Injury to the extensor tendons at the elbow often can be attributed to repetitive trauma or overuse, leading to mechanical fatigue or biomechanical overload. Some literature reports the possibility of exostosis in the area of the extensor tendons or a degenerative process that causes pain at the lateral epicondyle.2 Symptoms may be described as an ache at the elbow with sharp pain that infrequently radiates to the dorsal forearm and occasionally to the middle and ring fingers with attendant loss of grip.³

The most frequently involved tendon is that originating from the extensor carpi radialis brevis (ECRB). It is responsible for static and dynamic wrist extension required for certain tasks and stabilizes the wrist while grasping. Lesions can occur at the extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, and supinator tendon. According to the current literature, microtraumatic ECRB tendon tears may propagate to include the common extensors.¹ Plancher and associates¹ report that gross tendon rupture is noted in a large number of patients at the time of surgical intervention.

Microtears can result from repeated sprains, repetitive forceful wrist extension and gripping, and suboptimal mechanics in hitting. Inadequate racquet size or improper tool grip size also can predispose to injury. Other factors that may influence the onset of symptoms are inadequate strength, endurance, and flexibility of the forearm musculature; changes in regular activity; increasing age; and hormonal imbalance in women.³ The incidence is equal in men and women during the fourth and fifth decades, with 75% of all cases involving the dominant arm.¹ Among the older population, the insult can possibly be work-related, in contrast to the sports-related injuries seen in the younger population.

Lateral epicondylitis can be successfully managed nonsurgically in 90% of patients with a combination of activity modification, nonsteroidal antiinflammatory medication, functional and counterforce bracing, various therapeutic modalities, and injection therapy. A small percentage of patients with persistent and disabling symptoms require surgical intervention.⁴ Lesions caused by overuse during job-related activities are more likely to require surgical intervention secondary to an inability to stop the aggravating activity.

Indications for surgery are individualized according to patient demands and activity level. The period of disability and previous conservative management must be considered before surgical management is chosen. There are no absolute indications for surgical intervention to treat lateral epicondylitis, and the clinician must exercise caution in cases in which secondary gain may be important.

The most important factors in considering surgical intervention are the intensity, frequency, and duration of disability caused by pain. The Nirschl classification system indicating the severity phase of pain, its relation to activity and exercise, and symptom resolution following these activities may have some impact on the therapeutic intervention (Table 8-1). Constant and unrelenting focal lateral elbow discomfort is not tolerated well by active individuals and pain that accompanies exercise and activity (phase 4) may indicate pathologic tendon architectural alteration. Most patients treated surgically have symptoms for 1 year, but special consideration may be given to patients in whom other therapies have failed after 6 months of compliance with a well-tailored therapeutic regimen. Calcification around the lateral aspect of the elbow may portend a less favorable outcome to conservative measures. When symptoms are present for more than 12 months, they will rarely respond to further therapeutic management. Although cortisone injections have been the historical standard for acute pain relief in significant cases of tennis elbow, the high recurrence rate has prompted autologous whole blood, platelet rich plasma, sclerosing agents, botulinum toxin, and periarticular hyaluronate injections to provide more long-lasting results. At this time, despite some compelling reports, no consensus exists regarding the ideal injection for a given patient in a particular phase of their lateral epicondylosis malady.

Similarly, less invasive surgical interventions are being investigated by some authors for a quicker return to activity and exercise. Arthroscopic treatment when compared with open management may provide athletes a shorter time period to functional recovery. In contrast to percutaneous release, arthroscopic release appears to achieve outcomes more quickly and provide a clearer visualization of the pathology. Nonetheless, the benchmark procedure for this condition is an open release for which various modifications have been proposed. Regardless of the open method chosen, these procedures are technically simple and provide predictable and long-lasting results and rely on readily available instrumentation. No single technique has been or will be adopted by all surgeons.

According to Nirschl,5,6 85% of patients were able to return to all previous activities without pain. Pain that occurred during aggressive activities was noted in 12% of the cases observed, and no improvement was apparent in 3% of the cases. When both medial and lateral releases are performed, a high level of patient satisfaction was achieved in a group of 53 patients followed an average of 11.7 years, and 96% of patients returned to their sports activity. Reasons for failure include misdiagnosis or the concomitant diagnosis of entrapment of the posterior interosseous nerve, intraarticular disorders, or lateral elbow instability. Poor prognostic factors include poor initial response to cortisone injections, numerous previous cortisone injections, bilateral lateral epicondylitis, other concomitant associated disorders, and smoking.

GOALS: Achieve full range of motion (ROM) of adjacent joints, promote wound healing, control edema and pain, and increase active range of motion (AROM) of the elbow (Table 8-2)

After surgery, the therapist instructs the patient concerning the need to elevate the site to avoid edema and initiates gentle AROM exercises for the hand and shoulder. The patient is to remain immobilized in the postoperative splint with the elbow positioned at 90°. On the fifth day after surgery, the postsurgical dressing and splint are removed and therapy is initiated to the elbow.

The initial postoperative examination is conducted by a physical or occupational therapist. Upon removal of the postsurgical dressing, the examination conducted should measure and address ROM, edema, pain, functional ability, and wound healing. ROM of the hand, wrist, elbow, and shoulder along with girth measurements of the hand, forearm, elbow, and upper arm are taken. Pain levels can be monitored using a 0 to 10 VAS (Visual Analog Scale). It is recommended to have patients use this during therapy sessions and with the home exercise program for optimum accuracy. Functional ability can be monitored using the DASH (disabilities of the arm, shoulder, and hand) or PRTEE (patient-rated tennis elbow evaluation) questionnaire. The above recorded data should be taken at subsequent visits for comparison and assessment of the patient’s progress.

In this phase the patient’s wounds are kept clean and dry until the sutures are removed 10 to 14 days after surgery. After the operative site has been exposed, other forms of edema control can be used, including ice, pneumatic intermittent compression (performed at a 3 : 1 on/off ratio at a pressure of 50 mm Hg), and high-voltage galvanic stimulation (HVGS). The recommended settings for the use of HVGS to prevent edema are negative polarity with continuous modulation at 100 intrapulse microseconds and intensity to the sensory level.⁷ The patient also can be fitted with a light elastic compression wrap or stockinette (such as Coban or Tubigrip) to wear intermittently throughout the day and at night for continued edema control at home (Fig. 8-2). AROM exercises also are initiated for the elbow, forearm, and wrist after the postoperative dressing is removed.⁸ Passive ROM (PROM) and joint mobilization of the elbow and forearm are contraindicated at this time.

Some surgeons prefer to keep the elbow immobilized in a removable posterior elbow splint until the second week after surgery. This splint is typically fabricated from a low-temperature plastic with the elbow positioned at 90°; it is worn between exercise sessions and at night (Fig. 8-3).

Pain can be managed using HVGS at the same settings as those used for edema control; the physician also may prescribe oral medications.

The first postoperative visit is a good time to begin patient education regarding activity modification and proper mechanics during work- and sports-related activities. Patients should be educated to avoid forceful static grip, repetitive and static wrist extension, and resistive supination, which are commonly seen with use of hand tools such as screwdrivers, and pliers, and with keyboarding. Patients should also be advised to avoid the overhanded lifting technique.

The primary mode of lifting should be a bilateral underhanded or neutral forearm approach (Fig. 8-4).

During this initial phase, the therapist should closely monitor the patient’s reports of pain and tolerance to ROM exercises, noting any sympathetic changes that may lead to a complex pain syndrome. Signs and symptoms to be noted are as follows:

GOALS: Control edema and pain, achieve full elbow PROM, maintain full ROM of adjacent joints, and promote mobility of the scar tissue (Table 8-3)

After the immobilization phase, the therapist should initiate gentle AROM exercises for the patient’s elbow three to four times each day.⁹ During the first ROM phase, the therapist should emphasize the importance of complying with the home exercise program and attending the regular therapy sessions.

ROM exercises to be included are as follows:

The patient should avoid positions that place maximal stress on the common extensor tendons such as elbow extension with extreme wrist flexion (Fig. 8-5).³ To prevent reinjury, progressive resistive exercises also should be avoided at this time. Sports-related activities to avoid include tennis, golf, lacrosse, or forceful throwing of a ball.

Stanley and Tribuzi³ recommend isometric exercises with the wrist in a neutral position or at no more than 30° of extension or flexion in preparation for further resistive training. Exercises should be performed three to four times daily with 15 to 20 repetitions being sufficient. Isometrics should be performed with submaximal effort only.

As ROM progresses, the therapist should carefully monitor the patient’s edema. The management of edema is specific to the patient and only one technique may be required. The following technique can be used for mild edema:

Moderate edema is treated with the following:

After the sutures are removed and the incision has healed appropriately, scar management is needed.

This includes both desensitization and scar remodeling. Because hypersensitivity can limit functional use, desensitization should begin during the patient’s first therapy session after suture removal.⁹ Scar remodeling consists of using massage (when appropriate) to help maintain mobility of the scar by freeing restrictive fibrous bands, increasing circulation, and allowing the pressure to flatten and smooth the scar site (Fig. 8-6).⁹ The therapist also may consider using a silicone gel sheet or other silicone-based putty mix as a pad over the scar to assist in remodeling.

The therapist should instruct the patient to rub the sensitive area for 2 to 5 minutes three to four times daily with textures such as fur, yarn, rice, Styrofoam, or corn. Other useful textures include towels, clothing, dry beans, and rice.⁹

Patients will be limited to lifting no more than 10 lb after surgery. On grip strength testing, patients typically demonstrate a 50% deficit when the operative hand is compared with the nonoperative one.

GOALS: Control pain, maintain full elbow and forearm ROM, strengthen upper extremity, and regain normal forearm flexibility (Table 8-4)

Between 4 to 6 weeks after surgery, the therapist should initiate a progressive strengthening program.⁹ At this point in the rehabilitative process the patient should have full ROM of the hand, wrist, and elbow, and the focus should be on building strength and training for endurance with the goal of returning the patient to work or sports.

The goal of the strengthening program is to promote conditioning of the entire upper extremity, particularly the forearm, to prevent reinjury caused by overstretching or overloading. To ensure that maximal strengthening is achieved, eccentric exercises are recommended for the extrinsic forearm muscles.³ At this time it is appropriate to initiate extrinsic forearm stretching.

Each patient’s conditioning program is formulated according to activity tolerance, previous activity level, and requirements for return to work or sports. If the patient can perform active exercises without pain, he or she is well enough to begin resistive and light work or sports-related activities using free weights and a work stimulator such as Baltimore Therapeutic Equipment (BTE) or Lido (Fig. 8-7). The key is to continue educating the patient and training her or him to lift with the forearm in a neutral position and avoid postures that stress the extensor muscles.

The components of the program are as follows:

Normally a return to activity can be anticipated by the fourth month after surgery.⁸

The most common mobility problem involves loss of full elbow extension. By 6 to 8 weeks after surgery, the therapist can talk to the surgeon about using static progressive or dynamic splints to improve extension. Static splinting is achieved by using custom-made, low-temperature plastic material molded to the patient at the end ROM and adjusted weekly. Dynamic splints are available commercially. For hand and finger stiffness, use of a flexion glove or composite flexion stretching with a Coban or elastic (Ace) wrap is usually successful (Fig. 8-8).

If the scar management techniques detailed earlier do not produce the desired result, additional methods include the following:

Circumferential desensitization using fluidotherapy also may be considered.