The approach to the management of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy, is taken from the main specialties of tendinopathy rehabilitation. To be useful in achieving long-term goals and meeting individual needs, rehabilitation must be multi-pronged. We investigated various causes and consequences of Tennis Elbow in the research study including central sensitization muscle and tendon structural changes and mechanical abnormalities. It is therefore important to examine all these aspects of history taking and objective analysis and consider them when developing a rehabilitation plan.
Multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy. This includes education exercise tissue loading management manual therapy steroid injection and taping. All of these implementation methods can be implemented and customized depending the patient’s needs the physician’s clinical judgment and joint decision-making between patient and physician. Since exercise is the best program we can currently implement the management of TE should be exercise-based.
Educating patients about prognostic coping strategies and self-management of their condition may not be effective in the short term and cannot be used as a standalone measure. But it has long-lasting positive effects if combined with other products for the management of Tennis Elbow.
Patient education is defined as ”a planned learning experience that uses a combination of strategies such as educational counseling and behavior change strategies to influence patient knowledge and health behavior”. Educating patients about their care needs is helpful in a shared decision-making process that motivates the patient to comply with treatment and improves self-efficacy.
Since tendinopathy is a degenerative disease and the earlier stages are considered palliative inflammation the treatment will depend on the overall health of the body. Smoking processed foods and high fat and obesity can delay recovery. These things should be discussed with him patients in order to ensure successful participation in treatment.
According to Buchanan et al. 2022 patient education should include the following considerations:
- Avoid end range of motion extremes in both extension and flexion.
- Avoid repetitive movements of your hands and arms and take breaks from such activities when you need to do them.
- Avoid lifting heavy objects with your arms fully extended; perform a work or lifting load with the elbow partially flexed.
- Hold heavy equipment with two hands and use two-handed backhands in tennis.
- Limit the frequency of handshakes and hugs.
- If a movement causes the pain to return avoid and notify your doctor’s office.
TE is a degenerative condition characterized by increased thickness of the common extensor tendon and differential neuromuscular mechanisms with primary finger function during grip Pain with hand grip is the most common presentation of TE and consequently people with TE demonstrated their most powerful fingers in reduced finger extension angles compared to healthy individuals  and in reaction time of finger muscle activity  especially ECRB muscles.
Load reduction on the muscles is an effective management strategy that must go hand in hand with building resistance muscles to enable gradual progress toward target loads through training a are given to the mechanical properties of the tissue. The best way to change the load is to ask patient to work under them pain management and engage in exercises that load the muscles to below the pain threshold.
Pain and inflammation will occur in response to the increased load known as ”reactive tendinopathy”. Pain reduction is important in this phase through pain relief and burden relief. Identifying the underlying causes of pain and arthritis can help shift the burdens on the roots. A sudden increase in load through movement involving repetitive wrist extension from elbows flexed and elbows extended can provoke pain and inflammation at the common extensor origin. To relieve inflammation, instruct your patient on lifting objects with flexed fingers and supports the front fingers.
The classical model of exercise in tendinopathy rehabilitation is eccentric contraction as a standard protocol especially in Achilles and Patellar Tendinopathies. Eccentric exercise is considered an effective intervention for overuse muscle injuries and reinjury prevention. They are also better at preparing patients/athletes to return to activity or sporting activities compared to focused exercise. Muscle responses to eccentric exercise were observed in Achilles tendonitis after twelve weeks of training. But other studies found no difference in tendon response between concentric and eccentric exercise. Evidence regarding loading velocity to movement repetition rate duration of contraction and exercise combat remains inconclusive.
** Studies have shown that dramatic exercises for lateral epicondylitis are more effective compared to a combination of bracing ultrasound and multiple interventions.
ECRB is the main artery affecting TE. It has the function of stabilizing the wrist. This supports the use of isometric exercises in TE management. Isometric exercise was found to have hypoalgesic effects locally and at sites remote from the exercise phase during and after contraction.
Coombes et al compared the immediate effects of acute isometric exercise (above and below the pain threshold) on pain perception in patients with chronic TE . . . . The findings support the use of exercise beyond pain threshold in reducing acute rest pain immediately after exercise compared to the other group. Another interesting finding of this study was that increased fear of movement significantly increased pain intensity during exercise above the pain threshold.
Progressive exercise is necessary to increase the muscles’ ability to withstand loads. The following are ways to boost your workout:
- Elbow and forearm position: start with flexed elbow and forearm in supination then move forward with increasing elbow extension angle.
- Fingers flexion vs extension: starts with the fingers in flexion then progresses into extension to load the long extensors.
- Adding Weight: Whether With Exercise Bands or Dumbbells
- Bilateral movement. Bilateral symptoms reported by many individuals support the evidence that central sensitization is associated with TE .
- Functional training exercises and targets the entire upper body.
- Weight bearing exercises
Exercising within the pain-free range and avoiding exercises that aggravate pain are common recommendations given in any MSK administration. However, the long-term benefits of exercise for properly loading the tendon and building tissue tolerance may initially require some pain .
Mobility mobilization can be used with other measures to reduce pain and facilitate exercise. Rehay et al.  studied the effect of Mulligan mobilization on TE and found that nocturnal pain and VAS pain were significantly reduced within 3 months of application Heals and increases pain-free grip strength. Another study found that the same approach was superior to wait and see and corticosteroid injections .
Corticosteriod injections have good results only in the short term ( up to six weeks). Long-term outcome is poor and was found to be associated with recurrence. One study found that increased pain decreased grip strength at mid-term follow-up after corticosteriod injection. However, the short-term benefits of pain management can be explored to encourage the patient to participate in the exercise program.
Taping has good placebo analgesic effect and pain-free recovery in patients with chronic TE. One study compared the effects of kinesio taping and exercise in sham tape with exercise and exercise alone groups on the patient-rated tennis elbow evaluation (PRTEE) visual analogue scale (VAS). . . . . grip strength and disabilities of the arm shoulder and arm (QuickDASH) scale. The results of the study support a combination of kinesiotape and exercise.
- ↑ Jump up to:1.0 1.1 1.2 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. 2006 Nov 2;333(7575):939.
- ↑ Jump up to:2.0 2.1 Dimitrios S. Exercise for tendinopathy. World journal of methodology. 2015 Jun 26;5(2):51.
- ↑ Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Can Chiropr Assoc. 2015;59(4):349–362.
- ↑ Forbes R, Mandrusiak A, Smith M, Russell T. Training physiotherapy students to educate patients: a randomised controlled trial. Patient education and counseling. 2018 Feb 1;101(2):295-303.
- ↑ Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C, Maxwell J, Roussou E, Adebajo A. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Annals of the rheumatic diseases. 2016 Jun 1;75(6):1126-32.
- ↑ Buchanan BK, Varacallo M. Tennis elbow. InStatPearls [Internet] 2022 Feb 12. StatPearls Publishing.
- ↑ Jump up to:7.0 7.1 Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. Journal of musculoskeletal & neuronal interactions. 2018 Sep;18(3):323.
- ↑ Jump up to:8.0 8.1 Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case‐control study. Scandinavian journal of medicine & science in sports. 2016 Dec;26(12):1382-90.
- ↑ Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
- ↑ Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l’Esport. 2018 Jan 1;53(197):19-27.
- ↑ Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. Journal of biomechanics. 2010 Dec 1;43(16):3073-9.
- ↑ Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986 Jul;(208):65-8
- ↑ Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004 Feb;38(1):8-11, discussion :11
- ↑ Jump up to:14.0 14.1 Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology. 2008 Jul 22;47(10):1493-7.
- ↑ Ma KL, Wang HQ. Management of lateral epicondylitis: a narrative literature review. Pain Research and Management. 2020 May 5;2020.
- ↑ Naugle KM, Fillingim RB, Riley III JL. A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain. 2012 Dec 1;13(12):1139-50.
- ↑ Coombes BK, Wiebusch M, Heales L, Stephenson A, Vicenzino B. Isometric exercise above but not below an individual’s pain threshold influences pain perception in people with lateral Epicondylalgia. The Clinical journal of pain. 2016 Dec 1;32(12):1069-75.
- ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Medicine and science in sports and exercise. 2016 Apr;48(4):599-606.
- ↑ Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.
- ↑ Smith BE, Hendrick P, Bateman M, Holden S, Littlewood C, Smith TO, Logan P. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British journal of sports medicine. 2019 Jul 1;53(14):907-12.
- ↑ Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. Journal of back and musculoskeletal rehabilitation. 2019 May 10(Preprint):1-9.
- ↑ Mulligan MWM for tennis elbow. Available from: https://www.youtube.com/watch?v=thUlPbCX4fU
- ↑ Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
- ↑ Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ open. 2013 Oct 1;3(10):e003564.
- ↑ Cho YT, Hsu WY, Lin LF, Lin YN. Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomized, double-blinded, cross-over study. BMC musculoskeletal disorders. 2018 Dec;19(1):193.
- ↑ Giray E, Karali‐Bingul D, Akyuz G. The Effectiveness of Kinesiotaping, Sham Taping or Exercises Only in Lateral Epicondylitis Treatment: A Randomized Controlled Study. PM&R. 2019 Jan 4.
- ↑ KT Tape: Tennis Elbow. Available from: https://youtu.be/DgwQSPQv_Zo
- ↑ Meglio TV. https://youtu.be/8n5qKX8mctU. Available from: https://youtu.be/8n5qKX8mctU
- ↑ KT Tape: Tennis Elbow. Available from: https://youtu.be/GOwqNDP40TQ