Lateral and medial epicondylitis

REHABILITATION RATIONAL

Classic lateral epicondylitis (tennis elbow) is caused by repetitive microtrauma that result in degeneration of the extensor carpi radialis brevis tendon. Repetitive eccentric muscle overload has been implicated in the development of lateral epicondylitis . a change in the patients reguler activity or an overuse syndrome should be sought in the history as a precipitating cause. Pain with resisted wrist extension and full elbow extension differentiates involvement of the extensor carpi radialis longus from that of the extensor carpi radialis brevis. Mechanism Lateral epicondylitis. In tennis players, improper backhand stroke and wrist extension or flipping of the wrist may produce on overuse extensor tendonitis, especially of the extensor carpi radialis brevis muscle (fig.2-4). Serving with the racquet in pronation and snapping the wrist to impart spin also may cause lateral epicondylitis. Activities involving repetitive use of the extensor wad other than tennis may cause lateral epicondylitis. Medial epicondylitis. Golfers elbow is produced in the right elbow in a right-handed golf swing by

throwing the club head down at the ball with the right arm rather than pulling the club through with the left arm and trunk. This unorthodox swing cause stress at the flexor pronator group. Swimmers elbow ( also

Figure 2-5 A, Wrist extensor streching. Graps the hand and slowly flex the wrist down until sustained strech is felt. Hold for 10 second. Repeat 5 times per session, several times a day. B, Wrist flexor streching. Grasp the hand and slowly extend the wrist until a sustained strech is felt. Hold for 10 second. Repeat 5 times per session, several times a day.

Figure 2-4 Lateral extensor wad (Redrawn from Tullos H: Instr Course Lect,1991.)

Figure 2-6 A, eccentric wrist extension exercise with rubber band. B, Wris flexion-

resistive training. C, Wrist extension-resistive training. D, Elbow flexion-resistive training Medial epicondylitis) result from improper pull through mechanics in the backstroke. Symptoms of medial epicondylitis include pain at the muscle group origin with resisted wrist flexion, pronation, or both. Weakness, commonly a result of pain, also may be detected in grasping activities. General Rehabilitation Consideration Progressive rehabilitation for epicondylitis proceeds through three sequential stages. In the first (acute) please, the primary goal is to decrease inflammation and pain of the involved muscular origin. Submaximal conditioning may begin in this phase if the exercises do not cause pain. Recommended treatment methods for pain and inflammation include cryotherapy, whirlpool, HVGS, friction massage, and phonophoresis. Lontophoresis using an antiinflammatory such as dexamethasone also may be considered. It is important to avoid painful movements, like gripping activities,that aggravate the area. The second (subacute) phase involves active strengthening and introduction to functional activities. Both concentric and eccentric strengthening are used in the involved muscle groups. As with other elbow disorders, it is important to include shoulder strengthening if deficiencies are noted. Gradual exposure to stressful activities is begun toward the end of this phase and is increased only if activities can be performed without pain. The goal of the third (final) phase is to return the athlete to their sport and or high levelwork related activities. This is achieved through increase strengthening and endurance exercise, while maintaining joint flexibility. A general outline of rehabilitation includes gentle stretching exercise initiated through wrist flexion, extension, and rotation (Fig. 25). These are held for 10 seconds and repeated

for 5 to 10 repetitions. Vigorous stretching is avoided until the patient is pain free. When the injury result from eccentric overload, eccentric strengthening is important to prevent recurrence (fig.2-6, A). Resistive training includes wrist flexion
CLINICAL ORTHOPAEDIC REHABILITATION

Figure 2-7 wrist flexor and extensors. The patient rolls up a string with a weight tied on the end. The weight may be progressively increased. Flexors are worked with the palms up, extensors with the palms down. (from Galloway M, Demaio M,Mangine R: Rehabilitative techniques in the treatment of medial and lateral epicondylitis, Orthopedics 15 (9):1089,1992.)

Figure 2-8 Aircast T-pneumatic arm band is secured just distal to the medial epicondyle. Arm band worn with normal daily activity, as well as with repetitive activities in work or sports. ( From Aircast Corporation, Box T, Summit, New Jersey 07901.)

and extension in addition to forearm pronation and supination. This should be in a pain-free range (figs. 2-6, B-E, and 2-7) Equipment modifications that may be helpful include increasing the grip size of a racquet with good vibration absorption characteristics (graphite, ceramic, composites). There is some disagreement on grip size in the literature, and recent studies have suggested that grip size may be less important than previously thought. Lateral counterforce bracing is believed to diminish the magnitude of muscle tension in the region of the damage musculocutaneous unit (fig. 2-8). Counterforce bracing should be used as a supplement to, not a replacement for, muscular strengthening exercises. Epicondylitis is a common and often lingering pathologic condition. For this reasons, it is

critical that the rehabilitation process is progressed with minimal or no pain. The stressful components of high-level activity usually can be allleviated by altering the frequency, intensity, or duration of play.

REHABILITATION PROTOCOL Epicondylitis WILK AND ANREWS\ Phase 1-Acute Phase - goals: Decrease inflammation/pain . promote tissue healing. Retard muscular athropy Cryotherapy Whirlpool Stretching to increase flexibility. Wrist extension /flexion. Elbow extension/ flexion. orearm supination/pronation. HVGS Phonophoresis Initiate shoulder strengthening (if deficiencies are noted). Emphasize concentric/eccentric strengthening. Concentrate on involved muscle group (s). Wrist extension/flexion (see fig. 2-6, A) Forearm pronation/supination. Elbow flexion/extenxsion. Phase 2- Subacute Phase - Goals : Improve flexibility. Increase muscular strength and endurance. Increase functional activities and return function. Phase 3- Chronic Phase Goals : Improve muscular strength and endurance. Maintain/ enhance flexibility. Gradually return to sport/high-level activities. Continue strengthening exercises (emphasize eccentric/concentric). Continue to emphasize deficiencies in shoulder and elbow strength. Continue flexibility exercises Gradually diminish use of counterforce brace. Use cryotherapy as

Friction massage. Lontophoresis (with an antiinflammatory such as dexamethasone). Avoid painful movements (such as gripping) Continue flexibility exercises. May use counterforce brace. Continue use of cryotherapy after exercise or function. Initiate gradual return to stressful activities. Gradually reinitiate previously painful movements. -

needed. Initiate gradual return to sport activity. Equipment modifications (grip size, string tension, playing surface). Emphasize maintanance program.

Galloway, DeMaio, and Mangine also divide their approach to patients with epicondylitis (medial or lateral ) into three stages: The initial phase is directed toward reducing inflammation, preparing the patient for phase 2. The second phase emphasizes return of strength and endurance. Specific inciting factors are identified and modified. Phase 3 involves functional rehabilitation designed to return the patient to the desired activity level.

This protocol is also based on the severity of the initial symptoms and objective findings at initiation treatment.