Tennis Elbow – Physiotherapy Treatment #2
Introduction
The nature of treatment prescribed for Tennis Elbow vary from person to person depending upon various factors viz. age, general health, severity of pain, the causative factor, the period of onset of the symptoms etc. But in all cases the treatment aims at reducing pain and inflammation, enhancing the healing process and reducing the strain at the elbow joint.
1. Rest- Avoid any activity that causes or aggravates the pain.
2. Cryotherapy- Application of ice is very helpful in the acute stage. Ice relieves muscular spasm and hence the pain. It also has sedative and soothing effect. Prolonged icing is preferred. Crushed ice cubes wrapped in a thick towel is wrapped around the elbow for 15 minutes. Then remove it for 5 minutes and then reapplied for 15 minutes. This procedure is repeated twice or thrice a day. Brushing the painful area with the ice is suggested by a few. But in my experience prolonged icing is better than brushing with ice. Avoid application of ice directly as it may cause ice burns.
3. Heat Application- Once the acute stage has subsided, heat application is preferred. Heat relieves muscular spasm and hence the pain. It also has sedative and soothing effect. Hot Water Fomentation and Moist Heat are highly beneficial and can be applied at home itself. Superficial Heating Modalities like Infrared Radiation (IRR) and Deep Heating Modalities like Short Wave Diathermy (SWD) and Ultra Sound Therapy (UST) are very useful.
4. Transcutaneous Electrical Nerve Stimulater (TENS) -is very useful in treating the Tennis Elbow as it inhibits the feeling of pain.
5. Iontophoresis- Iontophoresis is the transfer of the ions of drugs into the body through the skin by the use of constant direct current. The principle of Iontophores is based on the fact that ions will migrate to the electrode of opposite charge under the influence of an electromotive force.
6. Active Exercises- Once the acute stage has subsided, mobilization exercises to the elbow joint is indicated. Active Exercises and carefully guided Passive Range of Motion Exercises to the elbow are advisable. When the Active Exercises and Passive Range of Motion Exercises are given, they must be given within the limits of severe pain. Painful movements may be attempted once the patient has attained confidence. If painful movements are attempted, it may adversely affect the already injured or damaged Common Extensor Tendon or the site of its attachment to the lateral epicondyle. Hence there may be an increase of pain. In such cases we cannot expect the co-operation of the patient which is very essential for carrying out the treatment successfully. Active Exercises and Passive Range of Motion Exercises are beneficial as they help to maintain the range of motion of the elbow joint. Moreover, these exercises help to stretch the muscles, the fascia, the ligaments and the joint capsule around the elbow joint. Such exercises relieves the spasm of the forearm muscles and hence the muscle tone is maintained. To start with, the exercises must be done in small amplitudes. The amplitude of the exercises may be increased gradually. The exercises may be more effective if they are done after the application of ice or heat.
7. Non Steroid Anti-inflammatory Drugs (NSAIDS).
8. Corticosteroids.
9. Anti-inflammatory Pain Relieving Creams or Gels- While applying creams or gels, care should be taken that they must be applied in a gentle way. Avoid massage at any cost. If massaged unscientificay the condition may worsen due to the following reasons.
a. If massaged the bone ends may get stimulated resulting in the formation of Osteophytes, which may worsen the condition. They may impinge upon the soft tissues in the region of elbow and enhances the pain. They may also interferes with the movement of elbow.
b. If massaged there may be oozing of blood from the already damaged or torn tissues resulting in the formation of haematoma (blood clots) in and around the site of damage. Such a situation delays the healing process
c. If massaged there may be mal alignment of the fibres of the already damaged or torn tissues. The approximation of the fibres of the already damaged or torn tissues is adversely affected. Such a situation delays the healing process.
All the above mentioned factors may collectively lead to Myositis Ossificans. Myositis Ossificans is the deposition of bone cells in the muscles, resulting in hard swellings which is very difficult to treat.
10. Physiotherapy Management- Physiotherapy plays an important role in treating the Tennis Elbow. Manipulations and exercises will be dealt with in detail later.
11. Splints and Supports- Wearing of a special Tennis Elbow Band just below the elbow is found to be beneficial. A bandage applied just below the elbow also helps to relieve the symptoms. Tennis Elbow Band or the bandage give support and protection to the elbow joint. A Wrist Splint may also help to relieve the symptoms in certain cases. These splints prevents excessive pulling of the Common Extensor Tendon at its place of insertion at the lateral epicondyle. It is advisable to do physiotherapy along with the application of splints or brace. Anyway, continuous use of bands, bandages and splints are not advisable as it may lead to-
a. Weakness of forearm muscles,
b. Inhibits blood circulation to forearm muscles,
c. Wasting of forearm muscles and
d. Flexion deformity of the elbow.
12. Steroid Injection - If all the above treatment procedures fail, an injection of steroid into the painful area of the elbow may relieve the pain. But it is usually found that the relief of pain due to steroid injection is of short duration. There may be recurrence of pain. The Steroid Injections may sometimes be repeated at short intervals if there is frequent recurrences of pain. To have more than three Steroid Injections at the same site is not advisable. Frequent Steroid Injections at the same site do have side effects. Hence Steroid Injection must be done only as a last resort. But to achieve short term relief, Steroid Injection is preferred. But for long term relief, physiotherapy is preferred. Some of the side effects are-
a. Pain on injection.
b. Infection at the site of injection.
c. Atrophy (shrinking) of the fatty tissue under the skin at the site of injection.
d. Depigmentation/Discolouration of the skin around the site of injection.
e. Rarely damage the Common Extensor Tendon and other soft tissues around the elbow joint.
f. May induce or enhance Diabetes.
Even if the pain has subsided, one still needs to be careful and cautious. One must give rest to the arm and avoid any activity that may bring back the symptoms. Physiotherapy is very important after Steroid Injection.
13. Shock Wave Therapy- High Energy Sound Waves are used. Using a device high energy sound waves are applied to the painful area. As its application is painful, anaesthesia is applied locally beforehand. One or more sessions may be required. It is considered to be safe without any side effects. But it is not clear as to how it helps to relieve the pain. Further research is needed in this field. The possible side effects may be-
a. Reddening of the skin.
b. Swelling of the area treated.
c. Damage to the Common Extensor Tendon and the soft tissues around the elbow.
Anyway, I haven’t come across a patient who has undergone Shock Wave Therapy.
14. Autologous Blood Injection- Blood is taken from the patient and then injected into the area around the damaged Common Extensor Tendon at the elbow. It is believed that the injected blood may enhance the healing of the damaged tendon. As the injection is painful, anaesthesia is applied locally beforehand. One or more sessions may be required. Splinting of elbow is needed after the procedure. Further research is needed. Physiotherapy is very much needed after Autologous Blood Injection.
Some of the side effects may be-
- Pain on injection.
- Infection at the site of injection.
- Bruising at the site of injection.
- Damage to the Common Extensor Tendon and other soft tissues around the elbow joint.
Anyway, I haven’t come across a patient who has undergone Autologous Blood Injection.
15. Botulinum Toxin A Injection - Botulinum Toxin A Injection into the muscles of the forearm is found to be effective in Tennis Elbow. This injection is preferred when the symptoms are severe enough for surgery to be considered.
Physiotherapy is very important after Botulinum Toxin A Injection.
16. Surgical Intervention- If the symptoms have not improved and persist for longer periods even after the above mentioned treatment procedures and extensive conservative therapy, then he may be a suitable candidate for surgical intervention. During the surgery the damaged portion of the Common Extensor Tendon is removed. Surgical corrections are also done for the other soft tissues around the elbow joint. The surgical procedure may be done through a large incision or through small incisions. Physiotherapy is very important post surgically.
