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TENNIS ELBOW REHABILITATION

Myofascial techniques using the muscle on stretch can also be effective

Ultrasound can also be effective in the early stages (14)

Iontophoresis has been used with some success also by driving steroid through the tissues (15)

Stretches should initially be active and then become passive (see fig.4)

Mobilisation of accessory movements of the elbow are imperative as is mobilisa- tion of a restricted radio-humeral joint

Mills’ manipulation can stretch adhe- sions by fully pronating the forearm with wrist flexion and then forcibly extending the elbow with a high veloc- ity low amplitude thrust (16) (see fig.5)

Dry needling and/or acupuncture are- known to be extremely effective even when other therapies have failed (17)

When active resisted movements are painless then strengthening exercises using light, free weights or a theraband will promote strength of the teno- osseus junction as well as the forearm extensors.

Injection Local steroid injection becomes relevant when conservative measures have failed. It is worth mentioning that injections seem to be more effective when treatment such as frictional massage have been tried previously, so it is important not to use a local injection as a first line treatment in tennis elbow.

The techniques preferred by the author include using accurate palpation to locate the site of maximal tenderness. Then after skin sterilisation and using a ‘no-touch’ technique inject 10mg of triamcinolone acetonide mixed in 1 ml of 1% lidocaine ‘peppering’ the solution around a cubic centimetre in the location of the tendon and teno-osseus junction and also in the sub-aponeurotic space.

A maximum of three injections are allowed to achieve full pain relief. If the second injection is ineffective then a third is not attempted. The need for any more than three injections within the first six weeks would imply that the treatment is not working. A full effect for four months or more can justify a repeat injec- tion. Intervals of less than two months would imply that other measures should be considered.

16 SportEX

Figure 6: Insulin syringe in use for local injection of triamcinolone acetonide

There is concern over the repeated use of steroid injection causing a reduction of fibroblastic and chondroblastic protein synthesis with consequent delay in heal- ing but since the alternative is a tenoto- my which involves complete disruption of the tendon attachment, it would seem reasonable to use injections if not required too frequently.

Sclerosant injections (Prolotherapy) have been tried and can reduce the frequency of episodes. These injections of a glucose solution thicken and strengthen connec- tive tissue in the area and have been known to prevent recurrence in about half of cases in the author’s experience.

Surgery After all conservative measures have been used and injections are becoming too fre- quent, then a surgical option is worth considering and is usually effective, in about 95% of cases.

Subcutaneous tenotomy uses a technique of minimal invasiveness by severing the attachment of ECRB at the lateral epi- condyle using a scalpel insertion under local anaesthetic. Scarring is almost non existent. The operation is followed by 7- 10 days immobilisation and a programme of playing light strokes at six weeks.

Three to six months is required for full recovery. The grip strength is not compro- mised in most cases.

Open tenotomy is

an option but leaves a larger scar. The procedure usually requires a general anaesthetic but the results are as favourable.

Rehabilitation This can commence when resisted move- ments are pain free. A co-ordinated, inte- grated rehabilitation programme should be instigated to return the player to their

Figure 7: Resistance tubing using the Ability Flex apparatus

chosen level of participation (18).

Counterforce bracing (non elastic) This can be an effective adjunct to treat- ment (19) by distributing force to the sur- rounding tissues. These braces have been shown to reduce ECRB activity during ten- nis strokes (20) and to increase isokinetic wrist extension and grip forces in testing (21). They should be worn in early reha- bilitation for activities of daily living and for the first few weeks of return to play.

Figure 8: Resisted backhand exercises

Figure 9: Epicondylar clasp, reducing transmitted tension at teno-periosteum

Alter pre-disposing factors: Use two-handed backhand Use lighter racket with larger head size Increase grip size Use new balls Reduce string tension Improve technique - (take lessons!) Loosen grip Optimise trunk rotation.

Prevention Take into account all of the above factors along with a thorough warm-up and stretching prior to play.

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