Bend

      To perform the elbow bend:

      • stand straight
      • lower the arm to one side
      • slowly bend the arm upwards until the hand touches the shoulder
      • hold this position for 15 to 30 seconds
      • repeat nine more times

      Wrist extensor stretch

      To perform the wrist extensor stretch:

      • raise the arm straight out in front of the body
      • with the palm facing down, slowly bend the wrist downwards
      • using the other hand, gently pull the stretching hand back towards the body
      • hold this position for 15 to 30 seconds
      • straighten the wrist again
      • repeat twice
      • do two more sets of 3 repetitions

      Wrist extensor flex

      Lateral epicondylalgia

      To perform the wrist extensor flex:

      • raise the arm straight out in front of the body
      • with the palm facing down, slowly bend the wrist upwards
      • using the other hand, gently pull the fingers back towards the body
      • hold this position for 15 to 30 seconds
      • straighten the wrist again
      • repeat twice
      • do two more sets of 3 repetitions

      Fist squeeze

      To perform the fist squeeze:

      • use a rolled-up towel, sock, or tennis ball and place in the palm
      • grip the ball or towel with the fingers to form a fist
      • squeeze tightly for 10 seconds
      • repeat nine more times

      Towel twist

      Lateral epicondylalgia

      To perform the towel twist:

      • hold a loosely rolled-up towel lengthways, with one hand at each end
      • keep the shoulders relaxed
      • twist the towel by moving the hands in opposite directions, as if wringing out water
      • repeat nine more times
      • then repeat ten more times twisting the towel in the reverse direction

      Complications

      Failing to address concomitant pathology

      • Patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not addressed; patients should be educated regarding the risks and benefits of surgery — the former include but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or worsening overall dysfunction
      • Radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed for lateral epicondylitis.

      Iatrogenic LUCL injury

      • Occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
      • Postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL compromise is significant

      Iatrogenic neurovascular injury

      • Radial nerve injury
      • Heterotopic ossification to decrease risk with via copious saline irrigation following decortication and debridement
      • Infection


      Prevention

      Other ways to prevent tennis elbow

      • Warming up – Warming up before playing a sport that involves repetitive arm movements, such as tennis or squash, is essential. Gently stretching the arm muscles will help to avoid injury.
      • Using lightweight tools –  Lighter sports equipment or racquets with a larger grip size will help reduce strain on the tendons. Damp tennis balls and older balls load the arm with unnecessary force.
      • Increasing the strength of forearm muscles – This can help support arm movement and prevent tennis elbow.
      • Decrease the amount of playing time if already injured or feeling pain in the outside part of the elbow.
      • Stay in overall good physical shape.
      • Strengthen the muscles of the forearm: (pronator quadratus, pronator teres, and supinator muscle)—the upper arm: (biceps, triceps)—and the shoulder (deltoid muscle) and upper back (trapezius). Increased muscular strength increases the stability of joints such as the elbow.
      • Like other sports, use equipment appropriate to your ability, body size, and muscular strength.[rx]
      • Avoid any repetitive lifting or pulling of heavy objects (especially over your head) [rx]
      • Vibration dampers (otherwise known as “gummies”) are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock.[rx]


      References

      Lateral epicondylalgia

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