Eblow rehabilitation

ELBOW REHABILITATION
-Dr. Krupal Modi(MPT)

EXTENSOR TENDINOPATHY
 No single treatment has proven to be totally
effective in the treatment of this condition. A
combination of the different treatments mentioned
below will result in resolution of the symptoms in
nearly all cases.
 The basic principles of treatment of soft tissue
injuries apply.
 Goals: control of pain, encouragement of the
healing process, restoration of flexibility and
strength, treatment of associated factors (e.g.
increased neural tension, referred pain), gradual
return to activity with added support and
correction of the predisposing factors.

1) CONTROL OF PAIN
 Clinical experience suggests that a low level of
pain, which does not worsen with training, is likely
to not be harmful for tendon healing.
 However, some patients require relative rest,
application of ice and analgesia for comfort.

2) ELECTROTHERAPEUTIC MODALITIES
 The application of electrotherapeutic modalities
such as ultrasound, laser and high voltage galvanic
stimulation may encourage the healing process.
 A summary of clinical trials investigating the efficacy
of ultrasound therapy in ‘lateral epicondylitis’ found
the advantage in success rate between ultrasound
and sham ultrasound to be 15%.
 The use of low-level laser treatment was not found
to be helpful.

 Heat may also be
helpful and a heat-
retaining brace such
as a neoprene sleeve
may be worn during
the rehabilitation
process.
 Effects : protection,
proper circulation,
body temperature,
recovery.

3) SOFT TISSUE THERAPY
 Soft tissue therapy is
performed at the site
of the lesion and to
adjacent tight or
thickened tissues.
 Transverse friction to
the site of the lesion
should be performed
with the tissue held in
tension by having the
wrist in passive flexion.

 Sustained myofascial
tension at the site of
the lesion may also be
performed.
 Areas of
hypersensitivity and
palpable bands in the
ECRB muscle should
be treated in active
wrist flexion with
sustained myofascial
tension and digital
ischemic pressure.

4) MANUAL THERAPY
 There is evidence of
positive short-term effects
with elbow manipulation,
but no long-term studies
have been performed.
 Cervical mobilization,
thoracic mobilization
and neural stretching
are commonly used as
adjuncts to other forms of
treatment.

5) TRIGGER POINTS
 In patients with lateral
elbow pain, active trigger
points associated with
muscle shortening are
frequently found in the
forearm extensor
muscles—brachioradialis,
extensor carpi radialis
longus, ECRB, extensor
digitorum, extensor carpi
ulnaris, extensor digiti
minimi and anconeus, as
well as the periscapular
area.

 Digital ischemic pressure or dry needling of
these trigger points will help restore normal muscle
length and reduce forces at the lateral epicondyle.

6) STRETCHING
 Stretching of the ECRB
muscle and associated
wrist extensors should
be performed.

7) MUSCLE STRENGTHENING
 A muscle strengthening
program should be
commenced as soon as
pain permits.
 This should commence
with isometric
contraction of the wrist
extensors.
 When this can be
performed without pain,
gradual progression to
concentric and then
eccentric exercises
should occur.
Elbow
extension

8) COUNTERFORCE BRACING
 Counterforce bracing appears to reduce the forces
on the extensor tendons although studies of its
efficacy show conflicting results.
 One study showed a reduction in ‘inconvenience
during daily activities’.
 The brace should be applied during the
rehabilitation process and on return to the
aggravating activity, such as tennis.

 Many patients
mistakenly assume that
the brace should be
applied over the painful
area itself but the
correct site is in the
upper forearm,
approximately 10 cm
(4 in.) below the
elbow joint.
 The brace should be
applied firmly.

SEARCH !!!!!
 How counter brace improves tennis elbow ???

9) TAPING
 One study showed that the application of a
diamondshaped taping technique resulted in an
improvement of symptoms.

10) CORTICOSTEROID INJECTION
 The use of corticosteroid injection in the treatment
of this condition is controversial.
 Corticosteroid injection was compared to
physiotherapy (ultrasound, deep friction massage,
exercise program) and a ‘wait and see’ group and
found to be significantly more effective in the
short term (at six weeks) but physiotherapy
appeared a more eff ective treatment in the
longer term (>12 weeks).

 The indications for corticosteroid injection in this
condition include failure of an appropriate rehabilitation
program after three months or localization of pain to the
lateral epicondyle probably due to periostitis.
 Corticosteroid and local anesthetic agents should be
injected around the ECRB tendon, directly over the
point of maximal tenderness but not into the tendon
substance itself.
 If used, corticosteroid injections should be regarded as
just one component of the treatment program and
followed by appropriate rehabilitation.

11) NITRIC OXIDE DONOR THERAPY
 An Australian study provided level 2 evidence that
nitric oxide donor therapy (glyceryl trinitrate [GTN]
patches applied locally 1.25 mg/day) improved
pain and function within three to six months.
 Glyceryl trinitrate patches come in varying doses; a
0.5 mg patch should be cut in quarters and applied
for 24 hours at a time and then replaced .
 Successful outcomes occurred at three to six
months, so patients need to have this explained.

12) ACUPUNCTURE
 There is some evidence of short-term (two to eight
weeks) benefit with the use of acupuncture for
lateral elbow pain.

SURGERY FOR TENNIS ELBOW
 Very occasionally, particularly in cases with a long
history of lateral elbow pain, the treatment program
mentioned above fails to resolve the patient’s
symptoms.
 Failure of conservative treatment after 12
months is a reasonable indication for surgery.
 Surgery involves excision of the degenerative
tissue within the ECRB tendon and release of
the tendon from the lateral epicondyle.

FLEXOR/PRONATOR TENDINOPATHY
 Treatment is along the same lines as treatment of
extensor tendinopathy.
 Particular attention should be paid to the tennis
forehand or the golf swing technique.
 Due to its close proximity to the medial epicondyle,
the ulnar nerve may become trapped in scar
tissue. This should be treated with neural
stretching.

MEDIAL COLLATERAL LIGAMENT SPRAIN
 Treatment in the early stages of the disease
involves
 modification of activity,
 correction of faulty technique,
 local electrotherapeutic modalities and
 soft tissue therapy to the medial ligament.
 Specific muscle strengthening should be
commenced, concentrating on the forearm flexors
and pronators.

 Medial strapping of the
elbow may offer
additional protection.
 Advanced pathology
may require
arthroscopic removal
of loose bodies and
bony spurs.
Occasionally, significant
instability develops and
requires ligament
reconstruction.

OLECRANON BURSITIS
 Treatment consists initially of NSAIDs, rest and firm
compression.
 If this fails, then aspiration of the contents of the bursa
and injection with a mixture of corticosteroid and local
anesthetic agents will usually be effective.
 If recurrent bursitis does not respond to aspiration
and injection, surgical excision of the bursa is
required. Doctor recommendation for physical therapy
after the operation for regaining or maintaining the ROM
and strength of the elbow.

 Ultrasound
 Soft tissue therapy
 Stretching of triceps
 Stregnthening : Static Triceps Contraction
 Taping
 Anti inflammatory drugs
 Activity modification

Eblow rehabilitation

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