Physical Medicine and Rehabilitation for Lateral Epicondylitis Treatment & Management

Physical Therapy

Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain. The use of iontophoresis with corticosteroids is not supported. A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching.^[10] Deep-tissue and friction massage help to release underlying adhesions and promote improved circulation to the area.

In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation/supination should be achieved prior to proceeding with a strengthening program. Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors.^{[11, 12]}

Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylitis.^[13] In a randomized, controlled laboratory study in 52 patients, maximum and pain-free grip strength were assessed, with patients wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of either the elbow strap or sleeve orthosis resulted in an immediate and equivalent increase in pain-free grip strength (p < 0.02); consequently, the researchers suggested that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.

In chronic refractory cases of lateral epicondylitis, scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.

Occupational Therapy

As activities are resumed, the patient's vocational and avocational pursuits must be considered. Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required. Gradual resumption of activities is recommended to improve tolerance and prevent recurrence.

The so-called radial tunnel syndrome should be considered for refractory cases of lateral epicondylitis. Criteria for diagnosis of radial tunnel syndrome are controversial in the literature.^[14] There exist cases of posterior interosseous nerve palsy associated with weakness in muscles that are innervated by that nerve. However, syndromes of forearm pain without associated weakness in muscles that are innervated by the posterior interosseous nerve are also seemingly labeled as radial tunnel syndrome.^[7]

Electrodiagnostic studies should be helpful in demonstrating nerve injury in cases of radial tunnel syndrome, thereby differentiating this entity from a forearm pain syndrome. In compression of the posterior interosseous nerve, patients report pain at the lateral aspect of the elbow and weakness in the wrist and hand, but no sensory symptoms. Electrodiagnostic findings in posterior interosseous nerve compression may include denervation in radial-supplied muscles distal to the supinator, and possibly slowing across the area of entrapment. Surgical intervention for radial tunnel syndrome or persistent tennis elbow should be approached with caution and only after a thorough workup and extensive conservative management.

For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.^{[15, 16]}

An orthopedic hand specialist may be consulted.

Topical NSAIDs may provide short-term pain relief, but evidence is conflicting on the use of oral NSAIDs.

If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed.^{[9, 17, 18, 19, 20, 21]} However, the role of corticosteroid injection in tendinopathy remains controversial. Most lateral epicondylitis is degenerative rather than inflammatory, and injecting steroid around a tendon can inhibit collagen repair; therefore, steroid injections should be used on a limited basis. Additionally, injecting a corticosteroid directly into a tendon can be deleterious. Nonetheless, steroid injections in some cases can bring about dramatic, albeit short-term, relief. When employing steroid injections, the following steps should be taken:

• Palpate the lateral epicondyle to locate the painful area (usually inferior and radial to the lateral epicondyle).
• Using a 25- or 30-gauge needle, inject 0.5-1 mL of triamcinolone (20 mg/mL) and 1-2 mL of 1% lidocaine. Infiltrate the area, distributing small aliquots of medication in a fanlike fashion. To avoid tissue rupture, take care not to inject directly into the origin of the extensor muscle group.
• Heavy lifting or repetitive activity by the patient should be minimized for 48-72 hours after the injection.

A prospective, randomized controlled, double-blinded study of 24 subjects concluded that both prolotherapy and corticosteroid therapy appeared to provide patients with long-term benefits. However, the study's small sample size prohibits determining whether one therapy is better than the other; larger, controlled trials are necessary.^[22]

Platelet-rich plasma has been used to treat chronic epicondylitis and has been shown to be more efficacious than corticosteroid injection, with improvement on both VAS and DASH scores at 2 year follow-up.^[23]

Other substances used for injection include local anesthetics and botulinum toxin. However, studies have provided conflicting evidence as to whether botulinum toxin injection has positive long-term benefits for lateral epicondylitis.^{[24, 25, 26]}

Other types of treatment have included acupuncture and extracorporeal shockwave therapy.^{[27, 28]} However, there is insufficient evidence to support acupuncture as a treatment for epicondylitis. Likewise, reviews of trials using shockwave therapy have found reasons not to support this as a treatment option.