Range of Motion Exercises
(see Figs. 2–31 and 2–32)
- Exercises emphasize end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation).
- Soft tissue mobilization is done with and perpendicular to the tissue involved.
- Phonophoresis or iontophoresis may be helpful.
- A gentle strengthening program should be used for grip strength, wrist extensors, wrist flexors, biceps, triceps, and rotator cuff strengthening.
- However, the acute inflammatory phase must have resolved first, with 2 weeks of no pain before initiation of graduated strengthening exercises.
- Development of symptoms (i.e., pain) modifies the exercise progression, with a lower level of intensity and more icing if pain recurs.
- The exercise program includes:
- Active motion and submaximal isometrics.
- Isotonic eccentric hand exercises with graduated weights not to exceed 5 pounds.
- Wrist curls
Sit with the hand over the knee. With palm up (supination), bend the wrist 10 times holding a 1- to 2-pound weight. Increase to two sets of 10 daily; then increase the weight by 1 pound up to 5–6 pounds. Repeat this with the palm down (pronation), but progress to only 4 pounds.
- Forearm strengthening
Hold the arm out in front of the body, palm down. The patient clenches the fingers, bends the wrist up (extension), and holds it tight for 10 seconds. Next, with the other hand, the patient attempts to push the hand down. Hold for 10 seconds, 5 repetitions, slowly increasing to 20 repetitions two to three times a day.
Weight on the end of a rope (Fig. 2–35) can be used to strengthen wrist flexors and extensors. The patient rolls up a string with a weight tied on the end. The weight can be progressively increased. Flexors are worked with the palms up; extensors with the palm down.
Elbow flexion and extension exercises (Figs. 2–36 and 2–37).
Squeeze a racquetball repetitively for forearm and hand strength.
- Progress strength, flexibility, and endurance in a graduated fashion with slow-velocity exercises involving application of gradually increasing resistance. A “no-pain–no-gain” philosophy is incorrect here.
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 of treatment.
Surgical treatment of tennis elbow is not considered unless the patient has recalcitrant symptoms for more than 1 year despite the nonoperative treatment previously discussed. Various operations have been described for tennis elbow pain. Many authors have recommended excision of torn, scarred ECRB origin, removal of granulation tissue, and subchondral bone drilling for neovascularization stimulation. The elbow capsule is not violated unless intra-articular pathology exists. We prefer to treat these patients arthroscopically whenever possible. Arthroscopic release of the ECRB tendon and decortication of the lateral epicondyle are analagous to the open procedure. Arthroscopic treatment of lateral epicondylitis offers several potential advantages over open procedures, and its success rate is comparable. The lesion is addressed directly, and the common extensor origin is preserved. Arthroscopy also allows for an intra-articular examination for other disorders. It also permits a shorter postoperative rehabilitation period and an earlier return to work or sports.
Postoperatively, we encourage our patients to begin active ROM within the first 24 to 48 hours. The patient is usually seen for follow-up within the first 72 hours. At this time, she or he is encouraged to begin extension and flexion exercises. After the swelling subsides, usually 2 to 3 weeks after surgery, the patient can rapidly regain full ROM and begin strengthening exercises. Return to throwing sports is allowed when the patient has regained full strength.