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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2022 Optimizing Recovery from Lateral Epicondylitis by Rachele Jones, PTA, ATC, CAFS Clinical Scenario...What would you do? A 45 yr old female is in the office for the first time for 3 weeks now of lateral elbow pain related to paddle tennis. Plain films are deferred due to no indications based on history and presentation. She is locally tender at the common extensor origin at the LEP. AROM of the elbow/wrist/forearm are normal with some pain during wrist extension and flexion more than supination. Resisted digit III extension, wrist extension and grip > supination all reproduce her CC. I would… Order plain films to R/O any osteophytic changes or DJD and if (-) have her do two weeks w/NSAID’s and ice 15min BID and return for FU in 3 wks for re-assessment. Provide counterforce brace and have her attempt to return to play. Order physical therapy - to include Class IV laser, manual therapy, PRE including eccentrics, and other modalities as needed. To include biomechanical assessment of especially proximal joints. Offer and perform steroid injection to reduce inflammation and have her do a gradual return to activity over the next 7 days - return for FU if needed in 3 wks. CURRENT EVIDENCE MD Aminul Hoque Rasel, MD Obaidul Haque, et al. Functional Outcome of Lateral Epicondylitis Patients After Physiotherapy Interventions: - A Pretest & Posttest Study from Bangladesh. J Adv Sport Phys Edu 2021:4(8):193-197 SUMMARY: Lateral epicondylitis is a common overuse condition seen in family practice and orthopedic offices. Decision making on appropriate care often includes consideration of injections, NSAID’s, counterforce braces, rest/ice and activity modification and physical therapy. Clinical decision making is always best informed by updated research findings. In this study Rasel et al found that a multi-modal PT program was effective at reducing symptoms and increasing function for a group of 18 patients over the 6 week study period. While symptoms may be controlled adequately at least in the short term by NSAIDs, rest/ice, braces or injections, the inclusion or preference for Physical Therapy allows for use of modalities, manual therapy techniques, exercise, patient ownership and active participation in their recovery, patient education regarding modifying future risk factors of recurrence, - all with relatively low cost care and low/no risk of adverse events. This study does lack a control group, weakening the overall strength of the findings to some degree. It is clinically relevant though in that it demonstrates a multimodal approach being effective. Oftentimes studies attempt to single out specific treatments to prove efficacy. In real-world PT care patients would, in fact, typically have numerous therapeutic measures utilized to speed recovery. The use of Class IV laser has been an effective tool we also utilize for soft tissue overuse/tendonitis-tendinosis type cases. It is also critical for high quality therapy to include kinetic chain assessment of both distal hand-fingers function but also especially proximal thoracic cage, scapula and even core/hips/LE function since deficits in body positioning and capacity elsewhere can increase the demand at the elbow-forearm-hand during repetitive gripping and reaching activities. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Lateral Epicondylitis is a very common musculoskeletal condition experienced by more than 1-3% of people in the US each year. Lateral epicondylitis does not lead to gross disability but does limit function. The object of this study is to identify the functional outcomes that occur with a 6-week period of physical therapy intervention. Methods: Eighteen patients (aged 25 - 65 yr old, 10 males and 8 females) were selected by inclusion and exclusion criteria for 6 weeks of TIW frequency of visits (18 sessions), with a multi-modal approach of physical therapy incorporating, US, E-stim, deep tissue friction massage, stretches and strengthening. Assessment of pain and dysfunction were measured by the Numerical Pain Rating Scale (NPRS) and Patient Rated Tennis Elbow Evaluation (PRTEE) at initial visit and at 6 weeks. Findings: Results show significant reduction in pain between baseline and posttest, Three variables were looked at including: pain in the affected arm, specific activities, and usual activities. Overall pain in the affected arm, specific activities, and usual activities were all under p= 0.0001 and p= 0.000. At pretest distribution of pain was found at pretest for 6 ( 30%), specific activities 4 (20%), and usual activities 3 (17%)all of which were comparatively reduced after 6 weeks of PT care. Author's Conclusion: Six weeks of Physical Therapy interventions showed improved outcomes for pain and function. THE PEAK PERFORMANCE PERSPECTIVE Physicians in family practice and orthopedic clinics will oftentimes diagnose lateral epicondylitis as the primary cause of elbow pain. Numerous options exist for initial treatment. Clinical decision making often involves weighing options that may produce early and quick pain relief but do not address underlying weakness and/or stiffness issues versus the choice to prescribe physical therapy. This study by Rasel et al provides some guidance on the benefits of early physical therapy intervention as a key option. Lateral epicondylitis or “tennis elbow” is a common injury that affects 1-3% (Lai, et al, Open Access J SpMed, 2018) of the general population yearly, approximately 1 million people experiencing pain and functional limitations which could affect them for a few months up to a year or more depending on when treatment is implemented. The exacerbating issue is typically overuse and strain from repetitive gripping, wrist extension, radial deviation, and/or forearm supination activities. These may range from athletics, outdoor chores/gardening, fitness, ADL, work related, or recreational endeavors. This study broke down each of the participants by socio-demographic variables of occupation, age, gender, hand dominance, sight of pain. Occupations ranged from housewife (7 participants), service holder (4) to farmer (1 pt); 10 men, 8 women; and 13 of the 17 right hand dominant were affected on their right side, with 17 of the 18 had repetitive or forceful tasks or movements. This data shows that this condition can affect people spanning a wide variety of activities in both men and women. Left untreated for too long a worsening case of lateral epicondylitis can also negatively impact socio-economics regarding work related cases, where Lai et al found a worker’s compensation payout of $6,593 per case. Early intervention should be key for treatment efficacy and return to normal function as quickly as possible but also can help lessen the economic effect on one’s individual finances and on the entire country when health insurance premiums are considered. This study used a multi-modal approach to treatment because we have found out that there is no gold standard singular treatment that alone is consistently highly effective. Treatments must be individualized and can include many of the treatment types Rasel et al included in their study: deep tissue friction massage, ultrasound, electric stim (TENS), stretching and strengthening - together addressing key needs such as controlling inflammation and pain, increasing ROM, and restoring optimal function. One shortcoming here was that there was no control group so we cannot with strong evidence here demonstrate that these findings were significantly better than the natural course of lateral epicondylitis. The anecdotal experience of many clinicians is that a typical natural history of lateral epicondylitis disrupts normal pain free activity and does not spontaneously resolve. Thus, the consideration of early treatment is very appropriate and produces the quickest results toward restoring pain free normal function, minimize risks, and striving to reduce total costs to individuals and the healthcare system as a whole, all while enabling the patient to be an active participant in their own recovery through their customized home exercise program. While the modalities included in this study can be helpful, we’ve certainly discovered that the addition of Class IV laser therapy can be an important treatment tool for reducing inflammation and pain. The exercise portion of this study was far more basic and limited in nature than we typically find necessary. For example, customizing stretches into some ulnar deviation movement stretching the common extensor origin is often utilized. Strengthening procedures were not well explained but did include Theraband ® based concentric and eccentric loaded drills for the wrist extensors. We also often find that supinator work needs to be done and dysfunction of this muscle can mimic a more classic lateral epicondylitis. Their exercise parameters of 3x10 QD for the strength exercises are limited in scope and fail to address the tissue’s varying tolerances to loading and primary focus during different phases of healing. - We find that beginning in the more acute/reactive phase it is helpful to use very low load and high volume work (i.e. 10- - - >30 reps done 2-3/day), progressing later into 2x15 QD with light - - > low moderate type loading. The eventual goal is 3x10-12 reps at a challenging load done TIW, more so like a typical strength training workout at the fitness center. The other “stretch” not addressed in the article is the contribution of nerve mobility, specifically the radial nerve Oftentimes manual techniques and home nerve mobility programs are needed to restore normal mobility without pain. Certainly, one critique was that they are only treating the injury via local elbow/forearm related strengthening without any regard for the proximal joints or body as the whole (trunk + lower extremity etc.) which could have predisposed them to their lateral epicondylitis. A prior study of lateral epicondylitis showed that scapular weakness could be a contributing factor. Strengthening around the shoulder may be necessary along with ROM of the thoracic spine. Another option for strengthening would be use of a dumbbell for consistent load vs variable/amplified resistance band loading and more functional gravity based loading. Another issue with the study was the small group size, however, since they did reach statistical significance the level of impact may be even more noteworthy based on the small and somewhat heterogeneous group. This study chose two tests, the NPRS and the Patient Rated Tennis Elbow Evaluation (PRTEE). We believe that physicians should expect high quality PT to include not only self-report style questionnaires that can be helpful with test-retest reliability and trustworthiness but also must include physical testing of function and kinetic chain performance. This helps identify any other triplanar deficits that may be forcing the hand/arm into less than ideal positions to function and therefore be contributing to the eventual epicondylitis being treated. Standard therapies will often address the local symptom well enough but patients who are not treated with more intensive biomechanical assessment and exercise risk recurrences. Commonly, lateral epicondylitis is thought of as a local tissue overuse…which it is, technically, however in practice requires further assessment to ensure any underlying factors have been addressed, minimizing the need to revisit formal care and engage in costly medical system testing and potentially escalated treatments. Usually, a symptom producing activity can be modified via adjusting the plane of motion or body positioning in order to perform it sx-reduced or even sx-free. THE PEAK PERFORMANCE EXPERIENCE Frank said: (3 months later) “I have played 18 holes of golf 1 time, raked leaves & have mowed the lawn without any issues” History: 80 y.o. active male who fell and landed on arm during snowboarding,, three days later sx’s after 9 holes of golf swinging the club. Patient took a couple months off to rest, did Class IV laser, exercise, massage TIW and some physical therapy with slow progress; after 2 wks of interventions trialed tennis and then had sx’s with overhand serve. Subjective: 2/10 intermittent pain 1-2x/wk, pain with heavy carrying, backstroke, heavy pressing, reaching with increased loads no significant impairment with ADL’s most affected by sport; goal is to return to tennis, golf, skiing, snowboarding, and windsurfing DX: R Rotator cuff overuse and R Lateral Epicondylitis Objective: Initial Evaluation Re-Evaluation ~ 6 wks Numeric Pain Rating Scale ( NPRS) 2/10 0/10 DASH/ Quick DASH sport N/T 75% 2% 50% ADL Self rating 70% >= 90% Palpation Point tenderness of lat epi none Wrist extension PROM 60 deg 65 deg Wrist Flexion PROM 67 deg 75 deg FA pronation 60 deg 67 deg Thor Rot ( L/R ) 25 deg /30 deg 40 deg / 43 deg Wrist extension isometric strength 11.8 kg 14.3 kg ( 87%) R Pec minor tightness Moderate minimal Functional Testing 1st grip sx’s 3#--- 25# L >=25# R 30# 8# wrist extension ( L/R ) NT 25x/23x OH reach 8# ( L /R ) 1x/5x 23x/20x Treatment: Ultrasound, E-stim, DTM/ cross - Friction massage to extensor muscle common origin , pec minor, PROM, AROM, resistance training to shoulder, forearm and wrist Re-Evaluation: improved palpation, AROM, PROM, overall function, and strength.