Tennis elbow physiotherapy exercises pdf

Advice with prescribed over-the-counter pain medication is recommended as the first-line treatment for most cases. Steroid injections are the most thoroughly investigated intervention. In the intermediate and longer term, Coombes et al 14 reported strong evidence that corticosteroid injections are less beneficial and show more adverse responses than all other interventions.

This is also in agreement with a previous analysis. Different doses and suspensions of corticosteroid did not alter outcomes, although repeated injections average 4. Another trial also reported high reoccurrence rates.

Three systematic reviews have investigated the injection of noncorticosteroid agents, although the number of relevant studies included in each is very small. Rabago et al 19 reviewed prospective case studies and controlled trials in respect of prolotherapy, polidocanol, whole blood, and PRP injections.

They concluded that for LE which is refractory to conservative treatment, there is some limited pilot level evidence for the effectiveness of these therapies. For botulinum toxin a meta-analysis of 4 RCTs showed beneficial effects in the short term in pain reduction, but no effect on grip strength.

No adverse effects were observed for sodium hyaluronate, lauromacrogol, prolotherapy, or PRP. Aprotinin was associated with itching and burning and botulinum toxin with weakness and paresis 14 and pain at the injection site. Randomized controlled trials published subsequent to the latest systematic reviews on injection therapy. Two studies of oral administration of analgesics produced inconclusive evidence. Five systematic reviews were identified. The most recent which covered tendinopathy generally 27 utilized laser dose standards defined by the World Association for Laser Therapy WALT to assess adequacy of treatment within included studies.

Comparably, corticosteroid injections show a more rapid onset in pain reduction and a larger effect size in the same period.

A subgroup analysis showed these effects were associated with narrowly defined doses of nm wavelength LLLT the treatment procedure is described as direct irradiation of approximately 5 cm 2 of the tendon insertion at the lateral elbow, with a dose of 0. The authors suggest these positive findings are in spite of a negative publication bias across relevant LLLT literature.

Only 2 studies present results for medium-term outcomes of LLT which show positive effects observed up to 24 weeks. The pattern of response to treatments was similar in each study. An area under the curve analysis reported a significant advantage of physiotherapy over injections for all primary outcomes but only for pain-free grip compared with wait and see. Authors generally conclude that for most patients a wait and see approach is advisable, although physiotherapy packages can give short- to medium-term benefits without risks associated with steroid injections.

Insufficient or inadequate evidence to support clinical recommendations is reported in Cochrane systematic reviews for the following treatments: oral NSAID, paracetamol, and codeine, 26 orthotics, 31 , 32 and acupuncture. Randomized controlled trials published subsequent to the latest systematic reviews on exercise and orthotics. Patients who fail to respond to conservative measures may be considered for surgery.

A Cochrane review investigating the effect of surgery on lateral elbow pain 34 did not identify any published controlled trials. However a more general review 35 suggests this may be due to the indications for surgery being not well codified and many different operative techniques being available.

A clear consensus on whether any given surgical procedure is superior is yet to be determined. Eleven of 13 pooled analyses undertaken as part of a Cochrane review 38 found no significant benefit of extracorporeal shockwave therapy ESWT over placebo.

A later review using a different method to assess treatment protocols 39 reported a subgroup analysis indicating that positive results are associated with adequate treatment doses. However since evidence of efficacy is inconsistent, the United Kingdom National Institute for Health and Clinical Excellence NICE guidelines N state that the procedure should be used only for refractory tennis elbow with special arrangements for clinical governance, consent, audit, or research.

In terms of adverse effects, ESWT may be associated with transient pain, nausea, and local reddening. There is no true consensus on the most efficacious management of LE especially for long-term outcomes. Furthermore, most studies do not differentiate between clinical and statistical significant effects.

Although corticosteroid injections do show large effect sizes in pain reduction, this is seen only in the short term and the treatment is associated with risks of adverse events and long-term reoccurrence.

If available, LLLT may be a safe alternative choice for beneficial but smaller short-term effects, especially if considered as an adjunct to exercise therapy. Combined physiotherapy treatment packages have been shown to give relief in the medium term but effects are only slightly better than advice and a wait and see approach in the long term.

There is very limited evidence to support injection of blood plasma or botulium toxin in refractory LE. Advice with a wait and see approach are recommended as the first-line treatment in primary care for most cases. The aim of treatment is to reduce pain and improve function, with minimal adverse effects. Referred pain from the neck or shoulder and local elbow causes including olecranon bursitis, osteoarthritis, and posterior interosseous nerve compression.

Most lateral epicondylagia can be managed in primary care setting. Indications for onward referral are given below. Wrist turn Bend your elbow at a right angle and hold out your hand, palm up. Turn your wrist slowly so that your palm is now facing down. Elbow bend Stand up straight and lower your arm to one side. Bend your arm slowly upwards so your hand is touching your shoulder. This leaflet provides general information about tennis elbow and simple exercises that may help.

Wrist flex. Keeping your arm straight in front with your palm facing. Tennis Elbow Lifting Heavy Objects Playing a racket sport can cause tennis elbow, but so can any activity that involves extending your wrist or rotating your forearm repetitively. Twisting a screwdriver or lifting heavy objects can. Tennis elbow may cause the most pain when you: Lift something. Make a fist or grip an object, such as a tennis racket.

It explains what tennis elbow is, the symptons and outlines what can be done to help. Progressions from Phase 2 to Phase 3 were made using basic principles of loading; longer lever arms, increased weight bearing, increase in weight or resistance, and plyometric activities.

The primary muscle groups that will be addressed for wrist and elbow strength are both the wrist extensors and the radial deviators and elbow flexors and extensors. The wrist and elbow program also includes flexibility within each phase to allow for differences in patient presentation and preferences.

Example of Wrist Extensor Strengthening Progression. Refer to Appendix B for detailed exercise choices and performance instructions.

Phase 1 is instructed to all patients, and the time to progress will vary and is based on specific criteria. To progress to Phase 2, the patient should be able to perform full wrist active range of motion and isometric wrist extension with no pain. Based on clinical experience, the patient should meet specific criteria before advancing to Phase 3.

First, the patient performs 20 repetitions with a set load of 2 lbs. Similar to scapular muscle training, the goal in the first phase is to have the patient perform each exercise with no symptom reproduction and proper technique for three sets of After proper motor recruitment is achieved, the goal is to improve muscle strength and endurance.

Therefore, the patient can perform up to three sets of 15, with 60 seconds of rest between sets, within the second and third phases of this program.

Accounting for individual variations in response to training, the patient is allowed to autoregulate reps, sets, or loads based on internal feedback.

Rehabilitation experts generally consider patient education as a unique and critical piece to rehabilitation. Education is unique in that it is ongoing and critical because without proper patient understanding of the insulting activities, it is likely that the patient will relapse with the symptoms or cause a delay in healing time. More specifically, the literature supports ergonomic modifications 41 and the following points of emphasis specific to tendonopathies: Rest from activities that increase tendon loading and aggravate pain.

The therapist will guide the patient in the proper loads and timing of those loads to ensure proper healing. Avoid repeated wrist, forearm or elbow movements. Do not avoid all upper limb motions as this will further reduce the tendons ability to take load.

When exercising, make sure the exercises do not increase your pain as this might be a signal that the load is too much. Be particular mindfully of stretching. Make modifications to your work area to promote good posture.

The following should also be considered:. Don't maintain fixed postures for long periods of time. Consider setting a timer every 30 minutes to stand up. Consult a trainer in your sport to help correct faulty mechanics or make appropriate adjustments in equipment. Avoid injections for pain management.

Patients receiving multiple corticosteroid injections as a treatment modality typically fair worse in function and pain management in the long term. The primary aim of joint mobilization techniques in this population is to reduce or eliminate pain at the lateral epicondyle and improve range of motion at the elbow and wrist. A recent systematic review and meta-analysis found that mobilization with movement MWM techniques were effective at reducing pain and improving daily function up to three months after discharge in patients with LET.

In general, the review also found that mobilizations were effective at reducing pain and improving grip strength as compared to controls. Based on the best evidence, the therapist is given the option to choose between three different techniques.

During the mobilization, the patient is asked to perform pain-free grip while holding isometrically for five seconds for repetitions.

The second technique involves the use of a mobilization belt using the same direction of force mentioned in the first technique, however the patient is asked to extend the elbow rather than sustain an isometric grip Figure 3 B. The third technique is an anterior glide of the radial head on the ulna Figure 3 C with no active movement from the patient. The third technique is utilized if the patient does not respond to the first two techniques.

Please see Appendix C for more information regarding joint mobilization techniques. Mobilization with Movement for the Elbow. Refer to Appendix C for more detailed performance instructions.

The interventions listed below and also described in Table 1 are intended to be supplemental to the outlined program above. It is recommended that all of the interventions listed below be addressed early in the plan of care as most of these agents will address pain directly and allow the patient to participate more fully in the exercise portion of the protocol which has been shown to be more effective for function in the long term.

It is also up to the individual treating therapist to determine the need for such an intervention and how long to use the following interventions within an episode of care. All patients should be instructed in wrist extensor stretching. Even if there are no flexibility deficits, stretching can provide short-term pain inhibition when compared to no treatment.

If the clinician opts for stretching, a judgement will have to be made in regard to how much tension to place on the wrist extensor mechanism. The previously described stretch will place less tension on the common wrist extensors when compared to a stretch where the elbow is placed in an extended position and the digits are maximally flexed.

The literature supports the use of counterforce braces early in the rehabilitation process for improving pain pressure thresholds 47 Figure 4. The rationale for its efficacy is that the counterforce brace places tension on a more distal segment of the tendon or muscle while allowing healing time to the injured proximal insertion of the common wrist extensors.

These straps may be of particular value to patients when eliminating the aggravating activity is not possible to allow for healing. For example, high-level tennis players or individuals with manual labor jobs may not have the option to relinquish the activity in which case the counterforce brace is logically a good alternative.

The patients are instructed to use the counterforce strap during work and sports activities as needed, but not wear the strap while at rest. The strap should be placed about two finger widths below the painful area and the patients are instructed to adjust the tension to comfort while muscles are relaxed, and not to over tighten. For the purposes of reducing local pain, promoting tissue healing by increasing blood flow, and increasing tissue extensibility the treating therapist is given the option of performing a variety of soft tissue techniques.

Deep friction massage DFM is typically performed in small circular movements across the common wrist extensor tendon. DFM is thought to assist the remodeling phase of an already degenerating tendon and to reduce scar tissue. Finally, myofascial techniques addressing the common wrist extensors are applied to relieve pain and improve soft tissue extensibility.

Cryotherapy may be effective in reducing local pain through a mechanism known as the gait control theory. However, because ice massage involves a direct application of ice to the skin, individuals may not tolerate it as well. In this case, the clinician has the option of providing a homemade or commercial ice pack with one thin layer typically a pillow case to the lateral elbow after treatment in the clinic.

As an alternative, the patient is given the option to apply an ice pack to the elbow for 10 minutes up to times a day to reduce pain. Lateral elbow tendinopathy is often misdiagnosed. Although beyond the scope of this commentary, it is crucial that clinicians perform a proper medical screen and differential assessment prior to initiating the DRP.

Common differential diagnosis for LET include cervical radiculopathy, radial tunnel syndrome, lateral collateral ligament pathology, radiocapitular osteoarthritis, fracture, triceps tendonitis, and referred pain from wrist injuries. Although the provided protocol is based on best available evidence, the authors acknowledge that the research regarding scapular muscle training for patients with LET is limited to observational studies only.

However, research is only part of evidence-based practice and the authors contend that patient values and circumstances as well as clinical expertise are also valuable in designing a comprehensive rehabilitation protocol. This clinical commentary outlines a regional and comprehensive rehabilitation program for patients with LET.

The DRP emphasizes a three-phase scapular muscle and wrist extensor exercise program and joint mobilization while also suggesting other evidence-based interventions that could be of assistance.

Based on individual presentations and response to treatment, the program is a flexible model through which effective and comprehensive treatment can be provided for patients with LET. National Center for Biotechnology Information , U.

Int J Sports Phys Ther. Joseph M. Ann M. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take. Enter U in the search box to learn more about "Tennis Elbow: Exercises". Author: Healthwise Staff. Care instructions adapted under license by your healthcare professional. If you have questions about a medical condition or this instruction, always ask your healthcare professional.

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