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Lateral epicondylopathy (LE) is the most common cause of elbow pain.  (1) The condition is related to repetitive wrist extension and is commonly referred to as “tennis elbow”, although the majority of those affected do not play tennis.  (2)

The pathogenesis of lateral epicondylopathy (LE) entails repetitive wrist extension causing micro-tearing of the common extensor tendon, ultimately leading to a failed healing response and degeneration. The primary site of injury is the extensor carpi radialis brevis (ECRB) tendon, 1-2 cm distal to its attachment on the lateral epicondyle.  (3-5)

Two new studies have helped to define the most appropriate exercises for stretching the ECRB and resolving LE. Read on for a quick demo of the top exercises.

A 2018 Clinics in Orthopedic Surgery study evaluated various combinations of flexion, extension, pronation, supination of the elbow and wrist, then determined that “elbow extension, forearm pronation, and wrist flexion was the most effective eccentric stretching for the ECRB.” (6) Here’s an updated ChiroUp StretchDemo video that incorporates this data:

 

A crucial key to successfully managing LE is the understanding that chronic “tendonitis” is a misnomer. Ongoing tendon irritations do not typically generate a chronic inflammatory response, i.e., “…itis”, but rather failed healing, i.e. “…opathy”.  (8,9) The successful management of lateral epicondylopathy requires a clear understanding of this concept – including a treatment goal to induce a controlled inflammatory reaction, rather than reduce one. For more about this differentiation, check out this prior ChiroUp blog.

 

Eccentric strengthening is a staple in the management of tendinopathy. A 2014 systematic review concluded: “The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy program for improved outcomes in patients with lateral epicondylitis.” (10)

 

Other studies have found that all outcome measures for the treatment of LE show improvement with the addition of eccentric wrist extensor strengthening.  (43) Eccentric strengthening is thought to stimulate collagen metabolism and synthesis. (43,58) The “Tyler Twist” exercise, utilizing a Theraband Flexbar is a novel approach to eccentric strengthening that has shown significant pain reduction and excellent outcomes in limited trials. (69,70)

 

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Food for thought:

Although the majority of studies related to the rehab of tendinopathy show a preference for eccentric loading, a new Journal of Hand Therapy study found: “eccentric-concentric training combined with isometric contractions was the most effective treatment (for LE).” (7)

In addition to exercise, the successful chiropractic evidence-based management of lateral epicondylopathy requires a multimodal approach.

Manipulation & Mobilization

  • Manipulation of the cervical and cervicothoracic region has been shown to decrease pain and disability in LE patients. (47-49,51)
  • Mobilization/ manipulation of the elbow demonstrates an immediate decrease in pain and a substantial increase in pain-free grip. (45,46,54,72)
  • Some studies suggest that mobilization or manipulation of the wrist may be as effective as conventional local treatment for LE. (52,53)

In case you missed it:

Check out this recent ChiroUp tutorial video for a demonstration of manipulation and mobilization for LE:

IASTM & Myofascial Release

Any tendinosis is associated with excessive, disorganized collagen formation, scarring, and contracture of peritendinous tissue.  (51)

  • IASTM is thought to help mobilize scar tissue and increase pliability by re-initiating an inflammatory process through controlled microtrauma. (51,56)
  • The use of IASTM has demonstrated “significantly better” outcomes than exercise alone – with 57% resolution of complaints after one month of care, and 78% resolution after two months. (57)
  • Myofascial release is an effective treatment for LE. (71)

 

Modalities

Feel free to share this exercise video tutorial with your patients – then visit ChiroUp.com when you’re ready to implement a system that automatically relays and incorporates condition-specific best practice evaluations, treatments, and exercises as they are published.  Imagine having daily access to 96 up-to-date condition synopses of the most common MSK conditions.  Give your patients the best chance of success through automated patient education and rehabilitation strategies.  Transform your practice by signing up for a free trial HERE.

 

ChiroUp Empowers:


 

 

References

  1. Bigorre N, Raimbeau G, Fouque P-A, Saint Cast Y, Rabarin F, Cesari B. Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: Is outcome influenced by the occupational disease compensation aspect? Orthopaedics & Traumatology: Surgery & Research. 2011; 97(2): 159-163
  2. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. Nov 4 2006;333(7575):939.
  3. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Aug 2008;27(8):1015-9.
  4. Conway JE. Clinical evaluation of elbow injuries in the athlete. J Musculoskeletal Med. 1998;15(10):43–52.
  5. Rettig AC. Elbow, forearm, and wrist injuries in the athlete. Sports Med. 1998;25(2):115–130.
  6. Joong-Bae Seo, MD, Sung-Hyun Yoon, MD, Joon-Yeul Lee, MD, Jun-Kyom Kim, MD, Jae-Sung Yoo, MD What Is the Most Effective Eccentric Stretching Position in Lateral Elbow Tendinopathy? Clinics in Orthopedic Surgery2018;10:47-54
  7. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13–19.
  8. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Aug 2008;27(8):1015-9.
  9. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: Pathogenesis, imaging, and treatment. RadioGraphics. 2010;(30):167-183.
  10. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014 Jan;28(1):3-19. doi: 10.1177/0269215513491974. Epub 2013 Jul 23

 

*All additional references available in the online ChiroUp LE protocol 

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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