Tennis Elbow 3

In part 2, I discussed some invasive and non-invasive treatment modalities for the management of tennis elbow. In part 3 I’d like to shed some light on the surgical management for Tennis elbow, then discuss exercise and stretching as my preferred modality of choice.

Before I begin discussing the surgical management, its relatively important to know that there is an overlap between different lateral elbow conditions and at times these conditions are misdiagnosed so what the clinicians starts out to treat can be entirely irrelevant to the patients case [1].

That said, Surgical management is generally reserved for non-responders; those who don’t improve with conservative management within 6-12 months. Keeping in mind that 90% of lateral epicondylitis cases can be treated conservatively [2]. So please don’t rush yourself and your surgeon to go into the OR. Trust me we love working in there, but we shouldn’t need to if there is a way around it.

So, when all conservative managements fail, the patient then undergoes one of many surgical techniques to debride the tissue. I will not go into the surgical details as they’re beyond the scope of this article, but it’s worth mentioning that success rate is in excess of 90%, in fact up to 97.7% in some cases which is pretty darn good, so fear not, there is always a fix [3].

Finally let’s talk about exercise and stretching as it is the bread and butter of this article which also happens to be my preferred modality of use, at least with the young populous. Again, there isn’t sufficient evidence to suggest that exercise is the best modality of treatment, hell there is even no systemic review on the matter, only some clinical trials which I’ll go over as we progress through the article. But its cheap, can be done at home and it might be just as effective or even better than other treatment modalities [4].

This will at least let the patient take control of their own treatment and give them the opportunity to make things better. The psychological effects in that regard are not be underestimated as it can help further improve clinical outcome [5].

That said, what kind of stretches and exercises are recommended? There seems to be mixed evidence as to what type of exercise is better when treating lateral epicondylitis. Unfortunately there aren't many high quality papers on different and combined types of exercises, so the ones I found will have to do.

Some evidence suggests that there is no difference between eccentric, concentric and stretching [6], but this particular study is of short duration (6 weeks), and from research done on other tendinopathies, eccentric training lasting longer than 12 weeks seems to be superior than concentric or stretching alone [7]. It is important to note that there was no increase in pain with the eccentric program which often creates compliance issues with the patients as they almost always link pain with damage, which is not the case in a lot of injuries. I'll be discussing this topic at a later point in time. For now, lets focus on this.

I do want to mention that in the 6-week duration study, there was no supervision on the intensity of the exercise which I think is crucial because the tendon needs to be pushed to their tolerant limit to improve.

The patients were given instructions and illustrations on how they should progress as they were given resistance bands, but I don’t think that is enough to get the most out of the eccentric exercise protocol, especially since they were instructed to halt their exercise as pain set in. Overall, I think the study design is acceptable but lacking in the intensity department. Had the patients been instructed to push past their pain a little bit, things would've be different.

And so, this study is the one I’m interested in because it had 3 groups, a concentric, eccentric-concentric, and an eccentric-concentric + isometric training groups [8]. The duration of the training was a bit longer (8 weeks), however, it was unsupervised without an increase in intensity. But it did instruct the patients to push the limits of their pain which is often necessary for improvement [9].

Anyways, the eccentric-concentric + Isometric group had the highest improvement in pain and functionality, as did the others but to a slightly lesser degree, and overall, the patients had excellent results.

The added isometric component is essential in my opinion as it has been proposed that LET is a grip overload problem and doing isometrics in particular help a great deal in its management [10].

That said, from my experience, I always opt for Isometrics with a combination of eccentrics/concentrics when treating LET. I prefer using them over the other treatment modalities as I monitor my patients and make adjustments according to their needs, invasive modalities are always on the table but i refrain from using them until I absolutely have to, and thankfully I haven't had the need to.

I wanted to demonstrate some of the isometric and eccentric exercises for the treatment of LET.

Unfortunately, due to the current world situation, I was unable to film them at the gym, and so hopefully I'll edit them at a later point in time when things settle down.

This concludes part 3 of the Tennis Elbow series, I hope it has been helpful and if you have any questions, don’t hesitate to contact me. And also reader feedback is of great value, your input is appreciated.

References :

  1. Laratta, J., Caldwell, J.-M., Lombardi, J., Levine, W., & Ahmad, C. (2017). Evaluation of common elbow pathologies: a focus on physical examination. The Physician and Sportsmedicine, 1–7. doi:10.1080/00913847.2017.1292831

  2. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61:832–839.

  3. Lo, M. Y., & Safran, M. R. (2007). Surgical Treatment of Lateral Epicondylitis. Clinical Orthopaedics and Related Research, PAP. doi:10.1097/blo.0b013e3181483dc4

  4. Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ, 333(7575), 939. doi:10.1136/

  5. Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient Involvement in Health Care Decision Making: A Review. Iranian Red Crescent Medical Journal, 16(1). doi:10.5812/ircmj.12454

  6. [6] [10] Martinez-Silvestrini, J. A., Newcomer, K. L., Gay, R. E., Schaefer, M. P., Kortebein, P., & Arendt, K. W. (2005). Chronic Lateral Epicondylitis: Comparative Effectiveness of a Home Exercise Program Including Stretching Alone versus Stretching Supplemented with Eccentric or Concentric Strengthening. Journal of Hand Therapy, 18(4), 411–420. doi:10.1197/j.jht.2005.07.007

  7. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360–6.

  8. Stasinopoulos, D., & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy, 30(1), 13–19. doi:10.1016/j.jht.2016.09.001

  9. Pienimäki, T. T., Tarvainen, T. K., Siira, P. T., & Vanharanta, H. (1996). Progressive Strengthening and Stretching Exercises and Ultrasound for Chronic Lateral Epicondylitis. Physiotherapy, 82(9), 522–530. doi:10.1016/s0031-9406(05)66275-x

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