Tennis Elbow – Lateral Epicondylitis
Managing Lateral Epicondylitis
Lateral epicondylitis, also known as “tennis elbow” is one of the most common overuse injuries involving the wrist extensors of the forearm. The primary cause of lateral epicondylitis is associated with activity involving contractile overload and chronic stress to the extensor tendon attachment onto the humerus. Previously referred to as an inflammatory condition, Lateral epicondylitis is now understood as a continuum of change – the result of a proliferative reaction to overload. Histopathological studies have shown that lateral epicondylitis is degenerative in nature and is due to repetitive microtrauma to the tendon where fibroblastic and vascular degeneration occurs following repetitive activity involving rotation of the forearm and gripping. The extensor carpi radialis brevis is the most commonly affected tendon.
Conservative management of Lateral Epicondylitis
Research supports that conservative management of lateral epicondylitis is successful in resolving symptoms in up to 90% of patients. Time frames for recovery is dependant on a number of factors including activity modification, technique correction for improved biomechanics, bracing and strengthening exercises. The basic premise of conservative management focuses on enhancing the natural healing process by integrating treatment progressions parallel to the bodies natural healing response.
Rest, NSAID’s, activity modification, Steroid Injection
Reducing or eliminating activity causing pain to the wrist extensors is important to reduce inflammation and prevent further injury to the area. Activity modification avoiding grasping or gripping in pronation and utilising controlled supination lifting technique can be used to reduce loading through the extensor muscles.
Non-steroidal anti-inflammatory drugs can also be used for acute lateral epicondylitis. Although lateral epicondylitis is characterised as a non-inflammatory condition, the use of NSAIDS may be effective in reducing pain associated with acute inflammation in surrounding tissue. Addressing biomechanical factors contributing to the injury is another important correction to reduce painful symptoms.
Steroid injections can be used to treat acute pain associated with lateral epicondylitis. Although not addressing the contributing factors, the injection can be used to allow patients to reduce pain initially when starting rehabilitation.
Current evidence supports that management of sub-acute and chronic lateral epicondylitis should focus on graded exercise with gradual load increase on the forearm extensors to avoid atrophy, improve strength and neuromuscular capacity. Inflammation process at the extensor insertion needs to have settled before commencing gradual strengthening exercises to avoid aggravating painful symptoms. A systematic review conducted in 2014 supports that commencing eccentric exercises in isolation or in conjunction with other treatment methods was effective in decreasing pain, improving functional capacity and grip strength. Evidence also supports that exercise rehabilitation should include static stretching and strengthening exercises with a focus on eccentric phase of movement.
Current evidence supports conservative management of lateral epicondylitis and highlights the importance of a progressive strengthening program through the rehabilitation process. These highlighted areas of management are important to return to pain free activity.