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| Ultrasound therapy in tennis elbow treatment (Ref: https://nesintherapy.com/) |
Tennis elbow is degeneration of the tendons that attach to the lateral epicondyle. The extrinsic and intrinsic factors are responsible for developing tennis elbow. There was found an association between repetitive movements of the arms and forceful activities for developing tennis elbow. The poor muscular strength of shoulder, elbow and wrist extensor are responsible for cause- effect relationship for developing tennis elbow by microtrauma in involved tissues.
The aim of rehabilitation is to enable the athlete to return to sports with full function in the shortest possible time. A variety of treatment options have been recommended for tennis elbow. Unfortunately, there are still no universally accepted therapeutic modalities. However, the treatment of tennis usually has 5 therapeutic goals: controlling elbow pain, preserving movement of the affected limb, improving grip strength and endurance, restoring normal function of the affected limb, and preventing further deterioration. Nonoperative treatment remains the priority and mainstay for most patients with tennis elbow. Surgical intervention is available for recalcitrant cases.
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| (Ref: https://www.ultrasound-guided-injections.co.uk/) |
Athletes will return to work within 6 weeks after rehabilitation. Tennis elbow takes from 6 months to 12 months to heal. If a tennis player covers the full rehabilitation phase, then they can return to play as early as possible. The patient can return to play at one and two months follow up by maintaining the aggravating factors.
Physiotherapy traditional treatment options include electrotherapeutic and non - electrotherapeutic modalities. One of the most common physiotherapy treatments for tennis elbow is the exercise program which is one of non - electrotherapeutic modalities. Aiming for improving function and reducing pain by stretching and strengthening the affected wrist extensors.
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| Physiotherapy manual therapy in tennis elbow rehabilitation session (Ref: https://www.mendcolorado.com/physical-therapy-blog/) |
Therapeutic exercise in tennis elbow rehabilitation program
1. Stretching exercise: Stretching exercise was advised for 30 seconds repeated 5 times, once or twice daily. Caution should be gentle if the pain on palpation is insertional (i.e. potentially related to enthesopathy) where compressive loads (stretching) can be catabolic in nature resulting in a negative response to other interventions.
Exercise #1: stretching wrist flexor group: Start with palm up and bend wrist to backhand side.
Exercise #2: stretching wrist extensor group: Start with palm down and bend wrist to palm side.
Exercise #3: Stretching ECRB: The best stretching position result for the ECRB tendon is achieved with the elbow in extension, Lateral elbow tendinopathy forearm in pronation, and wrist in flexion and with ulnar deviation (little finger).
Exercise #4: Thumb stretch (De quervain stretch)
(2) Strengthening: There are essentially three forms of musculotendinous contractions that strengthen soft tissue structures such as tendons: (i) isometric, (ii) concentric, and (iii) eccentric. Most therapists agree that eccentric contractions appear to have the most beneficial effects for the treatment of tennis elbow. Strength exercise needs 8 - 15 reps/set for 3 sets with no - resisted or mild resistance as tolerated.
Exercise #5: Clenching fist strongly: Squeeze hand 5 seconds and release.
Exercise #6: Isometric resisted wrist extension: Static resistance from good hand to injuried hand on backhand side for 5 seconds.
Exercise #7: Isometric resisted wrist flexion: Static resistance from good hand to injuried hand on palm side for 5 seconds.
Exercise #8: Wrist rotation with a stick.
Exercise #9: Resisted exercises all direction (backhand side - palm side - thumb side - little finger side) against small free weight slowly.
Exercise #10: Resisted exercises all direction (backhand side - palm side - thumb side - little finger side) against easy resisted rubber band slowly.
Exercise #11: Isometric resisted fingers extension: Static resistance from good hand to each finger of injuried hand on backhand side for 5 seconds.
Exercise #12: Isometric resisted fingers flexion: Static resistance from good hand to each finger of injuried hand on palm side for 5 seconds.
Exercise #13: Twisting a towel into the roll in horizontal and vertical plane. (Flexbar resistance bar can be used as well).
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| Felxbar resistance bar |
Exercise #14: Fingers extension exercise with fingers resistance band or rubber band slowly. (You can apply rubber band).
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| Rubber band |
Exercise #15: Maximum hand squeeze with resisted equipment.
Other physiotherapy electrotherapeutic and non electrotherapeutic modalities, including
(1) Ice: Applying ice at local pain has been a traditional household remedy for aches and pains.
(2) Extracorporeal Shock Wave Treatment (ECSWT): is one of the commonly used physical therapy modalities for treating tennis elbow, in spite of conflicting results in the available literature. The mechanism of ESWT has not been completely clarified, possibly including direct stimulation of healing, neovascularization, direct suppressive effects on nociceptors, and a hyperstimulation mechanism blocking the gate control.
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| ESWT as treatment option (Ref: https://gymna.com/) |
(3) Lasers: It has reported good results using lasers as a treatment for tennis elbow.
(4) Ultrasound: Pulsed and continuous ultrasound is used. Although the overall efficacy of this treatment for musculoskeletal disorders is in debate, this is my most common modality.
(5) Manual therapy and massage: For example, Mulligan’s technique, deep friction massage, myofascial fascial release. The purposes are reducing local pain, promoting tissue healing by increasing blood flow, promoting relaxation, and increasing tissue extensibility. The treating therapist is given the option of performing a variety of soft tissue techniques.
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| Laser therapy as rehabilitation option (Ref: https://www.asalaser.com/en/company/blog/) |
(6) Bracing and protective equipment: Many therapists use taping as an adjunct to exercise, in order to relieve pain and allow function restoration of movement patterns. Bracing is a commonly used form of intervention to immobilize and assist with pain control. Braces are used throughout the acute and chronic phases of the disease, and their mechanism of function is thought to result from counterforce control. There are many brace models, for example, Counterforce bracing or elbow strap which has been popular in the tennis elbow treatment. Using counterforce braces can significantly alleviate pain by pressing on the forearm extensor muscles and then inhibiting and dispersing the stress on the origin of affected ECRB, thereby facilitating its self-repair. Wrist extension splints, which is the functional position of the hand, is one of slight extension and pronation, and since active muscle tone. Simple cock-up splint which has the purpose to put the wrist extensor mechanism at rest.
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| Counter brace or Elbow strap (Ref: https://tenniscompanion.org/) |
(7) Activity Modification: Modification of activity and avoidance of overwork are essential components for any treatment protocol. Turning the palm up while lifting and avoiding palm - down exercises can transfer the force away from the lateral epicondyle to the medial epicondyle and help alleviate lateral elbow pain.
(8) Controlling Force loads: Controlling force loads will be vital both in the early and late treatment of lateral epicondylitis and is an important factor when considering preventative measures. Tennis patients with lateral epicondylitis should be encouraged to use a racquet with a mid- to large-size head, a lighter weight, and a reduced string tension by 3-5 Ibs. The hand grip should also be the right size. A handle with too small of a diameter will require increased grasp effort, thus presumably increasing the stress upon the wrist extensor muscle attachment. The injured player should also play with new tennis balls, since old tennis balls require more stroke force to achieve the same velocity. Clay courts, if available, are also helpful because horizontal ball velocity is decreased. The injured player should also undergo a thorough assessment of his/her playing technique. Stroke patterns that need to be examined include the player's use of weight transfer during all tennis strokes and the backhand stroke, in particular. Two handed backhand instead of a single handed backhand; turn the shoulder and trunk into the swing; and when the racket contacts the ball, the wrist should be slightly extended and deviated upward instead of flexed and deviated. In the occupational setting, an ergonomic analysis of task requirements is usually beneficial in determining which jobs may be likely to cause increased stress of the wrist extensor mechanism. Once identified, these jobs may then be altered to reduce the stress loads which may, in turn, decrease the incidence of job-related lateral epicondylitis. Assessment of playing technique and ergonomic analysis are important not only for treatment of injured clients but for preventing repetitive overuse injuries as well. downward.
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| One - backhand (left) is more risk in tennis elbow than two - backhand (right) (Ref: https://tennishead.net/) |
(9) Prevention of lateral epicondylitis: Warm up exercise is a crucial part before and after participating in any sport that can reduce the further injuries and is helpful for lasting the performance.
Traditional Chinese Medicine and Western acupuncture medicine have been used for tennis elbow management as optional. However, current data from evidence-based medicine indicate conflicting results. Two systematic reviews have not concluded whether acupuncture was effective for tennis elbow, whereas three systematic reviews suggest that acupuncture is very effective in the short term, with the long-term results remaining unclear.
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| Acupuncture for tennis elbow (Ref: https://glenabbeychiro.com/blog/) |
Pharmacotherapy:
(1) Autologous Blood Injection (ABI): Autologous blood injections are thought to work by stimulating an inflammatory response which will bring in the necessary nutrients to promote healing. Current evidence suggests that ABI can achieve good outcomes in the short term; however, no benefit has been found in the medium- or long - term follow - up. In addition, it should be noted that ABI has high risks of injection site pain and skin reaction.
(2) Platelet Rich Plasma injections (PRP): The blood plasma with concentrated platelets found in PRP contain growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing and repair, promote development of new blood vessels, and stimulate the healing process. The technique requires patient-blood extraction, centrifugation and re-injection of the plasma into the lateral epicondyle. Good outcomes have been reported.
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| PRP for tennis elbow (Ref: https://oneorth.co.uk/) |
(3) Botox Botulinum toxin may induce a period of temporary paralysis that gives time for the soft tissue pathology to recover.
(4) NSAIDS: It is traditional to offer oral NSAIDS for tennis elbow as Anti-Inflammatory Medications. Notably, repeated injections of the corticosteroid may result in iatrogenic tendon rupture and muscle atrophy. Therefore, clinicians should be alert to the abuse of corticosteroids in the treatment of LE on account of poor long-term efficacy and potential adverse effects.
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| Oral Non - Steroidal Anti - Inflammatory Drugs (Ref: https://www.verywellhealth.com/) |
(5) Local steroid injections: The injection of corticosteroid preparation with local anesthetic is the mainstay of treatment for this condition. The physician feels for the point of maximum tenderness and then injects the cocktail using aseptic technique. However as with the treatment of many musculoskeletal complaints, the correlation between initial response and longer term follow up was poor.
Surgery treatment
Majority of patients with tennis elbow respond to conservative treatment and do not require surgical intervention. However, Surgical intervention can be an option if symptoms were unresponsive after a prolonged period of conservative therapy. Various reports indicate that approximately 10% of patients with lateral epicondylitis will be unresponsive to conservative methods. Numerous surgical procedures have been described for the treatment of tennis elbow. Most involve debridement of the diseased tissue of the ECRB with decortication of the lateral epicondyle.
Reference:
https://www.ijhsr.org/IJHSR_Vol.7_Issue.4_April2017/38.pdf
https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5841
https://core.ac.uk/download/pdf/289200979.pdf
https://www.oatext.com/pdf/PRR-2-119.pdf
https://bjsm.bmj.com/content/39/12/944
https://he02.tci-thaijo.org/index.php/simedbull/article/view/127705/96253
https://www.researchgate.net/publication/335098297_Tennis_elbow_A_clinical_review_article
https://www.jospt.org/doi/pdf/10.2519/jospt.1994.19.6.357
https://www.researchgate.net/publication/230621315_Lateral_epicondylitis_A_review_of_the_literature
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1758-5740.2009.00023.x
https://www.hindawi.com/journals/prm/2020/6965381/
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